Journal of Hand Surgery (European Volume) http://jhs.sagepub.com/
Long-term outcome (20 to 33 years) of radial shortening osteotomy for Kienböck's lunatomalacia T. Viljakka, K. Tallroth and M. Vastamäki J Hand Surg Eur Vol published online 3 December 2013 DOI: 10.1177/1753193413512222 The online version of this article can be found at: http://jhs.sagepub.com/content/early/2013/11/29/1753193413512222
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512222
2013
JHS0010.1177/1753193413512222The Journal of Hand SurgeryViljakka et al.
JHS(E)
Full length article
Long-term outcome (20 to 33 years) of radial shortening osteotomy for Kienböck’s lunatomalacia
The Journal of Hand Surgery (European Volume) 0E(0) 1–9 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413512222 jhs.sagepub.com
T. Viljakka, K. Tallroth and M. Vastamäki Abstract Radial shortening osteotomy (RSO) as treatment for Kienböck’s disease usually improves patient symptoms for several years. Four small series have also shown that the effect may last for decades, but only two studies have used a patient-based assessment. We examined 16 patients, with a mean age at operation of 32 years, evaluating clinical and radiological results at a mean 25 (range 20 to 33) years after surgery. Three patients had progressive lunate collapse, of whom one patient needed a silicone implant arthroplasty 2 years after RSO and one patient a wrist fusion 16 years after RSO. The time between onset of symptoms and osteotomy in the remaining 14 patients averaged 20 months. The mean VAS for pain was 0.9 at rest, 0.9 with unloaded motion, 1.7 with slight, and 3.0 with heavy exertion. Two patients had marked wrist pain. Compared with the contralateral wrist the mean range of motion was 88%, grip strength was 95%, and key pinch 107%. The Disabilities of the Arm, Shoulder, and Hand score averaged 6.1, and the Mayo wrist score, 79.3. The Lichtman stage remained unchanged in 56% of patients. The inner structure of the lunate improved in all patients, and its shape remained unchanged in half of the cases. Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck’s disease. Keywords Kienböck’s disease, lunatomalacia, radial shortening osteotomy, outcome Date received: 3rd May 2013; revised 31st July 2013; accepted 5th August 2013
Introduction The treatment of Kienböck’s disease is still controversial, but radial shortening osteotomy (RSO) for patients with negative ulnar variance is widely accepted (Amillo et al., 1993; Calfee, 2010; Das Gupta et al., 2003; Marti et al., 1981; Nakamura et al., 1990; 1995; Razemon, 1984; Takahara et al., 2009; Wada et al., 2002; Weiss, 1993). Four studies have shown that the effect may last for two decades (Koh et al., 2003; Raven et al., 2007; Watanabe et al., 2008; Zenzai et al., 2005), but only two studies have used patientbased assessment (Raven et al., 2007; Watanabe et al., 2008). The aim of this study was to investigate very longterm outcomes after RSO.
final follow-up examination at a mean of 25 (range 20 to 33) years after their operation. Senior hand surgeons performed 12 (MV 6, TV 1) and senior residents four RSOs. Peroperative shortening averaged 5.7 (range 3–10) mm.
Technique A transverse osteotomy was performed via a dorsal approach. Fixation was dorsal plating for 13 and K-wires for three cases. The wrist was immobilized in a dorsal cast post-operatively for a mean of 6 (range 4–10) weeks. Following routine practice at that time, ORTON Research Institute and ORTON Orthopaedic Hospital, Helsinki, Finland
Methods We identified 16 patients (13 men) with Kienböck’s disease treated with radial shortening osteotomy between 1978 and 1988. All of them agreed to participate in the
Corresponding author: M. Vastamäki, ORTON Research Institute and ORTON Orthopaedic Hospital, Tammistontie 30, Kuusisto 21620, Finland. Email: [email protected]
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15/0/1 (mean –3.0 mm) 20 (6–54) 26 (39) 19 (28) 44 (68)
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RSO = radial shortening osteotomy
51 (63) 32.4 (16–45) 1/13/1/1 13 (81) 16
Pre-operatively, Disabilities of the Arm, Shoulder and Hand (DASH), Mayo wrist score, or VAS pain were not available, and data were incomplete in three patients. At follow-up, we determined pain using a visual analogue scale (VAS, range 0–10) at rest, with unloaded
16
Subjective measurements
Wrists, Mean n age, years (range)
Ranges of motion (ROM) and grip and key pinch strength were measured in the operated and contralateral wrists by one author (TV). The following were radiologically measured in both wrists: ulnar variance, radioscaphoid and scapholunate angles, metacarpal height ratio (metacarpal index), translation ratio, Ståhl index (relation of height to breath of the lunate bone as a percentage), and lunate-covering ratio (calculated by dividing the amount of the lunate supported by the radius by complete radioulnar width of the lunate). The metacarpal height ratio was calculated by dividing the height of the carpus by the length of the middle finger metacarpal (normal: 0.54 ± 0.03). The ulnar translation ratio was calculated by dividing the carpal-ulnar distance by the length of the middle finger metacarpal (normal: 0.30 ± 0.02). We also calculated an osteoarthritis index (arthrosis index) from 3 to 15, categorizing radioscaphoid, scaphotrapezoid, and scaphocapitate arthritic changes from 1 to 5 (1 = normal joint, 2 = joint line narrowed, 3 = joint line narrowed + sclerosis, 4 = joint line narrowed + sclerosis + osteophytes, 5 = joint deformed) (Viljakka et al., 2013). The inner structure of the lunate (cysts, uniformity, and density) was also assessed. The shape of the lunate was also estimated on the scale: same, worse = more deformed, or better than on the initial radiographs. Radiological outcome at 7 years was also estimated.
Table 1. Demographics of patients at the time of radial shortening osteotomy.
Objective measurements
Male, n (%)
Pre- and post-operative data came from patients’ medical records (Table 1). All 16 patients underwent physical and radiological examination pre-operatively, post-operatively, and at the final follow-up a minimum of 20 years post-operatively. Clinical outcome had previously been investigated at 7 years in most cases.
Patients, n
Assessments
Lichtman stage Range of motion at first consultation, Ulnar variance-/even/ not known 2/3A/3B/not mean, ° (contralateral wrist) known Extension Flexion Radial Ulnar deviation deviation
Duration of Follow-up, symptoms at RSO, mean years mean months (range) (range)
the plates were routinely removed in all patients after 1 to 2 years. One patient underwent silicone implant arthroplasty 2 years after RSO, and one patient had wrist fusion 16 years after RSO. They were excluded from the follow-up study.
24.9 (20–33)
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11* 27 41 0.007 14 29 37 0.037 11* 19 29 0.002 14 28 27 0.797 11* 44 68 0.000 14 45 59 0.009 12* 51 66 0.007 14 56 60 0.204
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VAS scale = from 0 (no pain) to 10 (maximum imaginable pain); DASH = Disabilities of the Arm, Shoulder and Hand; DASH Optional = work or hobby related. *In 2 to 3 patients, clinical pre-operative data were incomplete. **Three patients were not ready to provide responses to the DASH questionnaire.
