Genç AS; Desteli EE; YunusImren

Research Article

Austin J Orthopade & Rheumatol. 2016; 3(2): 1032.

Clinical and Radiological Results of Radial Shortening Osteotomy versus Proximal Row Carpectomy in Kienböck’s Disease

Genç AS, Desteli EE and YunusImren*

¹Department of Orthopedics and Traumatology, Samsun Gazi State Hospital, Turkey

²Department of Orthopedics and Traumatology, Usküdar State Hospital, Turkey

³YunusImren, MD, Department of Orthopaedics and Traumatology, Okmeydani Research and Training Hospital, Istanbul, Turkey

*Corresponding author: YunusImren, Okmeydani Training & Research Hospital, Istanbul, Turkey

Received: May 21, 2016; Accepted: July 19, 2016; Published: July 22, 2016

Abstract

In this prospective study, we aimed to evaluate the clinical and radiological results of our patients treated with Radial Shortening Osteotomy (RSO) and Proximal Row Carpectomy (PRC) together with a short review of the literature. The study included 35 patients with the diagnosis of Kienbock disease RSO was performed for 17 patients and 18 patients underwent PRC. 15 of the patients had Lichtman Stage 2, 14 patients had Stage 3A and 6 patients had Stage 3B disease. Q-DASH Score, Preoperative and postoperative Carpal Height Ratio (CHR), revised CHR, stahl index, radial inclination values were noted. Preoperative and postoperative flexion-extension range of Motion (ROM) and ulnar deviation angles were also obtained. Nakamura’s clinical evaluation system was performed to each patient. Results of clinical evaluation revealed significant progression at postoperative sixth month follow-up. Our results showed clinical improvement following surgeries of both RSO and PRC for Lichtman Stage 2, 3a and 3b disease. We consider that experience and technical familiarity of the surgeon is key factor to decide the type of the procedure to be performed.

Keywords: Kienböck’s disease; Proximal row carpectomy; Radial shortening; Lichtman’ classification

Introduction

Etiology of Kienbock disease remains unclear, this is mainly due to the rarity of the disease and lack of enough number of prospective studies. The treatment for Kienböck’s disease ranges from conservative modalities such as immobilisation to operative options such as radial shortening [1-4] ulnar lengthening [5] proximal row carpectomy [6] / silastic arthroplasty [7,8] intercarpal fusions [9] and revascularisation procedures [10,11].

Negative ulnar variance has been accepted as a predisposing factor to Kienbock disease, Hulten [12] in his study stated that in the case of negative ulnar variance, axial load on radial side of lunatum is increased which is a predisposing factor for lunatomalacia. Radial Shortening Osteotomy (RSO) is indicated in the case of negative ulnar variance as a joint leveling procedure [13-22]. Besides early stages of the disease, RSO has been found to be beneficial also in advanced stages [2,22]. Radial osteotomy has been found to increase vascularity of lunate and also made decompression [23-25]. Fragmantation and degenerative changes that occur particularly at proximal articular surface of lunate may ultimately lead collapse of the bone and the entire corpus. If carpal instability occurs in advanced disease, Proximal Row Carpectomy (PRC) can be considered [26]. PRC is a procedure used for the treatment of wrist arthritis, and has been reported to relieve pain and preserve wrist range of motion and grip strength [27-29]. Long-term outcomes of the most PRC and RSO procedures applied for treatment of Kienbock’s disease are satisfactory (Tables 1 & 2).

Table 1: Long term follow-up results treated by proximal row carpectomy.




  
    Author 
    Surgical method 
    Number of patients 
    Follow-up time 
    Comments 
  
  
    Liu et al. [58] 
    PRC
    10
    10-29 years
    Satisfactory    results,reserved their previous work
  
  
    Lumsden et al. [44] 
    PRC
    17
    15 years
    Good clinical    results
  
  
    Culp RW et al. [29] 
    PRC
    20
    3.5 years
    Patients with mild    preoperative arthritic changes had better results
  
  
    Croog AS et al. [42] 
    PRC
    21
    10 years
    Reliable procedure    for Lichtman Stage 3a and 3b
  
  
    De Smet L et al. [43] 
    PRC
    21
    67 months
    Satisfactory    clinical results
  
  
    Ali MH et al. [51] 
    PRC
    61
    19.8 years
    Unsatisfactory    results.Manyof the patients were unable to return to manual labor type    jobs.
  
