JBJS | Lunate Excision, Capitate Osteotomy, and Intercarpal Arthrodesis for Advanced Kienböck Disease : Long-Term Follow-up

The Journal of Bone & Joint Surgery, Volume 83, Issue 2

Articles | February 01, 2001

Lunate Excision, Capitate Osteotomy, and Intercarpal Arthrodesis for Advanced Kienböck Disease : Long-Term Follow-up

Katsumi Takase, MD; Atsuhiro Imakiire, MD

Investigation performed at the Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan
Katsumi Takase, MD Atsuhiro Imakiire, MD Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo, Japan 160-0023. E-mail address for K. Takase: k-takase@muf.biglobe.ne.jp
No benefits have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2001; 83:177-177

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

text A A A

Abstract

Background: Kienböck disease is caused by aseptic necrosis of the lunate. In the advanced stages of the disease, carpal collapse, joint incongruity, and osteoarthritis develop. We performed lunate excision, capitate osteotomy, and intercarpal arthrodesis (the modified procedure of Graner et al.) on fifteen patients with stage-IIIB or IV Kienböck disease. This report is a review of the findings in these patients.

Methods: The subjects ranged in age from twenty-six to fifty-four years (mean, 39.2 years) at the time of surgery. We evaluated the results more than five years postoperatively (range, sixty-two to 145 months postoperatively; mean, 79.3 months postoperatively). Therapeutic results were evaluated according to the scoring system of Evans et al.

Results: Pain disappeared after surgery in most patients. Others had a reduction in the intensity of the pain to a mild level. The grip strength on the affected side had recovered to about 80% of that on the unaffected side twelve months after surgery. The long-term results were graded as good in eleven of the patients, as fair in two, and as poor in two. Postoperative radiographs showed that the carpal bone parameters (carpal height index and radioscaphoid angle) had improved. Radiographic osteoarthritic changes occurred in all of the patients; however, except for moderate limitation of the range of motion at the wrist joint, these findings did not affect the level of pain, grip strength, or activities of daily living.

Conclusions: Lunate excision followed by capitate osteotomy and intercarpal arthrodesis (the modified procedure of Graner et al.) is a reliable form of treatment for advanced Kienböck disease, with favorable results for at least five years postoperatively.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Kienböck disease is caused by aseptic necrosis of the lunate. When the disease becomes advanced, carpal collapse, joint incongruity, and osteoarthritis develop. The choice of treatment for patients with symptomatic Kienböck disease depends largely on the severity of the disease^1-3. In the advanced stages, excision or reconstruction of the collapsed lunate itself is often performed⁴. These surgical procedures include excision arthroplasty^5-7, limited intercarpal arthrodesis^8,9, revascularization¹⁰, arthrodesis between the radius and the lunate¹¹, and vascular bundle implantation¹².

