Kienbock's disease: diagnosis and treatment

Kienbock's disease, or osteonecrosis of the lunate, can lead to chronic, debilitating wrist pain. Etiologic factors include vascular and skeletal variations combined with trauma or repetitive loading. In stage I Kienbock's disease, plain radiographs appear normal, and bone scintigraphy or magnetic resonance imaging is required for diagnosis. Initial treatment is nonoperative. In stage II, sclerosis of the lunate, compression fracture, and/or early collapse of the radial border of the lunate may appear. In stage IIIA, there is more severe lunate collapse. Because the remainder of the carpus is still uninvolved, treatment in stages II and IIIA involves attempts at revascularization of the lunate-either directly (with vascularized bone grafting) or indirectly (by unloading the lunate). Radial shortening in wrists with negative ulnar variance and capitate shortening or radial-wedge osteotomy in wrists with neutral or positive ulnar variance can be performed alone or with vascularized bone grafting. In stage IIIB, palmar rotation of the scaphoid and proximal migration of the capitate occur, and treatment addresses the carpal collapse. Surgical options include scaphotrapeziotrapezoid or scaphocapitate arthrodesis to correct scaphoid hyperflexion. In stage IV, degenerative changes are present at the midcarpal joint, the radiocarpal joint, or both. Treatment options include proximal-row carpectomy and wrist arthrodesis.     

Radial shortening for Kienb?ck's disease: factors affecting the operative result

The operative results of radial shortening in 23 patients with Kienb?ck's disease were analysed on the basis of age, stage of disease, ulnar variance and the amount of radial shortening. The patient's age was found to be the factor which affected the operative result most and unsatisfactory results were obtained in patients over 30 years old. However, neither the clinical stage nor ulnar variance affected the results significantly and the results in patients with ulnar zero or plus were no worse than in patients with ulnar minus. The risk of ulnar wrist pain was increased when the radius was shortened more than 4 mm in patients with positive or zero ulnar variance. This was an important cause of unsatisfactory operative results.     

Pressures in the distal radioulnar joint: effect of surgical procedures used for Kienbock's disease

Radial shortening and ulnar lengthening are two accepted surgical methods for treating Kienbock's disease. The effect of these procedures on the pressure within the distal radioulnar joint between the ulnar head and the sigmoid notch of the radius was experimentally evaluated in six fresh cadaver forearms. Radical shortening and ulnar lengthening led to increased pressure at the distal radioulnar articulation and caused shifting of the location of the center of pressure distally within the sigmoid notch. Radial displacement of the distal radial fragment at the time of radial shortening, however, decreased the peak pressures. Based on these experimental data, ulnar lengthening and radial shortening can be expected to alter the normal biomechanics of the distal radioulnar joint.     

Ulnar variance in Kienb?ck's disease.

The distal extent of the radius and ulna (ulnar variance) was compared on roentgenograms of normal wrists in randomly selected black and white patients and of fifteen affected wrists in patients with Kienbock's disease. The results establish a statistically significant association between negative ulnar variance and Kienbock's disease. Blacks have more positive ulnar variance and the disease is less likely to develop in them than in whites.     

Bilateral Kienbock's disease

We conducted a retrospective review of 11 patients with bilateral Kienbock's disease from our series of 251 patients with Kienbock's disease. There were no significant differences in radiographic parameters, including ulnar variance and carpal bone angle, between those with unilateral and those with bilateral Kienbock's disease. None of the patients with bilateral disease had been treated with corticosteroids or had a systemic disease that predisposed to osteonecrosis. Thus, this study failed to demonstrate any risk factor for bilateral, as opposed to unilateral Kienbock's disease.     

