Scaphocapitate arthrodesis with lunate preservation for Kienböck's disease: prospective outcomes study.

PURPOSE: The study evaluated the efficacy of SC arthrodesis with lunate preservation for treating patients diagnosed with stage IIIB or IIIC Kienböck's disease, who also exhibit neutral ulnar variance. The study further aimed to explore potential variations in outcomes between patients diagnosed with stage IIIB and IIIC Kienböck's disease. METHODS: Thirty-two patients diagnosed with stage IIIB (n = 19) and stage IIIC (n = 13) Kienböck's disease underwent SC arthrodesis with distal radius bone grafting stabilised by Herbert compression screws. All participants underwent pre- and post-operative assessments including VAS score for pain, ROM, grip strength, MMWS, and the Quick DASH score. Additionally, RS angle, LHI ratio, and CHI ratio were assessed. RESULTS: For all patients, the mean operative time was 73 min, follow-up was 45.6 months, time to union was 14 weeks, and time to full return to work was 24 weeks. The rate of union at the arthrodesis site was 91% (29 out of 32 patients) whilst the incidence of postoperative degenerative arthritis was 36% (8 out of 32 patients). Regarding changes in the means of outcomes from pre- to post-operatively, the VAS score decreased from 8.2 to 1.3 and grip strength improved from 36 to 79%. The RS angle was corrected from 59° to 50°. Significant improvements were noted in the mean MMWS from 45 to 75 and QuickDASH score from 78 to 21. However, no significant changes were observed in ROM, LHI, and CHI. There were no significant differences between patients with stage IIIB and stage IIIC in terms of these parameters, except for differences observed in the RS angle, LHI, and CHI preoperatively and in LHI and CHI postoperatively. CONCLUSION: Evidence level: II. Our research demonstrates that SC arthrodesis is a valuable approach for reducing pain, improving grip strength, and enhancing overall function in individuals with advanced Kienböck's disease. Importantly, our results indicate no notable differences in outcomes between patients diagnosed with stage IIIB or IIIC Kienböck's disease.

Capitate shortening osteotomy with or without vascularized bone grafting for the treatment of early stages of Kienböck's disease.

PURPOSE: The study evaluates the procedures of capitate shortening osteotomy with or without vascularized bone grafting (VBG) for the treatment of stage II or IIIA Kienböck's disease with neutral ulnar variance. METHOD: Forty-five patients with stage II (n = 21) and IIIA (n = 24) Kienböck's disease were included in the study. Patients were classified into two groups; isolated capitate shortening (ICS) group included 21 patients (stage II [n = 10] and stage IIIA [n = 11]) treated by capitate shortening without VBG of the lunate. Combined capitate shortening (CCS) group includes 24 patients (stage II [n = 11] and stage IIIA [n = 13]) who treated by capitate shortening combined with VBG of the lunate from the dorsal distal radius based on the fourth + fifth extensor compartment artery. All patients were evaluated pre- and post-operative for pain as measured by visual analogue scale score (VAS), range of motion (ROM), grip strength, modified Mayo wrist score (MMWS), lunate height index (LHI) ratio, and carpal height index (CHI) ratio. RESULTS: The mean operative time for CCS procedure was 85 min (76 to 120) and for ICS was 58 min (47 to 65). The mean follow-up period for all patients was 33 months (29 to 47). Patients with stage IIIA Kienböck's disease treated by CCS procedure had better post-operative VAS, ROM, grip strength, MMWS, LHI, and CHI ratio than patients treated by ICS procedure. ICS procedure reported 28% failure rate versus 8% for CCS. No differences were found between CCS and ICS procedures in patients with stage II Kienböck's disease in the term of clinical, radiographic outcomes, or failure rate. CONCLUSION: Using CCS procedure for the treatment of stage IIIA Kienböck's disease (lunate height collapse) with neutral ulnar variance can restore height and dimensions of the collapsed lunate and subsequently improve the final outcomes with lower failure rate. However, in patients with stage II Kienböck's disease (maintained lunate height), no advantages were noticed for CCS over ICS procedure. Lunate height index might be considered a prognostic factor for the treatment outcomes of Kienböck's disease.