Since 1979, we have performed the modified procedure of Graner et al.⁶ in patients with advanced Kienböck disease. This procedure involves excision of the collapsed lunate followed by osteotomy of the capitate and arthrodesis of all intercarpal joints except for the trapezium and the pisiform. Our report is a review of the results in fifteen patients who underwent the modified Graner procedure and were followed for more than five years.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1:: The modified Graner procedure. After excision of the collapsed lunate, the capitate is osteotomized and the proximal pole is shifted proximally to form a new radiocarpal joint. The articular cartilage of carpal bones, other than the trapezium and the pisiform, is excised at all intercarpal joints. Cancellous and cortical bone graft is placed in the empty spaces among the remaining carpal bones and into the osteotomy defect in the capitate. The shifted capitate and the other carpal bones are then fixed with Kirschner wires. During fixation, it is important to reduce the palmar rotation of the scaphoid to about 50°.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2:: Recovery of grip strength over time. Grip strength recovered to about 50% of that on the unaffected side at six months postoperatively and to about 80% of that on the unaffected side at one year postoperatively. However, grip strength did not recover further, even at more than five years postoperatively (when it was almost the same as it had been at one year).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 3:: Recovery of range of motion (flexion-extension arc) over time. The range of motion was the same as it had been before the operation or it had improved slightly by up to two years postoperatively, but it showed a tendency to decrease slightly two to three years postoperatively. At five years postoperatively, the range of motion was almost the same as it had been before the operation or it had decreased slightly.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4-A:: Figs 4-A through 4-F Case 9. Fig. 4-A Anteroposterior radiograph of a thirty-three-year-old man who had stage-IV Kienböck disease on the left side. Dorsiflexion was 50°, palmar flexion was 50°, and grip strength was 55% of that on the right side preoperatively. The carpal height index was 0.87 preoperatively. Fig. 4-B On the lateral radiograph, the radioscaphoid angle was 68° preoperatively. Fig. 4-C The modified Graner procedure was performed two years and six months after the onset of symptoms. On the anteroposterior radiograph made three months after the operation, the carpal height index had increased to 0.92.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4-B:: Figs 4-A through 4-F Case 9. Fig. 4-A Anteroposterior radiograph of a thirty-three-year-old man who had stage-IV Kienböck disease on the left side. Dorsiflexion was 50°, palmar flexion was 50°, and grip strength was 55% of that on the right side preoperatively. The carpal height index was 0.87 preoperatively. Fig. 4-B On the lateral radiograph, the radioscaphoid angle was 68° preoperatively. Fig. 4-C The modified Graner procedure was performed two years and six months after the onset of symptoms. On the anteroposterior radiograph made three months after the operation, the carpal height index had increased to 0.92.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4-C:: Figs 4-A through 4-F Case 9. Fig. 4-A Anteroposterior radiograph of a thirty-three-year-old man who had stage-IV Kienböck disease on the left side. Dorsiflexion was 50°, palmar flexion was 50°, and grip strength was 55% of that on the right side preoperatively. The carpal height index was 0.87 preoperatively. Fig. 4-B On the lateral radiograph, the radioscaphoid angle was 68° preoperatively. Fig. 4-C The modified Graner procedure was performed two years and six months after the onset of symptoms. On the anteroposterior radiograph made three months after the operation, the carpal height index had increased to 0.92.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4-D:: Fig. 4-D On the lateral radiograph made three months after the operation, the radioscaphoid angle had decreased to 45°. Fig. 4-E The patient returned to his preoperative job four months postoperatively. At the most recent follow-up evaluation (six years and six months postoperatively), he had no pain. The flexion-extension arc of the left wrist was 95°, grip strength was 88% of that on the right side, and the clinical result was graded as good. On the anteroposterior radiograph, the carpal height index had been maintained at 0.92. Fig. 4-F On the lateral radiograph made six years and six months postoperatively, the radioscaphoid angle was 45°. Osteophytes (arrow) can be seen on the dorsal side of the radius.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4-E:: Fig. 4-D On the lateral radiograph made three months after the operation, the radioscaphoid angle had decreased to 45°. Fig. 4-E The patient returned to his preoperative job four months postoperatively. At the most recent follow-up evaluation (six years and six months postoperatively), he had no pain. The flexion-extension arc of the left wrist was 95°, grip strength was 88% of that on the right side, and the clinical result was graded as good. On the anteroposterior radiograph, the carpal height index had been maintained at 0.92. Fig. 4-F On the lateral radiograph made six years and six months postoperatively, the radioscaphoid angle was 45°. Osteophytes (arrow) can be seen on the dorsal side of the radius.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4-F:: Fig. 4-D On the lateral radiograph made three months after the operation, the radioscaphoid angle had decreased to 45°. Fig. 4-E The patient returned to his preoperative job four months postoperatively. At the most recent follow-up evaluation (six years and six months postoperatively), he had no pain. The flexion-extension arc of the left wrist was 95°, grip strength was 88% of that on the right side, and the clinical result was graded as good. On the anteroposterior radiograph, the carpal height index had been maintained at 0.92. Fig. 4-F On the lateral radiograph made six years and six months postoperatively, the radioscaphoid angle was 45°. Osteophytes (arrow) can be seen on the dorsal side of the radius.

View Larger

TABLE I: Scoring System of Evans et al.13 for Evaluating Therapeutic Results*

*One point was given for each criterion that was met, for a total of 0 to 4 points. The result was rated as good (4 points), fair (3 points), poor (2 points), or very poor (1 or 0 points).