11** 11** 6.1 10.8 (0–23.3) (0–37.3) 14 9.2 8.6 0.270
11* 24 42 0.003 14 14 14 14 14 no pain 12 no pain 10 no pain 7 no pain 4 37 VAS 0.9 VAS 0.9 VAS 1.7 VAS 3.0 39 0.228 Pren operatively Mean Contralateral p At 25 years n Mean Contralateral p
Grip At rest
In motion Extension, Flexion, Radial Ulnar VAS pain ° ° deviation, deviation, ° °
Mean ROM improved in 14 patients (excluding the patients with a silicone implant and wrist fusion) over 25 years with the following mean improvements: extension 10%; flexion 2%; radial deviation 47%; and ulnar deviation 7%. Mean ROM of the unaffected wrist deteriorated during that time: extension 9%; flexion 13%; radial deviation 7%; and ulnar deviation 10%. Pre-operative extension of the operated wrist averaged 51°, flexion 44°, radial deviation 19°, and ulnar deviation 27°, improving at final follow-up to 56°, 45°, 28°, and 29° (Table 2). Extension of the operated wrist reached 93%, flexion 76%, radial
Time period
Objective results
Table 2. Outcome mean 25 years after radial shortening osteotomy for Kienböck’s disease.
Age at surgery averaged 32 (range 16–45) years (Table 1). Seven patients (44%) recalled some history of prior wrist trauma. Time from onset of symptoms to surgery ranged from 6 to 54 (mean, 20; median 23) months. At the time of the operation, 11 patients were engaged in heavy manual labour and five were doing light work. All patients had the disease in the dominant hand; five of them were lefthanded. The Lichtman stages (Lichtman et al., 1993) were II in one wrist, stage IIIA in 13 wrists, and stage IIIB in one wrist. In one patient, pre-operative radiographs were missing, but 1 year after RSO the stage was IIIB. Ulnar variance ranged from –1 to –5 mm with a mean of –3.0 mm. Mean ulnar variance in the opposite wrist was –1.9 mm.
Slight Heavy exertion exertion
We determined differences between the wrists for ROM, strength, and radiological findings using Pearson’s correlation test. Frequencies, proportions, means, ranges, and standard deviations (SD) were used as descriptive statistics. We performed all statistical analyses with SPSS® (Version 20.0, SPSS Inc., Chicago, Illinois). We obtained permission to perform this study from the ethics committee of the hospital district where the study was conducted.
6 8.4 12.2
DASH Strength Key mean, kg pinch
Statistical analysis
Results
14 79.3 (60–95)
DASH Optional
Mayo wrist score
movement, in slight exertion and in heavy exertion to gain a better understanding of pain. We also measured the DASH and Mayo wrist scores. Questionnaires (Appendix 1) were posted to the patients, along with an invitation to participate in the study. Patients completed the questionnaires at home and returned them at the follow-up visit. Their answers were checked during the follow-up visit. Three patients did not fill out the DASH questionnaire.
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Figure 1. (A) A 30-year-old man, wrist pain for 3 years without injury, RSO June 1986, pre-operative X-ray. Lichtman stage III A, ulnar variance –3 mm. (B) X-ray 22 years after RSO. Lichtman stage the same IIIA, no arthrosis. Ulna +2 variance. The lunate is deformed, but inner structure is rather normal. Grip strength 101% and ROM 85%, no pain. Mayo score 90.
deviation 104%, and ulnar deviation 78% of the unaffected side. Grip strength improved at final follow-up by 54% in the operated hand, but deteriorated by 7% in the other hand. Key pinch improved by 10% in the operated hand and decreased by 30% in the opposite hand. Grip strength still was reduced by 5%, but key pinch was 7% better compared with the contralateral side. Lichtman stage remained the same in one wrist, stage II; seven, stage IIIA; and one, stage IIIB. Two stage IIIA wrists deteriorated to stage IIIB, and two to stage IV. One stage IV wrist at final follow-up was missing pre-operative radiographs, but 1 year after RSO the wrist was stage IIIB. Lichtman stage deterioration was not due to progression of lunate collapse, but rather increase in arthritic changes. The shape of the lunate bone at the last follow-up was the same or better, but not normal, in seven wrists and somewhat more deformed in seven. Lunate inner structure was better (less cystic, more uniform and dense) in every patient. No significant differences in radiological indices between the pre-operative and final follow-up were detectable in the operated wrists, except that ulnar translation index was worse (0.29 vs. 0.37, p = 0.048). Significant differences between the operated and contralateral “normal” wrists at
final follow-up were detectable only in the Ståhl index (40 vs. 50, p = 0.001) and lunate covering index (0.66 vs. 0.58, p = 0.014). Carpal height ratio remained the same at 0.50 on both sides. Arthritic changes were minimal: our arthrosis index (3–15) was 4.4 in the affected wrist and 3.1 in the contralateral wrist. The radioulnar joint was normal in nine patients, had mild arthrosis (2/5) in two patients, and had moderate or severe arthrosis (index 4–5/5) in three patients. Mean ulnar variance was–3.0 pre-operatively (range –1 to –5) mm and 1.5 (range 0–5) mm at final follow-up. Clinical and radiological outcomes at 7 years were almost the same as at 25 years.
Subjective results VAS score in 14 patients (the silicone implant patient and wrist fusion patient excluded) averaged 0.9 at rest, 0.9 with unloaded movement, 1.7 with slight exertion, and 3.0 with heavy exertion (overall mean 1.6). Twelve patients were painless at rest, 10 painless with unloaded motion, seven in light use, and four patients had pain only with heavy use. Three wrists were completely painless in all activities (Table 2, Figures 1 and 2). Mean DASH score was 6.1; optional DASH, 10.8; and Mayo wrist score, 79.3 (Table 2).
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Viljakka et al.
Figure 2. (A) A 27-year-old man, 7 months after wrist injury RSO December 1983, pre-operative X-ray. Lichtman stage IIIA, ulnar variance –3 mm. (B) X-ray 23 years after RSO. Lichtman stage the same IIIA, arthrosis index 5, ulnar variance +5 mm. The lunate is deformed, inner structure rather normal. VAS in heavy strain 2, DASH 11.6, Mayo score 70.
Seven patients continued their previous work, two had changed to lighter work, and five were retired, one due symptoms in their wrist and four because of age. Seven patients rated the result as excellent, four as good, and three as moderate. All except one would choose the same treatment again.