Radial shortening for Kienb?ck disease

The cases of twenty-nine consecutive patients (thirty wrists) who had radial shortening for the treatment of stages I through IIIB Kienb?ck disease were reviewed to assess the results of this procedure. Thirteen patients (45 per cent) had a history of trauma, and all thirty wrists had a negative ulnar variance (average, 2.8 millimeters) on radiographs. All wrists were re-examined after an average follow-up of 3.8 years (minimum, two years). At that time, the pain had decreased in 87 per cent of the wrists. Extension of the wrist had improved an average of 32 per cent; flexion, 27 per cent; radial deviation, 30 per cent; ulnar deviation, 41 per cent; and grip strength on the affected side, 49 per cent. Analysis of the radiographs by computer digitization showed no significant changes in the amount of collapse of the lunate at the latest follow-up. In two wrists, there were complications at follow-up (excessive shortening of the radius and non-union of the radial osteotomy). Radial shortening is an effective treatment for Kienb?ck disease in wrists that do not have degenerative changes in adjacent carpal joints. Pain, range of motion, and strength can be expected to improve, but the radiographic appearance of the lunate changes little, if any.     

Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome

BACKGROUND: Idiopathic ulnar impaction syndrome can be defined as a degenerative condition of the ulnar aspect of the wrist in patients with congenital or dynamic positive ulnar variance without a history of fracture or premature physeal arrest. The purpose of this study was to evaluate the clinical features of idiopathic ulnar impaction syndrome and the outcomes of ulnar shortening osteotomy for this group of patients. METHODS: Thirty-one wrists in twenty-nine patients with idiopathic ulnar impaction syndrome were treated with an ulnar shortening osteotomy. Ulnar variance was measured on an anteroposterior radiograph of the wrist, and radioulnar distance was measured on a lateral radiograph, with the forearm in neutral rotation, to evaluate any displacement of the ulnar head from the distal aspect of the radius. All patients were followed clinically and radiographically for a mean of thirty-two months. RESULTS: An average preoperative ulnar variance of +4.6 mm (range, 2 to 7.5 mm) was reduced to an average of -0.7 mm (range, -4 to +1 mm) postoperatively. Preoperatively, the modified Gartland and Werley score was an average (and standard deviation) of 69.5 +/- 7.6, with twenty-four wrists rated poor and seven rated fair. Postoperatively, the score improved to an average of 92.5 +/- 8.0, with twenty-four wrists rated excellent; five, good; one, fair; and one, poor. Dorsal subluxation of the distal aspect of the ulna was found concomitantly in nine wrists, and it was found to be reduced by the shortening osteotomy. Seven patients had cystic changes in the carpal bones preoperatively, but these were not evident one to two years after the operation. CONCLUSIONS: Ulnar shortening osteotomy improved wrist function in patients with idiopathic ulnar impaction syndrome and reduced the subluxation of the distal radioulnar joint, which is commonly found in these patients. Degenerative cystic changes of the ulnar carpal bones appear to resolve following the shortening osteotomy.     

Is negative ulnar variance a risk factor for Kienb?ck's disease? A meta-analysis.

Current treatment for Kienbock's disease using joint-leveling procedures is based on the hypothesis that the disease is caused by negative ulnar variance. The authors conducted a meta-analysis to evaluate this hypothesis, and assessed the quality of available published studies. They searched MEDLINE to collect literature that evaluated this association. Only 3 of 18 collected studies had sufficient data or study design to meet their inclusion criteria. A summary odds ratio (OR) calculated using a conservative random-effect method showed that the odds of Kienb?ck's disease was 3.10 times more likely for those with negative ulnar variance than those with positive or neutral ulnar variance, but this was not significant (95% confidence interval, 0.95-10.05; p = 0.06). The combined OR was unstable because of marked heterogeneity across the studies. This meta-analysis reveals that there is insufficient data to support a significant (p < 0.05) association between negative ulnar variance and Kienbock's disease.     

Results of ulnar shortening osteotomy for ulnocarpal impaction syndrome in wrists with neutral or negative ulnar variance

Ulnocarpal impaction syndrome was diagnosed in six wrists of five patients with neutral or negative ulnar variance. All underwent ulnar shortening with satisfactory results. The average grip strength increased from 53% to 78% and the range of flexion-extension increased from 82% to 93%, the mean Cooney's score improved from 25 to 83. These cases show that ulnocarpal impaction syndrome can occur in wrists with zero or negative ulnar variance, and that ulnar shortening is an effective treatment for such wrists.     

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

Introduction

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.

Materials and methods

For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.