Criterion	Score (points)
Little or no discomfort in the wrist joint	1
Grip strength of more than 70% of that on the unaffected side	1
Flexion-extension arc of 60° or more	1
Return to original occupation	1

Add to My JBJS

TABLE I: Scoring System of Evans et al.13 for Evaluating Therapeutic Results*

*One point was given for each criterion that was met, for a total of 0 to 4 points. The result was rated as good (4 points), fair (3 points), poor (2 points), or very poor (1 or 0 points).

Criterion	Score (points)
Little or no discomfort in the wrist joint	1
Grip strength of more than 70% of that on the unaffected side	1
Flexion-extension arc of 60° or more	1
Return to original occupation	1

View Larger

TABLE II: Preoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.92	63	65/60	75
2	IIIB	0.94	52	65/60	90
3	IIIB	0.95	58	45/50	93
4	IV	0.93	58	60/55	73
5	IV	0.92	56	40/40	62
6	IV	0.92	64	30/50	44
7	IV	0.90	60	40/60	65
8	IV	0.89	68	40/50	80
9	IV	0.87	68	50/50	55
10	IV	0.86	69	30/30	52
11	IV	0.86	70	60/50	35
12	IV	0.85	79	40/45	67
13	IV	0.84	42	30/30	18
14	IV	0.82	74	35/40	42
15	IV	0.82	71	25/20	30

Add to My JBJS

TABLE II: Preoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.92	63	65/60	75
2	IIIB	0.94	52	65/60	90
3	IIIB	0.95	58	45/50	93
4	IV	0.93	58	60/55	73
5	IV	0.92	56	40/40	62
6	IV	0.92	64	30/50	44
7	IV	0.90	60	40/60	65
8	IV	0.89	68	40/50	80
9	IV	0.87	68	50/50	55
10	IV	0.86	69	30/30	52
11	IV	0.86	70	60/50	35
12	IV	0.85	79	40/45	67
13	IV	0.84	42	30/30	18
14	IV	0.82	74	35/40	42
15	IV	0.82	71	25/20	30

View Larger

TABLE III: Postoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.94	49	65/50	82
2	IIIB	0.97	52	50/60	85
3	IIIB	0.98	46	50/30	88
4	IV	0.94	49	50/40	91
5	IV	0.94	41	45/35	89
6	IV	0.98	54	30/30	80
7	IV	0.92	55	30/30	82
8	IV	0.94	51	30/35	80
9	IV	0.92	45	55/40	88
10	IV	0.95	55	30/20	90
11	IV	0.95	65	30/65	77
12	IV	0.86	52	35/25	108
13	IV	0.89	42	40/20	75
14	IV	0.92	54	40/40	78
15	IV	0.92	48	25/25	63

Add to My JBJS

TABLE III: Postoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.94	49	65/50	82
2	IIIB	0.97	52	50/60	85
3	IIIB	0.98	46	50/30	88
4	IV	0.94	49	50/40	91
5	IV	0.94	41	45/35	89
6	IV	0.98	54	30/30	80
7	IV	0.92	55	30/30	82
8	IV	0.94	51	30/35	80
9	IV	0.92	45	55/40	88
10	IV	0.95	55	30/20	90
11	IV	0.95	65	30/65	77
12	IV	0.86	52	35/25	108
13	IV	0.89	42	40/20	75
14	IV	0.92	54	40/40	78
15	IV	0.92	48	25/25	63

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Subjects

From 1979 to 1995, we performed the modified Graner procedure in nineteen patients. Four of these patients were excluded from the study because of inadequate long-term follow-up. The remaining fifteen patients consisted of twelve men and three women. The right side was affected in eleven of these patients, and the left side was affected in four; twelve dominant and three nondominant sides were affected. The ages of the patients at the time of surgery ranged from twenty-six to fifty-four years (mean, 39.2 years). The preoperative duration of symptoms ranged from six to 145 months (mean, 29.3 months). Six of the fifteen patients recalled a traumatic injury.

At the time of surgery, all of the patients were employed: eight, as construction workers; two, as cooks; two, as automobile mechanics; two, as office workers; and one, as a homemaker. Our indications for surgical intervention were pain with activity that had persisted for more than six months despite a nonoperative treatment program combined with palmar rotation of the scaphoid, or osteoarthritis at the radiocarpal joint or at the intercarpal joints as demonstrated on plain radiography (stage IIIB or IV according to the classification system of Lichtman et al.¹). The severity of the disease was stage IIIB in three patients and stage IV in twelve patients. The duration of postoperative follow-up was between sixty-two and 145 months (mean, 79.3 months). Therapeutic results were assessed according to the scoring system of Evans et al. (Table ITable I)¹³.