Complications Six of 16 patients suffered complications (38%). In four patients, the end result was poor and they were estimated as failures (25%). Of these four patients, one underwent silicone implant arthroplasty 2 years after osteotomy and one had wrist fusion 16 years after RSO. The patient with a silastic implant had a moderate clinical result. He was able to continue his work. After 25 years, his wrist was painful with heavier loading (VAS 5). The radiocarpal and radioulnar joints were arthritic (indexes 9/15 and 4/5). DASH score was 10 and Mayo wrist score was 80. The patient
with a wrist fusion was retired. The wrist was painless (VAS 0). DASH score was 0 and Mayo wrist score was 40. The radioulnar joint was arthritic (5/5). These two patients were excluded from the follow-up study. The other four of these complicated patients were included at follow-up data. Two of them had significant pain and were estimated as failures. One of them was 16 years old at the time of surgery and Lichtman stage was IIIB. She required further surgery due to ulnar impingement (ulnar variance +2 mm) 25 years after RSO with ulnar shortening without clinical benefit. After 26 years follow-up her wrist was painful; VAS maximum 8 and DASH score 23.3. The lunate was severely deformed, as it was before RSO, but the lunate inner structure was improved. No arthrosis was noted around the lunate or wrist, but the wrist had the same VISI deformity as pre-operatively. In three patients, complications were not related to the lunate bone, itself. Two patients had re-fracture of the radius after plate removal. One of them was
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1 –
7
3
3
25 (20–33) – – 5 1 5 11 2 1 – 6.1 (0–23.3) 79 (60–95) – 31 (16–45) 100
76–93 79 14
95
Improved 8 (0–23) in 92 38 (23–60) 75
81–82 83 12
88
93 31 (15–58) 64
31 (20–44) 44
78–87 71 14
86
VAS 2.4
14 (0–68)
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79–103 56 9
90
96 33 (11–55) 80
82 72 25
Koh et al. Raven et al. Zenzai et al. Watanabe et al. Current study
85
VAS 1.6
4 1 2 2 5 3 6 96
1 1 – – 78 – – 83 (63–100) –
11 10 4 2 5 6 3
6 9 1 3 4 4 3
– 1 – – – 1 –
IIIA II I
Patients, n Males, % Mean Dominant Extensionage, years hand, % flexion, (range) % of unaffected side Study
The treatment of Kienböck’s disease is still controversial (Allan et al., 2001; Beredjiklian, 2009; Dias and Lunn, 2010; Salmon et al., 2000; Schuind et al., 2008; Viljakka et al., 2013). Radial shortening osteotomy for patients with negative ulnar variance significantly unloads the lunate (Horii et al., 1990; Makabe et al., 2011) and has proven an appropriate treatment solution for Kienböck’s disease. Clinical and radiological early and mid-term results of RSO are well-documented (Amillo et al., 1993; Buck-Gramcko et al., 1990; Calfee et al., 2010; Das Gupta et al., 2003; Marti et al., 1981; Nakamura et al., 1995; Weiss, 1993), but only four studies report the long-term outcome after RSO (Koh et al., 2003; Raven et al., 2007; Watanabe et al., 2008; Zenzai et al., 2005) (Table 3). Subjective pain in Kienböck’s disease typically improves regardless of treatment type (Innes and Strauch, 2010). In four long-term follow-up studies, pain diminished markedly in 48% to 66% of patients (Table 3) over 14, 19, 21, and 22 years (Koh et al., 2003; Raven et al. 2007; Watanabe et al. 2008; Zenzai et al. 2005) (Table 3). In our study, three of 14 patients were totally painless, 12 had no pain at rest, seven had pain during light strain, and four had pain only with heavy use. These numbers are somewhat lower compared with the other studies. Two failures in our series had pain at rest (VAS 5 and 8). VAS values at rest were
Table 3. Literature on radial shortening osteotomy for Kienböck’s disease.
Discussion
Grip Pain, strength, none or % of mild, % unaffected side
DASH
Mayo wrist Lichtman stage, score At surgery, St follow-up
IIIB
IV
Follow-up, years (range)
treated with free cancellous bone graft and Rush pin fixation. The wrist was painful at follow-up: VAS 5 at rest, 5 with unloaded movement, and 7 in slight and 7 in heavy exertion, and a Mayo wrist score of 80. The radiocarpal and radioulnar joints were arthritic (indexes 6/15 and 2/5), and supination was restricted. Two complications were significant but not failures when considering the end result. One patient had nonunion of the radius, which was treated with free cancellous bone graft and cast immobilization. After 27 years his wrist was painful with heavy loading, VAS 4. He was able to continue his work and had a DASH score of 10. Radiocarpal osteoarthrosis index was 5/15. The other patient had over-shortening of the radius and 5 mm positive ulnar variance post-operatively. An ulnar shortening osteotomy corrected the supination restriction. After 20 years he was working as a truck driver and had only mild pain with heavy loading, with a VAS maximum 2. He had no radiocarpal arthrosis but mild radioulnar arthrosis (index 2/5). His DASH score was 0 and Mayo wrist score, 75. Thus, altogether four patients were considered failures, and in these patients there was marked progression of the lunate deformity or further surgery.
14.5 (10–21) 22 (16–31) 19 (13–25) 21 (14–28)
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Viljakka et al. mean 0.9 and with heavy use mean 3.0 (range 0–8), including complicated cases. Statistically significant improvements are seen in ROM after osteotomy in patients with early stage disease (Lichtman stages 1–3A), and most interventions, except partial arthrodesis and nonsurgical treatment, for late-stage disease (Innes and Strauch, 2010). Improvement in ROM was noted in all long-term studies (Table 3). In this study after 25 years, extension averaged 93% and flexion 76% of the unaffected side. Extension, flexion, radial deviation, and ulnar deviation improved, but all of these appeared to have deteriorated in the unaffected wrist. Grip strength is reported to improve significantly in early stage patients treated with osteotomy and all late-stage patients, except those managed nonsurgically (Innes and Strauch, 2010). The improvements in grip strength range from 74% to 86% of the unaffected side at 19 years (Zenzai et al., 2005), 53% to 88% at 21 years (Watanabe et al., 2008), and a mean of 90% after 22 years (Raven et al., 2007) (Table 3). In the present study, grip strength was 95% of the unaffected side and improved 54% from 235 N to 363 N in 25 years, whilst the strength of the contralateral hand deteriorated by 7%. Previous studies using patient-based assessment and function reported a mean DASH score of 9 after 21 years (Watanabe et al., 2008) and 14 after 22 years (Koh et al., 2003) (Table 3). In this study, including complicated cases the DASH score was little better, with a mean of 6.1. In the other studies, no failures were reported and follow-up rates varied between 40 to 75%. In our series, we noted six complications requiring re-operations. One patient had implant arthroplasty and one wrist fusion. These failures were excluded. Two other failures and two with significant complications were included to the follow-up study. Mean DASH score in complicated cases was 11 (0– 23.3). Mayo wrist score averaged 83 at 21 years (Watanabe et al. 2008), 78 at 19 years (Zenzai et al. 2005), and 79 at 25 years in our study (Table 3). Radiologically, the inner structure of the lunate improved in 58% of patients after 14 years, indicating healing of the ischemic lunate (Koh et al., 2003). In the other studies there are no such reports. Lichtman classification remained stable, deteriorating in only three of nine patients (Raven et al., 2007) and three of 14 patients (Zenzai et al, 2005). However, Watanabe (2008) found deterioration in half of their patients over 21 years. Conversely, our study showed improved lunate inner structure in every patient. However, Lichtman stage remained the same in only nine of 16 (56%) patients over 25 years. We noted arthritic changes in the radiocarpal area in 71% and in the
radioulnar joint in 36%. Koh et al. (2003) reported osteoarthrosis in 64% in the radiocarpal joint and 24% in the distal radioulnar joint, altogether in 73% of patients. The arthritic changes were mild, and in our study, the mean index was 4.4/15 (range 3–8). Changes in radiological indexes were few. No significant differences were noted in carpal height ratio or scapholunate and radioscaphoid angles, but significant changes were noted in the ulnar translation index, Ståhl index, and lunate covering index, meaning that the lunate suffered some deformation after RSO. There are limitations to this study. We used no validated scores for pain or wrist function at the time of surgery because they did not exist. Second, this retrospective follow-up study lacks any control group. Third, our material comprises so few patients that significance is not always reached in our statistical analysis. In conclusion, our results of radial shortening osteotomy are in accordance with other long-term studies. Osteotomy provides improvement in about 75% of patients lasting decades and is a good method of treatment for Kienböck’s disease in patients with negative ulnar variance. We believe that the outcome is preferable to the unpredictable long-term natural course of Kienböck’s disease (Salmon et al., 2000). Acknowledgements We thank Leena Ristolainen, PT, PhD, for statistical help and Carol Norris, PhD, for language revision.
