The classification and treatment of Kienbock's disease: the state of the art and a look at the future.

The proper treatment of Kienböck's disease, a disorder that displays slow progression with eventual collapse of the lunate and alteration of the surrounding carpal architecture, requires an understanding of its aetiology and natural history. A reproducible classification system assists the surgeon in making appropriate treatment choices. In this discussion, we review the history and rationale for the four-stage step-wise classification system, along with our current treatment algorithm. We also discuss emerging classification systems and speculate on future directions in treatment and research.

Quantitative assessment of the midcarpal shift test.

The subjective, clinical midcarpal shift test was compared with a quantitative measurement of carpal volar/dorsal translation versus ulnar deviation using a mechanical testing system. Testing was performed on 19 healthy volunteers (mean age, 33 years) and 3 patients (four wrists; mean age, 23 years) who had been diagnosed with ulnar midcarpal instability, a nondissociative form of carpal instability. During physical examination, each subject's wrist was graded I to V using the previously described classification of the degree of laxity and clunk observed with the midcarpal shift test. Each subject was also evaluated using a quantitative mechanical testing system that simulates the subjective clinical test. The testing system measures displacement of the distal carpal row, more specifically, the capitate, as the wrist is moved from neutral to ulnar deviation under a constant axial load of 44 N directed volarly at the head of the capitate. Reflective markers were attached to the skin above the proximal and distal ends of the third metacarpal and at the point where the 44-N load was applied to the carpus. Motion of the markers was used to calculate ulnar deviation and dorsal/volar translation of the carpus. The maximum slope of the carpal translation versus ulnar deviation curve was measured for each subject and compared with the results of the clinical midcarpal shift test. Higher maximum slopes were seen in subjects with the higher grades of carpal laxity. There were also differences with regard to the point at which the clunk occurred; the higher the clinical grade of laxity, the greater the ulnar deviation of the wrist at the point at which the clunk was observed. These differences were not significant, however. These data confirm the validity of the clinical test and establish its usefulness as a diagnostic indicator of midcarpal nondissociative carpal instability. The mechanized test also may be useful as a biomechanical marker, enabling the results of ligament sectioning to be effectively compared with defined clinical laxity.

External fixation for the treatment of Kienböck's disease.

With the advent of magnetic resonance imaging, the diagnosis of avascular necrosis of carpal bones can be made early, well before collapse and derangement of carpal mechanics occur. We believe that neutralization of forces early in the course of disease may permit natural healing (revascularization) of the bone. It is questionable whether tubular casts can supply adequate neutralization of force. We recommend the consideration of external fixation, rather than more extensive surgery, as a rational alternative for this purpose. After surgical revascularization, carpal bones go through a resorptive phase that makes them highly susceptible to collapse from compressive forces across the wrist. We advocate the postoperative use of an external fixator to neutralize these forces after a revascularization procedure is performed.

Palmar midcarpal instability: results of surgical reconstruction.

We reviewed the cases of 13 patients who underwent 15 surgical procedures for palmar midcarpal instability from 1981 to 1989. Six patients had a limited midcarpal arthrodesis, and nine patients had one of four different soft tissue reconstructive procedures. One hundred percent clinical follow-up was obtained at an average of 48 months. All six of the limited midcarpal arthrodeses were successful. Six of the nine soft tissue reconstructions failed. However, one procedure, a distal advancement of the ulnar arm of the arcuate ligament combined with a dorsal capsulodesis, restored stability in three of five wrists. We concluded that patients with palmar midcarpal instability may have significant disability that may be refractory to nonsurgical management. Limited midcarpal arthrodesis provides definitive treatment.

Proximal row carpectomy: a multicenter study.

Twenty patients underwent proximal row carpectomy and were retrospectively evaluated for pain, motion, grip strength, functional activity, and x-ray changes at a mean follow-up of 3 1/2 years. For nonrheumatoid patients, motion decreased 15% after surgery, mean grip strength improved 22%, and 82% believed their conditions were improved and said they would repeat the procedure. The procedure failed in all three patients with rheumatoid arthritis. Patients with mild preoperative arthritic changes had better results than those with advanced disease.

Lunate silicone replacement arthroplasty in Kienböck's disease: a long-term follow-up.

We report a long-term follow-up (average, 5 years) of 10 patients who had lunate silicone replacement arthroplasty for treatment of Kienböck's disease. Clinical results were assessed on relief of pain, return to normal occupation, and range of motion. At 18- to 20-months follow-up, eight patients had satisfactory results, whereas at final follow-up only five of the patients had satisfactory results. Three of five patients with radiographs averaging 57 months after operation had evidence of particulate synovitis. Contrary to our previous publications on silicone replacement arthroplasty, it was concluded that the success rate for silicone replacement arthroplasty and the incidence of particulate synovitis do not warrant the continued use of silicone replacement arthroplasty as a primary treatment modality for Kienböck's disease.

Microsurgical revascularization of ischemic rat femoral heads.

To demonstrate whether revascularization could be surgically induced in avascular bone the femoral heads of female albino rats were excised and drilled through and through. The femoral heads were then placed in the opposite thigh and by use of microvascular techniques the femoral artery was divided and lengthened with a 1 cm artery or vein graft, and reanastomosed after passing one end through the drilled hole in the transplanted femoral head. Arterial blood flowed through the graft within the drilled femoral head on its way to its normal distribution down the leg. Technetium 99m MDP methylene diphosphate, tetracycline labeling, latex injection, and histologic review were used to demonstrate new vessel growth. All grafts patent at the end of the experiment were associated with tetracycline labeling, positive technetium 99m methylene diphosphate counts and latex-filled vessels in the matrix of the femoral heads. Histologically the vascularized femoral heads showed evidence of neovascularization and new bone formation.