Preoperative Evaluation

Ulnar variance^14-16 and carpal collapse were measured on radiographs. We measured the ulnar variance with the method of Palmer et al.¹⁷. The carpal height index¹⁸ (the carpal height ratio^19,20 on the affected side divided by the carpal height ratio on the unaffected side) was calculated. The radioscaphoid angle was used to measure the degree of palmar rotation of the scaphoid. Using a true lateral radiograph made with the wrist in a neutral position, we measured this angle between the longitudinal axis of the radial shaft, drawn to the midpoint of the distal articular surface of the radius, and the longitudinal axis of the scaphoid, drawn to the midpoints of its proximal and distal poles²¹.

Surgical Technique

A 5-cm transverse skin incision was made on the dorsal side of the radiocarpal joint, and the extensor retinaculum was incised longitudinally between the third and fourth compartments. After excision of the collapsed lunate and the surrounding peripheral synovial tissue, the capitate was osteotomized and the proximal pole was shifted proximally into the lunate fossa. The articular cartilage of the carpal bones, other than the trapezium and the pisiform, was excised at all intercarpal joints. Cancellous and cortical bone graft, obtained from the ipsilateral iliac crest, was placed in the empty spaces among the remaining carpal bones and used to fill the gap created by the osteotomy of the capitate. After the bone grafts were placed, the shifted capitate and the other carpal bones were fixed with Kirschner wires (Fig. 1Fig. 1). We made a strong effort to reduce the palmar rotation of the scaphoid to about 50°, and we securely fixed the scaphoid in this position with the Kirschner wires.

An above-the-elbow cast was used for two weeks after surgery. A below-the-elbow cast was then applied, and it was removed at five weeks postoperatively. In the cast, the wrist joint was immobilized in a slightly dorsiflexed position, the thumb was immobilized up to the level of the interphalangeal joint, and each finger was immobilized up to the level of the metacarpophalangeal joint. After removal of the cast, the wrist position was maintained with a brace and active stretching exercises were prescribed. An exercise program of passive stretching and strengthening was begun two months after surgery, and the Kirschner wires were removed three months postoperatively. The patient was encouraged to wear the brace until four months postoperatively.

Statistical Analysis

Statistical comparisons of parameters were performed with the Student t test. The correlations between parameters were calculated with linear regression analysis.

Results

Introduction | Materials and Methods | Results | Discussion | References

Preoperative Evaluation

Preoperatively, ten of the fifteen patients had a neutral variance, two had a positive variance, and only three had a negative variance. Table IITable II shows the preoperative findings for each patient. The mean carpal height index was 0.94 (0.92, 0.94, and 0.95) in the wrists with stage-IIIB disease and 0.87 (range, 0.82 to 0.93) in those with stage-IV disease, indicating that the carpal height index was significantly reduced in the wrists with more advanced disease (p < 0.05). The reduction of the carpal height index signified the shifting of the capitate proximally, reducing the height of the entire carpus. However, there was no significant difference in the radioscaphoid angle between stages IIIB and IV (p = 0.13).

In addition, we evaluated the range of motion at the wrist joint and the grip strength preoperatively. Palmar flexion was 45°, 65°, and 65° (mean, 58.3°) in the patients with stage-IIIB disease, and it ranged from 25° to 60° (mean, 40°) in those with stage-IV. Dorsiflexion was 50°, 60°, and 60° (mean, 56.7°) in the patients with stage-IIIB disease, and it ranged from 20° to 60° (mean, 43.3°) in those with stage-IV. Grip strength on the affected side was 75%, 90%, and 93% (mean, 86%) of that on the unaffected side in patients with stage-IIIB disease, and it ranged from 18% to 80% (mean, 52.1%) of that on the unaffected side in those with stage-IV. These findings indicate that both grip strength and range of motion decrease significantly (p < 0.05) as the stage of the disease progresses from IIIB to IV.