  
    Lecamte F et al. [57] 
    PRC
    25
    30 months
    Recommend for    Lichtman Stage 3 disease



Table 1: Long term follow-up results treated by proximal row carpectomy.

Table 2: Long term follow-up results treated by radial shortening osteotomy.




  
    Author 
    Surgical method 
    Number of patients 
    Follow-up time 
    Comments 
  
  
    Matsui et al. [17] 
    Radial shortening
    11
    10 yrs
    Satisfactory    clinical results
  
  
    Salmon et al. [18] 
    Radial shortening
    15
    26 yrs
    Recommend RSO for    patients with carpal collapse accompanying severe pain
  
  
    Raven et al. [16] 
    Radial shortening
    12
    22 yrs
    Recommend RSO for Lichtman Stage 3a or less disease with    a (-) ulnar variance
  
  
    Altay et al. [53] 
    Radial shortening
    23
    7 yrs
    Reliable long-term    treatment for Lichtman Stage 3b disease
  
  
    Rodrigues- Pinto
    Radial shortening
    18
    10.3 yrs
    Effective for    Lichtman Stage 2,3a,3b disease.
  
  
    Axelsson et al. [19] 
    Ulnar lengthening
    22
    22 yrs
    All patients    returned to work
  
  
    Trail et al. [5] 
    Ulnar    lengthening and Radial shortening
    20
    11 yrs
    Satisfactory    clinical results
  
  
    Wada et al. [20] 
    Radial wedge    osteotomy
    13
    14 yrs
    Good clinical    results
  
  
    Koh et al. [14] 
    Radial wedge    osteotomy and Radial shortening
    25
    14.5 yrs
    Good clinical    results
  
  
    Zenzai et al. [15] 
    Radial shortening    with or without ulnar lengthening
    35
    19 yrs
    Satisfactory    results,reliable method
  
  
    Viljakka et al. [13] 
    Radial shortening
    16
    32 yrs
    Provides    decade-long improvement in 75% of patients
  
  
    Watanabe et al. [21] 
    Radial shortening
    13
    21 yrs
    Satisfactory    clinical results



Table 2: Long term follow-up results treated by radial shortening osteotomy.

In this prospective study we aimed to evaluate the clinical and radiological results of patients treated with RSO and PRC.

Materials & Methods

Approval was obtained from the local scientific department of our hospital and consent to study participation from all subjects for this prospective study. The study included 15 patients with the diagnosis of Kienbock disease who underwent operation between 2009 to 2012. RSO was performed for 17 patients (Group I), (Figures 1 & 2) and 18 patients underwent PRC (Group II) (Figures 3 & 4). Mean followup time was 18.4 months for Group I patients and 19.0 months for Group II patients. Mean age of Group I patients was 35 years and Group II patients was 41 years. 16 of the patients were male and 19 of them were female. 15 of 35 patients had dominant side disease and were operated from their dominant wrists. 14 of the 35 patients had a history of trauma (40%). According to Lichtman’s classification, [30] at the time of diagnosis, 15 of the patients had Stage 2, 14 patients had Stage 3A and 6 patients had Stage 3B disease. (Table 3) Palmer’s technique [31] was used to assess ulnar variance, according to this technique; 21 patients (60%) had a negative ulnar variance and 14 patients (40%) had a neutral ulnar variance.

Table 3: Distribution of the patients according to Lichtman’s classification.




  
    Stage 
    Radial Shortening 
    Proximal Row Carpectomy 
    Overall 
  
  
    1 
    
    
    
  
  
    2 
    15 
    
    15 
  
  
    3a 
    2 
    12 
    14 
  
  
    3b 
    
    6 
    6 
  
  
    4 
    
    
    
  
  
    Overall 
    17 
    18 
    35



Table 3: Distribution of the patients according to Lichtman’s classification.