Conflict of interests None declared.
Ethical Approval and Informed Consent Each author certifies that his or her institution approved the human protocol for their investigation, that all investigations were concluded in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
Funding During the study period, the authors’ institution received funding from Erityis Valtion Osuus, Helsinki University Hospital, Helsinki, Finland.
References Allan CH, Joshi A, Lichtman DM. Kienböck’s disease: diagnosis and treatment. J Am Acad Orthop Surg. 2001, 9: 128–36. Amillo S, Martinez-Peric R, Barrioss RH. Radial shortening for the treatment of Kienböck’s disease. Int Orthop. 1993, 17: 23–6.
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Beredjiklian PK. Kienböck’s disease. J Hand Surg. 2009, 34: 167–75. Buck-Gramcko D, Lankers J. Results in Kienböck’s disease (in German). Study on 91 patients. Handchir Plast Chir. 1990, 22: 28–38. Calfee R, Van Steyn M, Guyricza C, Adams A, Weiland A, Gelberman R. Joint leveling for advanced Kienböck’s disease. J Hand Surg Am. 2010, 35: 1947–54. Das Gupta K, Tunnerhoff H, Haussmann P. [STT-arthrodesis versus radial shortening osteotomy for Kienböck’s disease]. Handchir Mikrochir Plast Chir. 2003, 35: 328–32. Dias JJ, Lunn P. Ten questions on Kienböck’s disease of the lunate. J Hand Surg Eur. 2010, 35: 538–43. Horii E, Garcia-Elias M, An KN et al. Effect on force transmission across the carpus in procedures used to treat Kienböck’s disease. J Hand Surg Am. 1990, 15: 393–400. Innes L, Strauch R. Systematic review of the treatment of Kienböck’s disease in its early and late stages. J Hand Surg Am. 2010, 35: 713–7.e4. Koh S, Nakamura R, Horii E, Nakao E, Inagaki H, Yajima H. Surgical outcome of radial osteotomy for Kienböck’s disease—minimum 10 years of follow-up. J Hand Surg Am. 2003, 28: 910–26. Lichtman D, Degman G. Staging and its use in the determination of treatment modalities for Kienböck’s disease. Hand Clinics. 1993, 9: 409–16. Makabe H, Iwasaki N, Kamishima T, Oizumi N, Tadano S, Minami A. Computed tomography osteoabsorptiometry alterations in stress distribution patterns through the wrist after radial shortening osteotomy for Kienböck’s disease. J Hand Surg Am. 2011, 36: 1158–64. Marti R, Veldstra R, Vegter J. [Shortening osteotomy of the radius in the treatment of Kienböck’s disease.] Orthopäde. 1981, 10: 54–8. Nakamura R, Imaeda T, Miura T. Radial shortening for Kienböck’s disease: Factors affecting the operative result. J Hand Surg Br. 1990, 15: 40–5.
Nakamura R, Horii E, Imaeda T, Watanabe K, Tsunoda K. Current concepts of radial osteotomy for Kienböck’s disease. In: Vastamäki et al. (Eds.) Current Trends in Hand Surgery. Paris, Elsevier Science BW, 1995: 109–12. Razemon J-P. [Treatment of Kienböck’s disease by shortening of the radius.] Chirurgie. 1984, 110: 600–7. Raven EEJ, Haverkamp D, Marti RK. Outcome of Kienböck’s disease 22 years after distal radius shortening osteotomy. Clin Orthop. 2007, 460: 137–41. Salmon J, Stanley JK, Trail IA. Kienböck’s disease: conservative management versus radial shortening. J Bone Joint Surg Br. 2000, 82: 820–3. Schuind F, Eslami S, Ledoux P. Kienböck’s disease. J Bone Joint Surg Br. 2008, 90: 133–9. Takahara M, Watanabe T, Tsuchida H, Yamahara S, Kikuchi N, Ogino T. Long-term follow-up of radial shortening osteotomy for Kienböck’s disease. Surgical technique. J Bone Joint Surg Am. 2009, 91 Suppl 2: 184–90. Viljakka T, Tallroth K, Vastamäki M. Long-term outcome (22–36 years) of silicone lunate arthroplasty for Kienbock’s disease. J Hand Surg Eur. 2013. (Epub ahead of print 21 May 2013). Wada A, Miura H, Kubota H, Iwamoto Y, Uchida Y, Kojima T. Radial closing wedge osteotomy for Kienböck’s disease: an over 10 year clinical and radiographic follow-up. J Hand Surg Br. 2002, 27: 175–9. Watanabe T, Takahara M, Tsuchida H, Yamahara S, Kikuchi N, Ogino T. Long-term follow-up of radial shortening osteotomy for Kienböck’s disease. J Bone Joint Surg Am. 2008, 90: 1705–11. Weiss A-P. Radial shortening. Hand Clinics 1993, 9: 475–82. Zenzai K, Shibata M, Endo N. Long-term outcome of radial shortening with or without ulnar shortening for treatment of Kienböck’s disease: a 13–25 year follow-up. J Hand Surg Br. 2005, 30: 226–8.
Appendix 1 Lunatomalacia Questionnaire
Name tag
Date _________________ The questions below regards your right/left wrists, that was operated at Hospital ORTON in the year 19__ Encircle the right alternative. In the end of the questionnaire is room for free comments. Uncertain questions can be gone through at the examination. Background 1) Sex:
Female
[0]
Male
[1]
2) Dominant hand:
Left
[0]
Right
[1]
No
[0]
3) Wrist trauma before symptoms Yes [1]
Which trauma ____________________
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Viljakka et al. 4) Are you employed at the moment? Yes
[1]
No
[0]
5) Heaviness of the work 1. Light sedentary 2. Light labour 3. Moderate labour 4. Heavy 6) What is / was your profession?_____________________________________________________________ 7) Did you change your profession due to wrist disorder ? Yes [1] No [0] 8) Are you retired at the moment? Yes [1] No [0] 9) Did you retire because of your wrist distress? Yes [1] No [0]
If you answered Yes, please specify year: _________
10) Have you pain in your wrist at rest? Yes [1] No [0] 11) Have you pain in your wrist in motion or exertion? Yes [1] No [0] 12) Have you night pain in your wrist? Yes [1] No [0] 13) Have you restricted motion in your wrist? Yes [1] No [0] 14) How much pain do you have today in your wrist, on a scale 0–10? 0 = no pain, 10 = the worst pain imaginable: During exertion 0 |______________________________________________________________________| 10 At rest 0 |______________________________________________________________________| 10 At night 0 |______________________________________________________________________| 10 15) Would you again choose an operation for your wrist under the same circumstances? Yes [1] No [0] 16) Regarding the operation result, are you:
Excellent [1]
Good [2]
Fair
[3]
Poor
[4]
Comments ________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________
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Long-term outcome (20 to 33 years) of radial shortening osteotomy for Kienböck's lunatomalacia T. Viljakka, K. Tallroth and M. Vastamäki J Hand Surg Eur Vol published online 3 December 2013 DOI: 10.1177/1753193413512222 The online version of this article can be found at: http://jhs.sagepub.com/content/early/2013/11/29/1753193413512222
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On behalf of: British Society for Surgery of the Hand
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512222
2013
JHS0010.1177/1753193413512222The Journal of Hand SurgeryViljakka et al.