There was a significant correlation between the carpal height index and dorsiflexion (r = 0.542, p < 0.05), between the carpal height index and palmar flexion (r = 0.701, p < 0.01), and between the carpal height index and grip strength (r = 0.792, p < 0.01). Furthermore, the radioscaphoid angle was significantly correlated with grip strength (r = 0.532, p < 0.05) but not with range of motion (dorsiflexion, p = 0.587; palmar flexion, p = 0.658).

Arthritic Changes

Intraoperatively, the articular cartilage of the proximal part of the capitate was not found to be abnormal, but the articular cartilage in the lunate fossa of the radius showed fibrillation and erosion in most of the patients and eburnation in two. Postoperatively, osteoarthritic changes were observed radiographically in all fifteen patients. Most osteoarthritic changes occurred on the radial side as reactive osteophytes around the newly formed radiocapitate joint two to three years after surgery. However, narrowing of the newly formed joint space was observed in only two patients postoperatively.

Therapeutic Results

According to the Evans scoring system, good results were achieved in eleven patients; fair results, in two; poor results, in two; and very poor results, in none. There was no difference in the results between the patients with stage-IIIB disease and those with stage-IV disease. The mean carpal height index increased from 0.89 to 0.94. The mean radioscaphoid angle decreased from 63.5° to 50.5° (Table IIITable III). Grip strength was restored to about 50% of that on the unaffected side at six months postoperatively and to about 80% at one year postoperatively. However, grip strength did not improve further, even at more than five years after the operation (Fig. 2Fig. 2).

The radiocarpal flexion-extension arc remained the same as it had been before surgery or improved slightly for up to two years postoperatively. However, it then had a tendency to decrease slightly by three years after surgery. At more than five years postoperatively, the mean range of motion was almost the same as it had been before surgery or had decreased slightly (range, 50° to 115°; mean, 74.3°) (Fig. 3Fig. 3). In addition, when mean dorsiflexion and mean palmar flexion were assessed separately there was a tendency toward a slight decrease in the range of motion two to three years after surgery; dorsiflexion was affected more than palmar flexion was.

At the most recent examination, two of the fifteen patients had pain with activity but had no pain at rest. In these two patients, narrowing of the newly formed joint space was observed radiographically. Fourteen of the fifteen patients were able to return to their preoperative line of work. The mean period between the operation and their return to work was 6.7 months.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The chief symptoms of Kienböck disease are pain, decrease in grip strength, and reduction of range of motion, all of which depend on the stage of the disease and the activity level of the patient^22,23. Pain can also result from ischemia²⁴ or pathological fracture^25,26 of the lunate in the early stages of the disease. These symptoms can be treated conservatively^27-29 or with biomechanical decompression of the lunate^30-33. However, in the advanced stages of the disease, such treatments are ineffective because patients also have symptoms associated with joint incongruity and osteoarthritis. Roca et al.⁴ suggested that excision of the lunate was the most effective procedure for patients with osteoarthritic changes in the joints articulating with the lunate. In order to maintain carpal alignment and to prevent carpal instability after excision of the lunate, various procedures such as limited intercarpal arthrodesis^8,9,16, tendon bundle implantation⁵, insertion of artificial implants^34-36, and vascular bundle implantation¹² have been performed.

To maintain carpal alignment and to prevent carpal instability after excision of the lunate, we performed the modified Graner procedure, which involves pan-intercarpal arthrodesis and articulation of the proximal part of the capitate with the distal part of the radius. In the original Graner procedure, the palmar rotation of the scaphoid was not corrected. However, because we believe that it does considerably affect grip strength, we made a strong effort to correct the palmar rotation and we reduced the radioscaphoid angle to approximately 50°.

We noted reduced pain and improved grip strength following the modified Graner procedure. The long-term results of the procedure were favorable. Pain relief and recovery of grip strength were almost the same one year postoperatively as they were more than five years after surgery.

When we examined the effects of excision of the lunate and pan-intercarpal arthrodesis on the radiocarpal joint, we noted a reduction of the range of motion and the occurrence or aggravation of osteoarthritic changes three years after surgery. In 1986, Watson et al.⁹ reported a high prevalence of osteoarthritic changes after intercarpal arthrodesis. In our study, all fifteen patients had an occurrence or aggravation of osteoarthritic changes three to five years after surgery. However, these changes were on the dorsoradial side of the newly formed radiocapitate joint in most of the patients and did not seem to cause clinical symptoms. This finding suggests that the loss of intercarpal mobility is partially compensated for by the newly formed radiocapitate articulation in the early postoperative period.