Diagnostic and operative arthroscopy of the knee under local anesthesia with parenteral medication.

Arthroscopy of the knee under local anesthesia was performed on 102 patients for operative and diagnostic purposes between January and December of 1985. The procedures were performed on a same day basis without a pneumatic tourniquet. The operative record of each patient was reviewed to determine postoperative diagnosis and treatment. The data was matched to a patient questionnaire that measured individual reaction to local anesthesia. The effectiveness and level of patient acceptance of this anesthetic technique for operative arthroscopy was then evaluated. Ninety-one patients responded to the questionnaire, 82 of whom had prior anesthetic experience. Ninety-five percent of the patients had minimal or no discomfort during the procedure. Eighty percent indicated a preference for local anesthesia in the event of subsequent arthroscopy. No complications relating to the anesthetic agent were noted. Arthroscopy of the knee under local anesthesia for routine operative arthroscopy was found to be safe, reliable, practical, and to have a high patient acceptance rate.

Flexor tendon repair and rehabilitation in zone II open sheath technique versus closed sheath technique.

A comparative prospective study of the surgical management of the tendon sheath after repair of flexor tendons in zone II is reported. The study included only patients with lacerations of both flexor tendons and no other associated injuries. A modified Kessler suture was used to repair the profundus tendon and the superficialis tendon was repaired with a horizontal mattress suture. In 48 fingers the flexor tendon sheath was left open and it was closed in the second group of 42 fingers. When it was impossible to close the tendon sheath, a vein patch was taken from the dorsal veins of the hand. Both groups of patients were treated with the same regimen of controlled motion rehabilitation and supervised by the same hand therapist. Results were evaluated by the Strickland formula for total active motion of the proximal and distal interphalangeal joints. There was no statistical difference between the results of open sheath versus closed sheath in these two groups of patients treated postoperatively with the same controlled motion rehabilitation program.

The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. A preliminary report.

Many patients with acute herniated nucleus pulposus can be expected to resolve their conditions with conservative management. To date, however, no reliable sign has been described in the literature that can predict which patient will respond. This report shows that the ability to achieve normal lumbar extension represents such a sign. Of 67 patients who met the criteria for inclusion in the study, 35 patients were treated without operation; 97% were able to achieve normal lumbar extension within three days of admission to the hospital. Thirty-two patients underwent laminotomy and discectomy because they failed to improve with conservative measures. Of these patients, only two (6%) were able to achieve normal lumbar extension preoperatively. Furthermore, some of these patients responded so dramatically to extension therapy that the use of extension exercises as a therapeutic modality is recommended.

The evaluation of chronic wrist pain.

Guidelines for the assessment of the chronically painful wrist are described, including the uses and limitations of plain roentgenograms, arthrography, CT, tomography, and cineradiography. A careful review of these studies is emphasized.

Dynamic triquetrolunate instability: case report.

A case is reported that demonstrates dynamic triquetrolunate instability with the additional finding of obstruction to smooth intercarpal motion by a tag of torn interosseous triquetrolunate ligament. The patient was successfully treated with excision of the ligamentous tag accompanied by triquetrolunate fusion.

Kienböck's disease--update on silicone replacement arthroplasty.

In a previous paper, early lunate silicone replacement arthroplasty (SRA) for Kienböck's disease was advocated because of poor results obtained in stage III disease. Since then, an additional 16 patients have been operated on. Thirteen had stage III disease, and 12 underwent successful SRA. This result is attributed to the modification in anatomical configuration and the improvement in the physical characteristics of the new high-performance silicone lunate implant. Because SRA gives good results in a high percentage of patients in stage III disease, alternative modes of therapy may be considered in stage I or stage II disease without jeopardizing the ultimate result from SRA in stage III disease.

Ulnar midcarpal instability-clinical and laboratory analysis.

Patients with ulnar midcarpal instability have a characteristic pattern of clinical signs and symptoms related to the midcarpal joint. The usual presenting complaint is a painful wrist click which can be reproduced by ulnar deviation, axial compression, and pronation of the wrist. Routine x-rays are usually normal, but cinefluoroscopy reveals sudden dissociation between the proximal and distal carpal rows resulting in a dorsiflexion collapse deformity. In six of our patients, conservative therapy sufficed to relieve symptoms. Four other patients required surgical stabilization. We close to stabilize the triquetrohamate joint because it was a relatively easy procedure and eliminated instability in most instances. Laboratory studies aided in understanding the pathomechanics of midcarpal instability, which consisted of dorsal subluxation of the capitate and hamate on the lunate and triquetrum. We believe that midcarpal instability is not a rare condition but may often be confused clinically with more common carpal dissociations.

Irreducible distal radioulnar joint occurring in a Galeazzi fracture - case report.

This is a report of an irreducible distal radioulnar joint associated with a Galeazzi fracture. The irreducible dislocation of the radioulnar joint was not appreciated until 2 weeks following compression plating of the radius fracture. The extensor carpi ulnaris was found to be wrapped anteriorly about the ulnar border of the distal ulna and was trapped in this position by the displaced ulnar styloid. The patient was successfully treated with open reduction of the styloid fracture and temporary wire fixation.

Hip arthroplasties in Gaucher's disease.

In six patients with Gaucher's disease, arthroplasties were performed on ten hips for avascular necrosis of the femoral head. The follow-up ranged from two to twelve years. There were three Vitallium mold (cup) arthroplasties, seven primary total hip-replacement arthroplasties, and two revisions of total hip-replacement arthroplasties. Increased intraoperative and postoperative bleeding was often encountered. The cup arthroplasties yielded good results on long-term follow-up, but there was a high rate of loosening of the prosthetic components in the total hip replacements. There was one postoperative pathological fracture but there were no infections.