JHS(E)
Full length article
Long-term outcome (20 to 33 years) of radial shortening osteotomy for Kienböck’s lunatomalacia
The Journal of Hand Surgery (European Volume) 0E(0) 1–9 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413512222 jhs.sagepub.com
T. Viljakka, K. Tallroth and M. Vastamäki Abstract Radial shortening osteotomy (RSO) as treatment for Kienböck’s disease usually improves patient symptoms for several years. Four small series have also shown that the effect may last for decades, but only two studies have used a patient-based assessment. We examined 16 patients, with a mean age at operation of 32 years, evaluating clinical and radiological results at a mean 25 (range 20 to 33) years after surgery. Three patients had progressive lunate collapse, of whom one patient needed a silicone implant arthroplasty 2 years after RSO and one patient a wrist fusion 16 years after RSO. The time between onset of symptoms and osteotomy in the remaining 14 patients averaged 20 months. The mean VAS for pain was 0.9 at rest, 0.9 with unloaded motion, 1.7 with slight, and 3.0 with heavy exertion. Two patients had marked wrist pain. Compared with the contralateral wrist the mean range of motion was 88%, grip strength was 95%, and key pinch 107%. The Disabilities of the Arm, Shoulder, and Hand score averaged 6.1, and the Mayo wrist score, 79.3. The Lichtman stage remained unchanged in 56% of patients. The inner structure of the lunate improved in all patients, and its shape remained unchanged in half of the cases. Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck’s disease. Keywords Kienböck’s disease, lunatomalacia, radial shortening osteotomy, outcome Date received: 3rd May 2013; revised 31st July 2013; accepted 5th August 2013
Introduction The treatment of Kienböck’s disease is still controversial, but radial shortening osteotomy (RSO) for patients with negative ulnar variance is widely accepted (Amillo et al., 1993; Calfee, 2010; Das Gupta et al., 2003; Marti et al., 1981; Nakamura et al., 1990; 1995; Razemon, 1984; Takahara et al., 2009; Wada et al., 2002; Weiss, 1993). Four studies have shown that the effect may last for two decades (Koh et al., 2003; Raven et al., 2007; Watanabe et al., 2008; Zenzai et al., 2005), but only two studies have used patientbased assessment (Raven et al., 2007; Watanabe et al., 2008). The aim of this study was to investigate very longterm outcomes after RSO.
final follow-up examination at a mean of 25 (range 20 to 33) years after their operation. Senior hand surgeons performed 12 (MV 6, TV 1) and senior residents four RSOs. Peroperative shortening averaged 5.7 (range 3–10) mm.
Technique A transverse osteotomy was performed via a dorsal approach. Fixation was dorsal plating for 13 and K-wires for three cases. The wrist was immobilized in a dorsal cast post-operatively for a mean of 6 (range 4–10) weeks. Following routine practice at that time, ORTON Research Institute and ORTON Orthopaedic Hospital, Helsinki, Finland
Methods We identified 16 patients (13 men) with Kienböck’s disease treated with radial shortening osteotomy between 1978 and 1988. All of them agreed to participate in the
Corresponding author: M. Vastamäki, ORTON Research Institute and ORTON Orthopaedic Hospital, Tammistontie 30, Kuusisto 21620, Finland. Email: [email protected]
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15/0/1 (mean –3.0 mm) 20 (6–54) 26 (39) 19 (28) 44 (68)
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RSO = radial shortening osteotomy
51 (63) 32.4 (16–45) 1/13/1/1 13 (81) 16
Pre-operatively, Disabilities of the Arm, Shoulder and Hand (DASH), Mayo wrist score, or VAS pain were not available, and data were incomplete in three patients. At follow-up, we determined pain using a visual analogue scale (VAS, range 0–10) at rest, with unloaded
16
Subjective measurements
Wrists, Mean n age, years (range)
Ranges of motion (ROM) and grip and key pinch strength were measured in the operated and contralateral wrists by one author (TV). The following were radiologically measured in both wrists: ulnar variance, radioscaphoid and scapholunate angles, metacarpal height ratio (metacarpal index), translation ratio, Ståhl index (relation of height to breath of the lunate bone as a percentage), and lunate-covering ratio (calculated by dividing the amount of the lunate supported by the radius by complete radioulnar width of the lunate). The metacarpal height ratio was calculated by dividing the height of the carpus by the length of the middle finger metacarpal (normal: 0.54 ± 0.03). The ulnar translation ratio was calculated by dividing the carpal-ulnar distance by the length of the middle finger metacarpal (normal: 0.30 ± 0.02). We also calculated an osteoarthritis index (arthrosis index) from 3 to 15, categorizing radioscaphoid, scaphotrapezoid, and scaphocapitate arthritic changes from 1 to 5 (1 = normal joint, 2 = joint line narrowed, 3 = joint line narrowed + sclerosis, 4 = joint line narrowed + sclerosis + osteophytes, 5 = joint deformed) (Viljakka et al., 2013). The inner structure of the lunate (cysts, uniformity, and density) was also assessed. The shape of the lunate was also estimated on the scale: same, worse = more deformed, or better than on the initial radiographs. Radiological outcome at 7 years was also estimated.
Table 1. Demographics of patients at the time of radial shortening osteotomy.
Objective measurements
Male, n (%)
Pre- and post-operative data came from patients’ medical records (Table 1). All 16 patients underwent physical and radiological examination pre-operatively, post-operatively, and at the final follow-up a minimum of 20 years post-operatively. Clinical outcome had previously been investigated at 7 years in most cases.
Patients, n
Assessments
Lichtman stage Range of motion at first consultation, Ulnar variance-/even/ not known 2/3A/3B/not mean, ° (contralateral wrist) known Extension Flexion Radial Ulnar deviation deviation
Duration of Follow-up, symptoms at RSO, mean years mean months (range) (range)
the plates were routinely removed in all patients after 1 to 2 years. One patient underwent silicone implant arthroplasty 2 years after RSO, and one patient had wrist fusion 16 years after RSO. They were excluded from the follow-up study.
24.9 (20–33)
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11* 27 41 0.007 14 29 37 0.037 11* 19 29 0.002 14 28 27 0.797 11* 44 68 0.000 14 45 59 0.009 12* 51 66 0.007 14 56 60 0.204
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VAS scale = from 0 (no pain) to 10 (maximum imaginable pain); DASH = Disabilities of the Arm, Shoulder and Hand; DASH Optional = work or hobby related. *In 2 to 3 patients, clinical pre-operative data were incomplete. **Three patients were not ready to provide responses to the DASH questionnaire.