Results

Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.

Conclusions

Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.     

Kienböck Disease in a 66-Year-Old Man after Distal Ulna Fracture

Kienböck disease after fracture-dislocations around the wrist is a rare occurrence. This case report presents a case of a 66-year-old man who developed Kienböck disease 18 months after his distal ulnar fracture. The patient developed negative ulnar variance after union of the distal ulnar fracture. Nonsurgical treatment was not effective in relieving his pain. Radial shortening osteotomy was performed based on the negative ulnar variance that developed. One year postoperatively, visual analog scale improved to 0, grip strength improved to 25 kg, and flexion-extension arc improved to 150 degrees. The patient achieved satisfactory clinical outcomes. This is a therapeutic level IV study.     

Clinical and experimental study of shortening osteotomy of forearm bone(s) in Kienb?ck's disease

Sixty-nine patients with Kienb?ck's disease were surgically treated from 1972 to 1987. Eleven patients with ulnar minus variance, 48 with neutral variance and 10 with ulnar plus variance were treated with shortening osteotomy of the radius. Ten patients with ulnar plus variance were treated with shortening osteotomy of both the radius and ulna. All cases were followed up from one to eleven years. Satisfactory improvement was attained in 85% of cases. Radiologic evaluation showed revascularization of the lunate in 94%. Collapse of the lunate did not progress in 60%. In 14 wrists of adult Japanese monkeys, ulnar minus and plus variants were created, and radial-ulna compression force was measured with intraarticular pressure sensors. Intraarticular forces were then measured following shortening osteotomy of the forearm bone(s). These procedures uniformly decreased pressure in the radial-ulna joint.     

Ulnar shortening for tears of the triangular fibrocartilaginous complex

Ten consecutive patients had their ulnas shortened for treatment of ulnar wrist pain associated with triangular fibrocartilaginous complex tears. Each injury was traced to a previous fall or an overuse syndrome. Conservative treatment failed. In all patients, x-ray films showed ulnar positive or neutral variance. The ulna was shortened an average of 2 mm. Frank ulnolunate abutment and/or cartilage degeneration was found in six cases. Follow-up averaged 23 months, and except for one patient in whom radiocarpal arthritis developed, the remaining patients were satisfied and returned to their work or previous level of activity. Relief of pain, grip strength, and range of motion were excellent, except for an average decrease in flexion of 25.8 degrees (p = 0.01). Hardware irritation was noted in six patients. These findings substantiate the use of ulnar shortening to relieve ulnolunate impingement in patients with ulnar positive or neutral wrists in whom ulnar wrist pain develops and who demonstrate triangular fibrocartilaginous complex tears after acute trauma and/or overuse syndromes.     

L’ostéotomie du capitatum dans la maladie de Kienböck. Résultats cliniques et radiologiques à cinq ans de recul moyen. À propos de 12 cas

Kienböck's disease could occur pain and reduce wrist's range of motion despite of an early radiologic staging. Usual surgical procedures unload the lunate. Radial shortening is the common procedure in negative ulnar variance. For wrists with neutral or positive ulnar variance, this procedure could produce a distal radio-ulnar discrepancy and an ulnocarpal impingement. We perform, in these cases, a capitate shortening. The goal of this study is to relate the wrist functional outcome and the radiological result in 12 cases. It was a consecutive retrospective study of 12 patients (nine male, three female). Eight Lichtman's stage II and four stage III A with neutral or positive ulnar variance. The wrists were painful and with a reduce range of motion. The surgical procedure consisted in a dorsal approach and a 2-mm shortening osteotomy in the capitate's waist. Bone clips were used for fixation. The follow-up average period was 65.8 months. All patients had pain relief. The wrist's range of motion improved in all cases. Any single complication was noted. The patients recovered their professional or usual occupation with an average of 3.6 months. Lunate's vascularization improved in all cases. Any intracarpal complication or capitate non-union occured. The capitate shortening is a simple and low aggressive procedure. Wrist's functional outcome has good results. We recommend this procedure for symptomatic patients in early Kienböck's disease with neutral or positive ulnar variance.     

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.     

Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome

A retrospective review was performed that compared the results of 2 different surgical treatments for ulnar impaction syndrome in 22 patients over a 6-year period. Ulnar shortening osteotomy and wafer distal ulna resection (wafer resection procedure) were each performed in 11 patients based on the preference of 3 individual hand surgeons. All patients presented with ulnar wrist pain and positive ulnar variance on either neutral rotation or pronated-grip x-rays and each failed conservative management. At a minimum follow-up time of 18 months, 9 patients had good to excellent results following ulnar shortening osteotomy compared with 8 following the wafer resection procedure. This difference was not statistically significant. All patients regained functional wrist motion and 21 of the 22 patients had satisfactory pain relief. There was 1 poor result in the wafer group that required revision to complete resection of the distal ulna. Five secondary procedures were required in the osteotomy group to remove painful hardware and union was delayed in 2 patients. Although ulnar shortening osteotomy provides effective treatment for ulnar impaction syndrome, the wafer resection procedure provides favorable pain relief and restoration of function but without the potential for nonunion or hardware removal. (J Hand Surg 2000; 25A:55-60.     

Technique of ulnar shortening

Ulnar shortening or recession is a common treatment for an expanding number of clinical indications. This procedure has become more reliably performed because of specialized equipment that permits the creation of 2 precise 45-degree osteotomy surfaces and a known amount of ulnar shortening. Further refinements in technique have facilitated compression of the osteotomy surfaces and application of an interfragmentary lag screw at a specified angle. More recently, advancements in technology have increased the surgical options available to the surgeon and have provided for a low-profile surgical plate that may be placed on either the ulnar subcutaneous border or the volar-ulnar surface. In addition, osteotomy widths ranging from 3.5 to 18.1 mm may be performed with the available equipment. The complication rate of ulnar shortening is very low, and the overall clinical success rate is encouragingly quite high.     

Ulnar shortening or arthroscopic wafer resection for ulnar impaction syndrome

The outcome of ulnar shortenings was compared to the outcome after arthroscopic wafer resections for ulnar impaction (or abutment) syndrome in patients with a positive ulnar variance. Both surgical techniques are described. The outcome was measured by the DASH score, the visual analogue score for pain and the working incapacity. The mean DASH score in the ulnar shortening group was 26, in the wafer group it was 36. The VAS were respectively 4.4 and 4.6. The working incapacity was 7 months in the ulnar shortening group and 6.1 months in the wafer group. The differences between the two groups were not statistically significant.     

The effect of radial shortening on wrist joint mechanics in cadaver specimens with inherent differences in ulnar variance

PURPOSE: To assess load changes in the wrist and forearm resulting from surgically-induced radial shortening in wrists with inherent differences in ulnar variance. METHODS: Eleven fresh cadaver upper extremities, 4 with ulnar-plus variance of 2 mm or greater and 7 with ulnar-minus variance of 2 mm or greater were used. The radius and ulna of each specimen were instrumented with load cells, a 15-mm segment of the radius was resected and replaced with aluminum blocks of various sizes, and the specimens were loaded with 143 N (32 lb) at 1-mm differences of radial length. The load distribution between the radius and ulna was measured. RESULTS: The load distribution in the specimens with an ulnar-plus variance averaged 69% through the radius and 31% through the ulna. In the wrists with ulnar-minus variance, the load distribution averaged 94% through the radius and 6% through the ulna. The mean force in the ulna increased and the mean force in the radius decreased with incremental shortening of the distal end of the radius. The mean force through the ulna in the ulnar-plus-variance group was always higher than that of the ulnar-minus-variance group. When compared not by the number of millimeters of radial shortening but by the adjusted ulnar variance, there was no difference between the ulnar-plus-variance and the ulnar-minus-variance groups. CONCLUSIONS: Wrists with ulnar-minus variance could accommodate radial shortening without as much increase in the ulna load as wrists with ulnar-plus variance. The clinical relevance is that a patient with an ulnar-minus variance may accommodate more radial shortening after a wrist fracture without developing an ulnar impaction syndrome than a patient with an ulnar-plus-variant wrist.     

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.