Surgical method for radial shortening

Surgery was performed through a volar approach; an incision was centered over the radial border of the FCR tendon. The tendon sheath was released and the FCR was retracted radially to protect the radial artery. The flexor pollicis longest end on was retracted to the ulnar side to protect the median nerve. The pronator quadratus was released from the radial border of the radius and retracted ulnarly. A forearm-shortening osteotomy plate was placed on the volar aspect of the radius (Figure 1). A locking screw was placed in the most distal screw hole, and a 3.5-mm nonlocking screw was placed in the reduction slot. The osteotomy was performed over the oblique lag screw hole. This area was marked on the radius with the plate in place. The plate was then removed. A transverse or oblique osteotomy to the distal radius was performed. The plate was then replaced and fixed to the radius. The most distal 3.5-mm locking screw was placed first. The radius was shortened, and the 3.5- mm nonlocking screw in the reduction slot was tightened. The remaining 3.5-mm locking screws were placed. Patients were casted until osteotomy site healed, at approximately 6 weeks.

Figure 1: Preoperative AP view before RSO.

    
    
    Figure 1: Preoperative AP view before RSO.

Figure 2: Postoperative AP view after RSO (same patient).

    
    
    Figure 2: Postoperative AP view after RSO (same patient).

Figure 3: Preoperative AP view before PRC.

    
    
    Figure 3: Preoperative AP view before PRC.

Figure 4: Postoperative AP view after PRC (same patient).

    
    
    Figure 4: Postoperative AP view after PRC (same patient).

Surgical method for proximal row carpectomy

A dorsal longitudinal incision was performed. Extensor retinaculum was divided over the fourth compartment. Extensor Digitorum Communis was retracted to the ulnar side. Extensor pollucis longus and wrist extensors were retracted to the radial side. Posterior interosseous nevre was resected, wrist capsule was opened longitudinally and lunate fossa and the articular surface of the capitate were exposed. Capsular incision was extended transversely to the either side to facilitate exposure of the scaphoid. Scaphoid was osteotomized in its mid-portion. After osteotomy of the scaphoid, its proximal pole was removed. Lunate was grasped with a towel clip and was excised. Triquetrum was removed in a similar fashion. Finally the distal pole of the scaphoid was removed. Passive flexion/extension of the hand was made in neutral and slight radial deviation to detect any impingement of the trapezium and the radial styloid. The wound was irrigated and capsule was closed and a suction drain was placed. At two weeks, the sutures were removed, and motion was started by a flexible splint.

Six months after the operation, patients were re-evaluated and modified Nakamura clinical scoring system [32] (Table 4) was used for clinical evaluation [3,4,33-38]. In Nakamura’s evaluation system, radiological evaluation makes 9 points in total. Because insufficient radiological evaluation would affect the final result, we excluded 9 points and thus total points were calculated [3]. Preoperative and postoperative angular examination was made using a goniometer. Range of motion (ROM) of wrist was noted while patient was in a sitting position and hands were put on the table. Preoperative and postoperative grip strength was examined by jamar hand dynamometer [39], dominant side was 5% decreased to equalize dominant and non-dominant sides. Grip strength was measured while shoulder was in adduction and neutral rotation, elbow at 90 degrees flexion, forearm and hand in neutral position. Test was repeated 3 times and means value was noted. Pinchmeter was used to evaluate pinch strength of 1st and 2nd fingers. Patients were in a sitting position and elbow in 90 degrees flexion. For upper extremity functional evaluation Q-DASH score [40] was used. Preoperative and postoperative Carpal Height Ratio (CHR), revised CHR, stahl index, radial inclination values were noted. Preoperative and postoperative flexion-extension Range of Motion (ROM) and ulnar deviation angles were also obtained.

Table 4: Content of modified Nakamura clinical scoring system.