11** 11** 6.1 10.8 (0–23.3) (0–37.3) 14 9.2 8.6 0.270
11* 24 42 0.003 14 14 14 14 14 no pain 12 no pain 10 no pain 7 no pain 4 37 VAS 0.9 VAS 0.9 VAS 1.7 VAS 3.0 39 0.228 Pren operatively Mean Contralateral p At 25 years n Mean Contralateral p
Grip At rest
In motion Extension, Flexion, Radial Ulnar VAS pain ° ° deviation, deviation, ° °
Mean ROM improved in 14 patients (excluding the patients with a silicone implant and wrist fusion) over 25 years with the following mean improvements: extension 10%; flexion 2%; radial deviation 47%; and ulnar deviation 7%. Mean ROM of the unaffected wrist deteriorated during that time: extension 9%; flexion 13%; radial deviation 7%; and ulnar deviation 10%. Pre-operative extension of the operated wrist averaged 51°, flexion 44°, radial deviation 19°, and ulnar deviation 27°, improving at final follow-up to 56°, 45°, 28°, and 29° (Table 2). Extension of the operated wrist reached 93%, flexion 76%, radial
Time period
Objective results
Table 2. Outcome mean 25 years after radial shortening osteotomy for Kienböck’s disease.
Age at surgery averaged 32 (range 16–45) years (Table 1). Seven patients (44%) recalled some history of prior wrist trauma. Time from onset of symptoms to surgery ranged from 6 to 54 (mean, 20; median 23) months. At the time of the operation, 11 patients were engaged in heavy manual labour and five were doing light work. All patients had the disease in the dominant hand; five of them were lefthanded. The Lichtman stages (Lichtman et al., 1993) were II in one wrist, stage IIIA in 13 wrists, and stage IIIB in one wrist. In one patient, pre-operative radiographs were missing, but 1 year after RSO the stage was IIIB. Ulnar variance ranged from –1 to –5 mm with a mean of –3.0 mm. Mean ulnar variance in the opposite wrist was –1.9 mm.
Slight Heavy exertion exertion
We determined differences between the wrists for ROM, strength, and radiological findings using Pearson’s correlation test. Frequencies, proportions, means, ranges, and standard deviations (SD) were used as descriptive statistics. We performed all statistical analyses with SPSS® (Version 20.0, SPSS Inc., Chicago, Illinois). We obtained permission to perform this study from the ethics committee of the hospital district where the study was conducted.
6 8.4 12.2
DASH Strength Key mean, kg pinch
Statistical analysis
Results
14 79.3 (60–95)
DASH Optional
Mayo wrist score
movement, in slight exertion and in heavy exertion to gain a better understanding of pain. We also measured the DASH and Mayo wrist scores. Questionnaires (Appendix 1) were posted to the patients, along with an invitation to participate in the study. Patients completed the questionnaires at home and returned them at the follow-up visit. Their answers were checked during the follow-up visit. Three patients did not fill out the DASH questionnaire.
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Figure 1. (A) A 30-year-old man, wrist pain for 3 years without injury, RSO June 1986, pre-operative X-ray. Lichtman stage III A, ulnar variance –3 mm. (B) X-ray 22 years after RSO. Lichtman stage the same IIIA, no arthrosis. Ulna +2 variance. The lunate is deformed, but inner structure is rather normal. Grip strength 101% and ROM 85%, no pain. Mayo score 90.
deviation 104%, and ulnar deviation 78% of the unaffected side. Grip strength improved at final follow-up by 54% in the operated hand, but deteriorated by 7% in the other hand. Key pinch improved by 10% in the operated hand and decreased by 30% in the opposite hand. Grip strength still was reduced by 5%, but key pinch was 7% better compared with the contralateral side. Lichtman stage remained the same in one wrist, stage II; seven, stage IIIA; and one, stage IIIB. Two stage IIIA wrists deteriorated to stage IIIB, and two to stage IV. One stage IV wrist at final follow-up was missing pre-operative radiographs, but 1 year after RSO the wrist was stage IIIB. Lichtman stage deterioration was not due to progression of lunate collapse, but rather increase in arthritic changes. The shape of the lunate bone at the last follow-up was the same or better, but not normal, in seven wrists and somewhat more deformed in seven. Lunate inner structure was better (less cystic, more uniform and dense) in every patient. No significant differences in radiological indices between the pre-operative and final follow-up were detectable in the operated wrists, except that ulnar translation index was worse (0.29 vs. 0.37, p = 0.048). Significant differences between the operated and contralateral “normal” wrists at
final follow-up were detectable only in the Ståhl index (40 vs. 50, p = 0.001) and lunate covering index (0.66 vs. 0.58, p = 0.014). Carpal height ratio remained the same at 0.50 on both sides. Arthritic changes were minimal: our arthrosis index (3–15) was 4.4 in the affected wrist and 3.1 in the contralateral wrist. The radioulnar joint was normal in nine patients, had mild arthrosis (2/5) in two patients, and had moderate or severe arthrosis (index 4–5/5) in three patients. Mean ulnar variance was–3.0 pre-operatively (range –1 to –5) mm and 1.5 (range 0–5) mm at final follow-up. Clinical and radiological outcomes at 7 years were almost the same as at 25 years.
Subjective results VAS score in 14 patients (the silicone implant patient and wrist fusion patient excluded) averaged 0.9 at rest, 0.9 with unloaded movement, 1.7 with slight exertion, and 3.0 with heavy exertion (overall mean 1.6). Twelve patients were painless at rest, 10 painless with unloaded motion, seven in light use, and four patients had pain only with heavy use. Three wrists were completely painless in all activities (Table 2, Figures 1 and 2). Mean DASH score was 6.1; optional DASH, 10.8; and Mayo wrist score, 79.3 (Table 2).
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Viljakka et al.
Figure 2. (A) A 27-year-old man, 7 months after wrist injury RSO December 1983, pre-operative X-ray. Lichtman stage IIIA, ulnar variance –3 mm. (B) X-ray 23 years after RSO. Lichtman stage the same IIIA, arthrosis index 5, ulnar variance +5 mm. The lunate is deformed, inner structure rather normal. VAS in heavy strain 2, DASH 11.6, Mayo score 70.
Seven patients continued their previous work, two had changed to lighter work, and five were retired, one due symptoms in their wrist and four because of age. Seven patients rated the result as excellent, four as good, and three as moderate. All except one would choose the same treatment again.