This procedure creates the risk of osteonecrosis of the proximal pole of the capitate. When the capitate is osteotomized, the blood supply to the proximal part is completely disrupted unless some ligaments are left intact. Avascular necrosis of the proximal part of the capitate may cause or aggravate osteoarthritic changes as well. Therefore, internal fixation of the proximal part of the capitate to the other carpal bones is required to enhance the potential for revascularization while consolidation of the intercarpal arthrodesis occurs.

Most of our patients had no clinical symptoms except restriction of the range of motion at the wrist joint at the time of the long-term follow-up (Fig. 4-AFigs. 4-A, Fig. 4-B, Fig. 4-C, Fig. 4-D, Fig. 4-E, and Fig. 4-F). It is possible that the patients with radiographic osteoarthritic changes will have clinical symptoms in the future. If they do, we may need to consider arthrodesis of the wrist.

The results of the present study indicate that lunate excision followed by capitate osteotomy and intercarpal arthrodesis is a reasonable form of treatment, with favorable results for at least five years postoperatively, for patients with symptomatic Kienböck disease.

References

Introduction | Materials and Methods | Results | Discussion | References

Lichtman DM; Alexander AH; Mack GR; and Gunther SF: Kienböck's disease-update on silicone replacement arthroplasty. J Hand Surg [Am],1982.7: 343-7, 7343 1982 [PubMed]

Linscheid RL: Ulnar lengthening and shortening. Hand Clin,1987.3: 69-79, 369 1987 [PubMed]

Schattenkerk ME; Nollen A; and van Hussen F: The treatment of lunatomalacia. Radial shortening or ulnar lengthening. Acta Orthop Scand,1987.58: 652-4, 58652 1987 [PubMed]

Roca J; Beltran JE; Fairen MF; and Alvarez A: Treatment of Kienböck's disease using a silicone rubber implant. J Bone Joint Surg Am,1976.58: 373-6, 58373 1976 [PubMed]

Eaton RG: Excision and fascial interposition arthroplasty in the treatment of Kienböck's disease. Hand Clin,1993.9: 513-6, 9513 1993 [PubMed]

Graner O; Lopes EI; Carvalho BC; and Atlas S: Arthrodesis of the carpal bones in the treatment of Kienböck's disease, painful ununited fractures of the navicular and lunate bones with avascular necrosis, and old fracture-dislocations of carpal bones. J Bone Joint Surg Am,1966.48: 767-74, 48767 1966 [PubMed]

Nahigian SH, Li CS, Richey DG, Shaw DT.: The dorsal flap arthroplasty in the treatment of Kienböck's disease. J Bone Joint Surg Am,1970.52: 245-52, 52245 1970 [PubMed]

Watson HK; Ryu J; and DiBella A: An approach to Kienböck's disease: triscaphe arthrodesis. J Hand Surg [Am].,1985.10: 179-87, 10179 1985 [PubMed]

Watson HK; Ryu J; and Akelman E: Limited triscaphoid intercarpal arthrodesis for rotary subluxation of the scaphoid. J Bone Joint Surg Am,1986.68: 345-9, 68345 1986 [PubMed]

Hori Y; Tamai S; Okuda H; Sakamoto H; Takita T; and Masuhara K: Blood vessel transplantation to bone. J Hand Surg [Am].,1979.4: 23-33, 423 1979 [PubMed]

Bach AW, Almquist EE, Newman DM.: Proximal row fusion as a solution for radiocarpal arthritis. J Hand Surg [Am],1991.16: 424-31, 16424 1991 [PubMed]

Tamai S; Yajima H; and Ono H: Revascularization procedures in the treatment of Kienböck's disease. Hand Clin,1993.9: 455-66, 9455 1993 [PubMed]

Evans G; Burke FD; and Barton NJ: A comparison of conservative treatment and silicone replacement arthroplasty in Kienböck's disease. J Hand Surg [Br],1986.11: 98-102, 1198 1986 [PubMed]

Gelberman RH; Salamon PB; Jurist JM; and Posch JL: Ulnar variance in Kienböck's disease. J Bone Joint Surg Am,1975.57: 674-6, 57674 1975 [PubMed]