  
    Clinical Assessment 
    Points 
  
  
    Pain in the wrist 
    
  
  
    None 
    10 
  
  
    Mild with strenuos activity 
    7 
  
  
    Mild with light work 
    4 
  
  
    Grip strength (percentage of unaffected side) 
    
  
  
    90% 
    5 
  
  
    80% 
    4 
  
  
    70% 
    3 
  
  
    60% 
    2 
  
  
    50% 
    1 
  
  
    Increase in range of flexion and extension 
    
  
  
    >20° 
    6 
  
  
    10°- 19° 
    5 
  
  
    5°- 9° 
    3 
  
  
    Overall grade 
    Total Points 
  
  
    Excellent 
    15-21 
  
  
    Good 
    14-Sep 
  
  
    Fair 
    8-Mar 
  
  
    Poor 
    0-2



Table 4: Content of modified Nakamura clinical scoring system.

SPSS for Windows programme 17.0 version was used for statistical analysis. Categoric comparisons were made using pearson chi square, fisher x2 and Yates x2 tests. Paired samples t-test and Wilcoxon test were used for preoperative and postoperative comparison.

Results

Results of clinical evaluation revealed significant progression at postoperative sixth month follow-up. Mean preoperative Jamarmeter value was 20.05±9.30 and postoperatively it was 29.80±14.50 for Group 1 and 17.70±4.40 and postoperatively it was 27.80±14.0 for Group 2, mean preoperative pinchmeter value was 7.05±1.70 and postoperatively it was 8.22±1.50 for Group 1 and for Group 2 preoperatively it was 4.95±1.15 and postoperative mean value was 6.30±0.90 (Table 5) Preoperative and postoperative mean flexion arc, extension arc and ulnardeviation values were found to be signicantly increased following both radial shortening osteotomy and proximal row carpectomy (p<005) (Table 6). Mean time of union for the osteotomy sites was 6.5 weeks in Group 1 patients. According to the results of radiological evaluation, carpal height ratio, revised carpal height ratio, stahl index and radial inclination did not change significantly following radial shortening osteotomy (Group 1) and Stahl index and Radial inclination values did not significantly change following proximal row carpectomy (Group 2) (p>0.05). However mean carpal height ratio and revised carpal height ratio values were found significantly different following proximal row carpectomy (p<0.05) (Table 7). Postoperative mean Q-DASH scores in Group1 and 2 patients were found to be 15.9 (4-29) and 28.4 (9-50) respectively preoperatively it was 56.3 (13-86) for Group 1 and 56.3 (25-72) for Group 2 (25-72).

Clinical Assessment	Points
Pain in the wrist
None	10
Mild with strenuos activity	7
Mild with light work	4
Grip strength (percentage of unaffected side)
90%	5
80%	4
70%	3
60%	2
50%	1
Increase in range of flexion and extension
>20°	6
10°- 19°	5
5°- 9°	3
Overall grade	Total Points
Excellent	15-21
Good	14-Sep
Fair	8-Mar
Poor	0-2

		Pre-treatment (mean±SD)	Post-treatment (mean±SD)	P- Value
Radial Shortening	Range of flexion	48.90±10.40	65.70±6.80	p<0.05
	Range of extension	43.70±15.75	59.60±6.80	p<0.05
	Ulnar deviation	35.30±9.40	41.70±5.70	p<0.05
Proximal Row Carpectomy	Range of flexion	31.20±11.80	34.80±6.40	p<0.05
	Range of extension	29.90±11.20	31.80±9.80	p<0.05
	Ulnar deviation	29.90±11.20	31.80±9.80	p<0.05

		Pre-treatment mean±SD	Post-treatment mean±SD	P- Value
Radial Shortening	CHR	0.50±0.05	0.48±0.05	0,674
	RCHR	1.38± 0.10	1.36± 0.12	0,88
	SI	0.45 ±0.10	0.43 ±0.08	0,58
	RI	22.20± 3.90	22.00 ±0.40	0,59
Proximal row carpectomy	CHR	0.48± 0.03	0.26 ±0.05	0,018
	RCHR	1.30± 0.05	1.02 ±0.05	0,018
	SI	0.30 ±0.04	0.28± 0.02	0,169
	RI	22.40 ±3.00	21.80± 0.05	0,791