Complications Six of 16 patients suffered complications (38%). In four patients, the end result was poor and they were estimated as failures (25%). Of these four patients, one underwent silicone implant arthroplasty 2 years after osteotomy and one had wrist fusion 16 years after RSO. The patient with a silastic implant had a moderate clinical result. He was able to continue his work. After 25 years, his wrist was painful with heavier loading (VAS 5). The radiocarpal and radioulnar joints were arthritic (indexes 9/15 and 4/5). DASH score was 10 and Mayo wrist score was 80. The patient
with a wrist fusion was retired. The wrist was painless (VAS 0). DASH score was 0 and Mayo wrist score was 40. The radioulnar joint was arthritic (5/5). These two patients were excluded from the follow-up study. The other four of these complicated patients were included at follow-up data. Two of them had significant pain and were estimated as failures. One of them was 16 years old at the time of surgery and Lichtman stage was IIIB. She required further surgery due to ulnar impingement (ulnar variance +2 mm) 25 years after RSO with ulnar shortening without clinical benefit. After 26 years follow-up her wrist was painful; VAS maximum 8 and DASH score 23.3. The lunate was severely deformed, as it was before RSO, but the lunate inner structure was improved. No arthrosis was noted around the lunate or wrist, but the wrist had the same VISI deformity as pre-operatively. In three patients, complications were not related to the lunate bone, itself. Two patients had re-fracture of the radius after plate removal. One of them was
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6
1 –
7
3
3
25 (20–33) – – 5 1 5 11 2 1 – 6.1 (0–23.3) 79 (60–95) – 31 (16–45) 100
76–93 79 14
95
Improved 8 (0–23) in 92 38 (23–60) 75
81–82 83 12
88
93 31 (15–58) 64
31 (20–44) 44
78–87 71 14
86
VAS 2.4
14 (0–68)
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79–103 56 9
90
96 33 (11–55) 80
82 72 25
Koh et al. Raven et al. Zenzai et al. Watanabe et al. Current study
85
VAS 1.6
4 1 2 2 5 3 6 96
1 1 – – 78 – – 83 (63–100) –
11 10 4 2 5 6 3
6 9 1 3 4 4 3
– 1 – – – 1 –
IIIA II I
Patients, n Males, % Mean Dominant Extensionage, years hand, % flexion, (range) % of unaffected side Study
The treatment of Kienböck’s disease is still controversial (Allan et al., 2001; Beredjiklian, 2009; Dias and Lunn, 2010; Salmon et al., 2000; Schuind et al., 2008; Viljakka et al., 2013). Radial shortening osteotomy for patients with negative ulnar variance significantly unloads the lunate (Horii et al., 1990; Makabe et al., 2011) and has proven an appropriate treatment solution for Kienböck’s disease. Clinical and radiological early and mid-term results of RSO are well-documented (Amillo et al., 1993; Buck-Gramcko et al., 1990; Calfee et al., 2010; Das Gupta et al., 2003; Marti et al., 1981; Nakamura et al., 1995; Weiss, 1993), but only four studies report the long-term outcome after RSO (Koh et al., 2003; Raven et al., 2007; Watanabe et al., 2008; Zenzai et al., 2005) (Table 3). Subjective pain in Kienböck’s disease typically improves regardless of treatment type (Innes and Strauch, 2010). In four long-term follow-up studies, pain diminished markedly in 48% to 66% of patients (Table 3) over 14, 19, 21, and 22 years (Koh et al., 2003; Raven et al. 2007; Watanabe et al. 2008; Zenzai et al. 2005) (Table 3). In our study, three of 14 patients were totally painless, 12 had no pain at rest, seven had pain during light strain, and four had pain only with heavy use. These numbers are somewhat lower compared with the other studies. Two failures in our series had pain at rest (VAS 5 and 8). VAS values at rest were
Table 3. Literature on radial shortening osteotomy for Kienböck’s disease.
Discussion
Grip Pain, strength, none or % of mild, % unaffected side
DASH
Mayo wrist Lichtman stage, score At surgery, St follow-up
IIIB
IV
Follow-up, years (range)
treated with free cancellous bone graft and Rush pin fixation. The wrist was painful at follow-up: VAS 5 at rest, 5 with unloaded movement, and 7 in slight and 7 in heavy exertion, and a Mayo wrist score of 80. The radiocarpal and radioulnar joints were arthritic (indexes 6/15 and 2/5), and supination was restricted. Two complications were significant but not failures when considering the end result. One patient had nonunion of the radius, which was treated with free cancellous bone graft and cast immobilization. After 27 years his wrist was painful with heavy loading, VAS 4. He was able to continue his work and had a DASH score of 10. Radiocarpal osteoarthrosis index was 5/15. The other patient had over-shortening of the radius and 5 mm positive ulnar variance post-operatively. An ulnar shortening osteotomy corrected the supination restriction. After 20 years he was working as a truck driver and had only mild pain with heavy loading, with a VAS maximum 2. He had no radiocarpal arthrosis but mild radioulnar arthrosis (index 2/5). His DASH score was 0 and Mayo wrist score, 75. Thus, altogether four patients were considered failures, and in these patients there was marked progression of the lunate deformity or further surgery.
14.5 (10–21) 22 (16–31) 19 (13–25) 21 (14–28)
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Viljakka et al. mean 0.9 and with heavy use mean 3.0 (range 0–8), including complicated cases. Statistically significant improvements are seen in ROM after osteotomy in patients with early stage disease (Lichtman stages 1–3A), and most interventions, except partial arthrodesis and nonsurgical treatment, for late-stage disease (Innes and Strauch, 2010). Improvement in ROM was noted in all long-term studies (Table 3). In this study after 25 years, extension averaged 93% and flexion 76% of the unaffected side. Extension, flexion, radial deviation, and ulnar deviation improved, but all of these appeared to have deteriorated in the unaffected wrist. Grip strength is reported to improve significantly in early stage patients treated with osteotomy and all late-stage patients, except those managed nonsurgically (Innes and Strauch, 2010). The improvements in grip strength range from 74% to 86% of the unaffected side at 19 years (Zenzai et al., 2005), 53% to 88% at 21 years (Watanabe et al., 2008), and a mean of 90% after 22 years (Raven et al., 2007) (Table 3). In the present study, grip strength was 95% of the unaffected side and improved 54% from 235 N to 363 N in 25 years, whilst the strength of the contralateral hand deteriorated by 7%. Previous studies using patient-based assessment and function reported a mean DASH score of 9 after 21 years (Watanabe et al., 2008) and 14 after 22 years (Koh et al., 2003) (Table 3). In this study, including complicated cases the DASH score was little better, with a mean of 6.1. In the other studies, no failures were reported and follow-up rates varied between 40 to 75%. In our series, we noted six complications requiring re-operations. One patient had implant arthroplasty and one wrist fusion. These failures were excluded. Two other failures and two with significant complications were included to the follow-up study. Mean DASH score in complicated cases was 11 (0– 23.3). Mayo wrist score averaged 83 at 21 years (Watanabe et al. 2008), 78 at 19 years (Zenzai et al. 2005), and 79 at 25 years in our study (Table 3). Radiologically, the inner structure of the lunate improved in 58% of patients after 14 years, indicating healing of the ischemic lunate (Koh et al., 2003). In the other studies there are no such reports. Lichtman classification remained stable, deteriorating in only three of nine patients (Raven et al., 2007) and three of 14 patients (Zenzai et al, 2005). However, Watanabe (2008) found deterioration in half of their patients over 21 years. Conversely, our study showed improved lunate inner structure in every patient. However, Lichtman stage remained the same in only nine of 16 (56%) patients over 25 years. We noted arthritic changes in the radiocarpal area in 71% and in the
radioulnar joint in 36%. Koh et al. (2003) reported osteoarthrosis in 64% in the radiocarpal joint and 24% in the distal radioulnar joint, altogether in 73% of patients. The arthritic changes were mild, and in our study, the mean index was 4.4/15 (range 3–8). Changes in radiological indexes were few. No significant differences were noted in carpal height ratio or scapholunate and radioscaphoid angles, but significant changes were noted in the ulnar translation index, Ståhl index, and lunate covering index, meaning that the lunate suffered some deformation after RSO. There are limitations to this study. We used no validated scores for pain or wrist function at the time of surgery because they did not exist. Second, this retrospective follow-up study lacks any control group. Third, our material comprises so few patients that significance is not always reached in our statistical analysis. In conclusion, our results of radial shortening osteotomy are in accordance with other long-term studies. Osteotomy provides improvement in about 75% of patients lasting decades and is a good method of treatment for Kienböck’s disease in patients with negative ulnar variance. We believe that the outcome is preferable to the unpredictable long-term natural course of Kienböck’s disease (Salmon et al., 2000). Acknowledgements We thank Leena Ristolainen, PT, PhD, for statistical help and Carol Norris, PhD, for language revision.