Hulten O: ï¿½ber anatomische Variationen der Handgelenkknochen. Ein Beitrag zur Kenntnis der Genese zwei verschiedener Mondbeinveranderungen. Acta Radiol,1928.9: 155-68, 9155 1928

Pisano SM; Peimer CA; Wheeler DR; and Sherwin F: Scaphocapitate intercarpal arthrodesis. J Hand Surg [Am],1991.16: 328-33, 16328 1991 [PubMed]

Palmer AK; Glisson RR; and Werner FW: Ulnar variance determination. J Hand Surg [Am],1982.7: 376-9, 7376 1982 [PubMed]

Stahelin A; Pfeiffer K; Sennwald G; and Segmüller G.: Determining carpal collapse. An improved method. J Bone Joint Surg Am,1989.71: 1400-5, 711400 1989 [PubMed]

Youm Y; McMurtry RY; Flatt AE; and Gillespie TE: Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexion-extension. J Bone Joint Surg Am.,1978.;60:: 423-31, ;60:423 1978 [PubMed]

McMurtry RY; Youm Y; Flatt AE; and Gillespie TE: Kinematics of the wrist. II. Clinical applications. J Bone Joint Surg Am,1978.60: 955-61, 60955 1978 [PubMed]

Linscheid RL; Dobyns JH; Beabout JW; and Bryan RS: Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am,1972.54: 1612-32, 541612 1972 [PubMed]

Alexander AH, and Lichtman DM: Kienböck's disease. Orthop Clin North Am,1986.17: 461-72, 17461 1986 [PubMed]

Armistead RB; Linscheid RL; Dobyns JH; and Beckenbaugh RD: Ulnar lengthening in the treatment of Kienböck's disease. J Bone Joint Surg Am,1982.;64:: 170-8, ;64:170 1982 [PubMed]

Jensen CH: Intraosseous pressure in Kienböck's disease. J Hand Surg [Am],1993.18: 355-9, 18355 1993 [PubMed]

Gelberman RH; Bauman TD; Menon J; and Akeson WH.: The vascularity of the lunate bone and Kienböck's disease. J Hand Surg [Am],1980.5: 272-8, 5272 1980 [PubMed]

Lee MLH: The intraosseous arterial pattern of the carpal lunate bone and its relation to avascular necrosis. Acta Orthop Scand,1963.33: 43-55, 3343 1963 [PubMed]

Beckenbaugh RD; Shives TC; Dobyns JH; and Linscheid RL: Kienböck's disease: the natural history of Kienböck's disease and consideration of lunate fractures. Clin Orthop,1980.149: 98-106, 14998 1980 [PubMed]

Kristensen SS; Thomassen E; and Christensen F: Kienböck's disease-late results by non-surgical treatment. A follow-up study. J Hand Surg [Br],1986.11: 422-5, 11422 1986 [PubMed]

Stï¿½hl F: On lunatomalacia (Kienböck's disease). A clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment. Acta Chir Scand,1947.Suppl: 126, Suppl126 1947

Kinnard P; Tricoire JL; and Basora J: Radial shortening for Kienböck's disease. Can J Surg,1983.26: 261-2, 26261 1983 [PubMed]

Nakamura R; Watanabe K; Tsunoda K; and Miura T: Radial osteotomy for Kienbock's disease evaluated by magnetic resonance imaging. 24 cases followed for 1-3 years. Acta Orthop Scand,1993.64: 207-11, 64207 1993 [PubMed]

Ovesen J: Shortening of the radius in the treatment of lunatomalacia. J Bone Joint Surg Br,1981.63: 231-2, 63231 1981 [PubMed]

Zelouf DS, and Ruby LK: External fixation and cancellous bone grafting for Kienböck's disease: a preliminary report. J Hand Surg [Am],1996.21: 746-53, 21746 1996 [PubMed]

Agerholm JC, and Goodfellow JW: Avascular necrosis of the lunate bone treated by excision and prosthetic replacement. J Bone Joint Surg Br,1963.45: 110-6, 45110 1963

Barber MH, and Goodfellow JW: Acrylic lunate prostheses. A long-term follow-up. J Bone Joint Surg Br,1974.56: 706-11, 56706 1974 [PubMed]

Swanson AB: Silicone rubber implants for the replacement of the carpal scaphoid and lunate bones. Orthop Clin North Am,1970.1: 299-309, 1299 1970 [PubMed]

Topics

View Large | Download Slide(.ppt)
Add to My JBJS

View Larger

TABLE I: Scoring System of Evans et al.13 for Evaluating Therapeutic Results*

*One point was given for each criterion that was met, for a total of 0 to 4 points. The result was rated as good (4 points), fair (3 points), poor (2 points), or very poor (1 or 0 points).