Structural Versus Nonstructural Bone Grafting for the Treatment of Unstable Scaphoid Waist Nonunion Without Avascular Necrosis: A Randomized Clinical Trial.

PURPOSE: We evaluated the impact of structural versus nonstructural bone grafting on the time to union, scaphoid deformity correction, and clinical outcomes in adults with unstable scaphoid waist nonunion without avascular necrosis. We hypothesized that nonstructural grafting would provide earlier time to union, restoration of scaphoid anatomy, and equivalent clinical outcomes compared with structural grafting. METHODS: We prospectively randomized 98 patients to undergo open reduction, iliac crest bone grafting with either corticocancellous (CC group) or cancellous bone only (C-only), and internal fixation using a Herbert screw. The lateral intrascaphoid angle (LISA) and scaphoid height length ratio (HLR) were measured on wrist computed tomography scans along the scaphoid longitudinal axis before surgery and an average of 84 weeks afterward. Pain, range of motion, grip strength, and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were measured before surgery and an average 84 weeks afterward. RESULTS: The trajectory of scaphoid union showed a higher union rate of the C-only group at 12, 14, and 16 weeks after surgery. However, at 24 weeks after surgery, there was no difference between the groups, The union rate was 94% in patients treated with C-only and 90% with CC grafting. In patients with preoperative LISA less than 70° and/or HLR less than 0.80 (n = 53), there were no differences between the CC and C-only grafting techniques for radiographic and clinical outcomes, QuickDASH scores, and malunion rate. In patients who had preoperative LISA greater than 70° and/or HLR greater than 0.80 (n = 45), radiographic outcome measures, range of motion, and QuickDASH scores were significantly better in the CC than in the C-only group. Scaphoid malunion was observed in 9 of 22 of C-only patients (41%) and 4 of 23 of CC patients (18%). CONCLUSIONS: The severity of the scaphoid deformity may be a factor in determining the best graft type, because this may affect the rate of successful deformity correction. Corticocancellous grafting in patients who had a high degree of scaphoid deformity provided consistent deformity correction and superior QuickDASH scores. Otherwise, C-only grafting provides earlier time to union and equivalent clinical and radiographic outcomes compared with CC grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Treatment of Kienböck's Disease With Neutral Ulnar Variance by Distal Capitate Shortening and Arthrodesis to the Base of the Third Metacarpal Bone.

PURPOSE: We evaluated whether a surgical technique combining distal capitate shortening and arthrodesis to the base of the third metacarpal bone for the treatment of the early stages (stages II and IIIA) of Kienböck's disease with neutral ulnar variance resulted in pain relief, improvement in wrist motion, or changes in the radiographic evaluation. METHODS: This retrospective study reviewed 22 patients with early stages of Kienböck's disease with neutral ulnar variance, treated by distal capitate shortening and arthrodesis to the base of the third metacarpal bone. Patients were divided into 2 groups by disease stage: stage II (n = 12) and stage IIIA (n = 10). There were 8 women and 14 men, with an average age of 35.7 years. The following parameters were measured before and after surgery: visual analog scale (VAS) for pain evaluation, grip strength, range of motion (ROM), ulnar variance, carpal height index, lunate height index, and the scapholunate and scaphocapitate angles. The patients were evaluated in accordance with Modified Mayo Wrist Score (MMWS). RESULTS: The average follow-up period was 30.5 months (range, 26-36 months). The stage II group showed significant improvements in the mean VAS (58-5), ROM (57% to 73%), grip strength (54% to 75%), and MMWS (51-78). Patients in the stage IIIA group showed nonsignificant changes in mean VAS score (64-42.5), ROM (52.5% to 55.5%), grip strength (46.5% to 57.5%), and MMWS (36-50.5). Significant decreases in the carpal height index and scaphocapitate angle, and an increase in scapholunate angle in all stage IIIA patients were observed. CONCLUSIONS: Distal capitate shortening with capitometacarpal arthrodesis can alleviate pain and improve ROM and grip strength in patients with stage II Kienböck's disease, but not in those with stage IIIA. Moreover, it cannot prevent carpal collapse, especially in stage IIIA of the disease. We do not recommend this technique for treating stage IIIA patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.