Conflict of interests None declared.
Ethical Approval and Informed Consent Each author certifies that his or her institution approved the human protocol for their investigation, that all investigations were concluded in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
Funding During the study period, the authors’ institution received funding from Erityis Valtion Osuus, Helsinki University Hospital, Helsinki, Finland.
References Allan CH, Joshi A, Lichtman DM. Kienböck’s disease: diagnosis and treatment. J Am Acad Orthop Surg. 2001, 9: 128–36. Amillo S, Martinez-Peric R, Barrioss RH. Radial shortening for the treatment of Kienböck’s disease. Int Orthop. 1993, 17: 23–6.
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Beredjiklian PK. Kienböck’s disease. J Hand Surg. 2009, 34: 167–75. Buck-Gramcko D, Lankers J. Results in Kienböck’s disease (in German). Study on 91 patients. Handchir Plast Chir. 1990, 22: 28–38. Calfee R, Van Steyn M, Guyricza C, Adams A, Weiland A, Gelberman R. Joint leveling for advanced Kienböck’s disease. J Hand Surg Am. 2010, 35: 1947–54. Das Gupta K, Tunnerhoff H, Haussmann P. [STT-arthrodesis versus radial shortening osteotomy for Kienböck’s disease]. Handchir Mikrochir Plast Chir. 2003, 35: 328–32. Dias JJ, Lunn P. Ten questions on Kienböck’s disease of the lunate. J Hand Surg Eur. 2010, 35: 538–43. Horii E, Garcia-Elias M, An KN et al. Effect on force transmission across the carpus in procedures used to treat Kienböck’s disease. J Hand Surg Am. 1990, 15: 393–400. Innes L, Strauch R. Systematic review of the treatment of Kienböck’s disease in its early and late stages. J Hand Surg Am. 2010, 35: 713–7.e4. Koh S, Nakamura R, Horii E, Nakao E, Inagaki H, Yajima H. Surgical outcome of radial osteotomy for Kienböck’s disease—minimum 10 years of follow-up. J Hand Surg Am. 2003, 28: 910–26. Lichtman D, Degman G. Staging and its use in the determination of treatment modalities for Kienböck’s disease. Hand Clinics. 1993, 9: 409–16. Makabe H, Iwasaki N, Kamishima T, Oizumi N, Tadano S, Minami A. Computed tomography osteoabsorptiometry alterations in stress distribution patterns through the wrist after radial shortening osteotomy for Kienböck’s disease. J Hand Surg Am. 2011, 36: 1158–64. Marti R, Veldstra R, Vegter J. [Shortening osteotomy of the radius in the treatment of Kienböck’s disease.] Orthopäde. 1981, 10: 54–8. Nakamura R, Imaeda T, Miura T. Radial shortening for Kienböck’s disease: Factors affecting the operative result. J Hand Surg Br. 1990, 15: 40–5.
Nakamura R, Horii E, Imaeda T, Watanabe K, Tsunoda K. Current concepts of radial osteotomy for Kienböck’s disease. In: Vastamäki et al. (Eds.) Current Trends in Hand Surgery. Paris, Elsevier Science BW, 1995: 109–12. Razemon J-P. [Treatment of Kienböck’s disease by shortening of the radius.] Chirurgie. 1984, 110: 600–7. Raven EEJ, Haverkamp D, Marti RK. Outcome of Kienböck’s disease 22 years after distal radius shortening osteotomy. Clin Orthop. 2007, 460: 137–41. Salmon J, Stanley JK, Trail IA. Kienböck’s disease: conservative management versus radial shortening. J Bone Joint Surg Br. 2000, 82: 820–3. Schuind F, Eslami S, Ledoux P. Kienböck’s disease. J Bone Joint Surg Br. 2008, 90: 133–9. Takahara M, Watanabe T, Tsuchida H, Yamahara S, Kikuchi N, Ogino T. Long-term follow-up of radial shortening osteotomy for Kienböck’s disease. Surgical technique. J Bone Joint Surg Am. 2009, 91 Suppl 2: 184–90. Viljakka T, Tallroth K, Vastamäki M. Long-term outcome (22–36 years) of silicone lunate arthroplasty for Kienbock’s disease. J Hand Surg Eur. 2013. (Epub ahead of print 21 May 2013). Wada A, Miura H, Kubota H, Iwamoto Y, Uchida Y, Kojima T. Radial closing wedge osteotomy for Kienböck’s disease: an over 10 year clinical and radiographic follow-up. J Hand Surg Br. 2002, 27: 175–9. Watanabe T, Takahara M, Tsuchida H, Yamahara S, Kikuchi N, Ogino T. Long-term follow-up of radial shortening osteotomy for Kienböck’s disease. J Bone Joint Surg Am. 2008, 90: 1705–11. Weiss A-P. Radial shortening. Hand Clinics 1993, 9: 475–82. Zenzai K, Shibata M, Endo N. Long-term outcome of radial shortening with or without ulnar shortening for treatment of Kienböck’s disease: a 13–25 year follow-up. J Hand Surg Br. 2005, 30: 226–8.
Appendix 1 Lunatomalacia Questionnaire
Name tag
Date _________________ The questions below regards your right/left wrists, that was operated at Hospital ORTON in the year 19__ Encircle the right alternative. In the end of the questionnaire is room for free comments. Uncertain questions can be gone through at the examination. Background 1) Sex:
Female
[0]
Male
[1]
2) Dominant hand:
Left
[0]
Right
[1]
No
[0]
3) Wrist trauma before symptoms Yes [1]
Which trauma ____________________
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Viljakka et al. 4) Are you employed at the moment? Yes
[1]
No
[0]
5) Heaviness of the work 1. Light sedentary 2. Light labour 3. Moderate labour 4. Heavy 6) What is / was your profession?_____________________________________________________________ 7) Did you change your profession due to wrist disorder ? Yes [1] No [0] 8) Are you retired at the moment? Yes [1] No [0] 9) Did you retire because of your wrist distress? Yes [1] No [0]
If you answered Yes, please specify year: _________
10) Have you pain in your wrist at rest? Yes [1] No [0] 11) Have you pain in your wrist in motion or exertion? Yes [1] No [0] 12) Have you night pain in your wrist? Yes [1] No [0] 13) Have you restricted motion in your wrist? Yes [1] No [0] 14) How much pain do you have today in your wrist, on a scale 0–10? 0 = no pain, 10 = the worst pain imaginable: During exertion 0 |______________________________________________________________________| 10 At rest 0 |______________________________________________________________________| 10 At night 0 |______________________________________________________________________| 10 15) Would you again choose an operation for your wrist under the same circumstances? Yes [1] No [0] 16) Regarding the operation result, are you:
Excellent [1]
Good [2]
Fair
[3]
Poor
[4]
Comments ________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________
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