Criterion	Score (points)
Little or no discomfort in the wrist joint	1
Grip strength of more than 70% of that on the unaffected side	1
Flexion-extension arc of 60° or more	1
Return to original occupation	1

Add to My JBJS

TABLE I: Scoring System of Evans et al.13 for Evaluating Therapeutic Results*

*One point was given for each criterion that was met, for a total of 0 to 4 points. The result was rated as good (4 points), fair (3 points), poor (2 points), or very poor (1 or 0 points).

Criterion	Score (points)
Little or no discomfort in the wrist joint	1
Grip strength of more than 70% of that on the unaffected side	1
Flexion-extension arc of 60° or more	1
Return to original occupation	1

View Larger

TABLE II: Preoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.92	63	65/60	75
2	IIIB	0.94	52	65/60	90
3	IIIB	0.95	58	45/50	93
4	IV	0.93	58	60/55	73
5	IV	0.92	56	40/40	62
6	IV	0.92	64	30/50	44
7	IV	0.90	60	40/60	65
8	IV	0.89	68	40/50	80
9	IV	0.87	68	50/50	55
10	IV	0.86	69	30/30	52
11	IV	0.86	70	60/50	35
12	IV	0.85	79	40/45	67
13	IV	0.84	42	30/30	18
14	IV	0.82	74	35/40	42
15	IV	0.82	71	25/20	30

Add to My JBJS

TABLE II: Preoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.92	63	65/60	75
2	IIIB	0.94	52	65/60	90
3	IIIB	0.95	58	45/50	93
4	IV	0.93	58	60/55	73
5	IV	0.92	56	40/40	62
6	IV	0.92	64	30/50	44
7	IV	0.90	60	40/60	65
8	IV	0.89	68	40/50	80
9	IV	0.87	68	50/50	55
10	IV	0.86	69	30/30	52
11	IV	0.86	70	60/50	35
12	IV	0.85	79	40/45	67
13	IV	0.84	42	30/30	18
14	IV	0.82	74	35/40	42
15	IV	0.82	71	25/20	30

View Larger

TABLE III: Postoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.94	49	65/50	82
2	IIIB	0.97	52	50/60	85
3	IIIB	0.98	46	50/30	88
4	IV	0.94	49	50/40	91
5	IV	0.94	41	45/35	89
6	IV	0.98	54	30/30	80
7	IV	0.92	55	30/30	82
8	IV	0.94	51	30/35	80
9	IV	0.92	45	55/40	88
10	IV	0.95	55	30/20	90
11	IV	0.95	65	30/65	77
12	IV	0.86	52	35/25	108
13	IV	0.89	42	40/20	75
14	IV	0.92	54	40/40	78
15	IV	0.92	48	25/25	63

Add to My JBJS

TABLE III: Postoperative Findings

*The grip strength is given as the percentage of the strength on the unaffected side.

Case	Lichtman Stage¹	Carpal Height Index	Radioscaphoid Angle (deg)	Palmar Flexion/Dorsiflexion (deg)	Grip Strength* (%)
1	IIIB	0.94	49	65/50	82
2	IIIB	0.97	52	50/60	85
3	IIIB	0.98	46	50/30	88
4	IV	0.94	49	50/40	91
5	IV	0.94	41	45/35	89
6	IV	0.98	54	30/30	80
7	IV	0.92	55	30/30	82
8	IV	0.94	51	30/35	80
9	IV	0.92	45	55/40	88
10	IV	0.95	55	30/20	90
11	IV	0.95	65	30/65	77
12	IV	0.86	52	35/25	108
13	IV	0.89	42	40/20	75
14	IV	0.92	54	40/40	78
15	IV	0.92	48	25/25	63