J Korean Orthop Assoc.  2010 Aug;45(4):256-263.

Treatment of Kienbock's Disease Using the 4+5 Extensor Compartmental Vascularized Bone Grafting Procedure: Early Experience

• Cheon SJ
• Lim JM
• Kim HT
• Suh JT

Abstract

PURPOSE
Kienbock's disease can be treated with a vascularized bone graft to provide relief of wrist joint symptoms and prevent collapse of the lunate. We evaluated the functional outcome and subjective satisfaction in patients with Kienbock's disease treated with the 4+5 extensor compartmental vascularized bone graft. MATERIALS AND
METHODS
We included 6 patients in the study. 3 males and 3 females with an average age of 37.5 years (range 21-49). Kienbock's disease was staged by Lichtman classifi cation based on plain radiography. Three patients were in stage II and three in stage IIIA. Cooney's wrist function score was used to evaluate changes in severity of pain, functional status, range of motion, and grip strength. We also assessed subjective patient satisfaction, carpal height ratio and bone union on the radiographs, and the occurence of complications. The mean follow-up period was 30 months.
RESULTS
Four patients had excellent and two had good outcomes of wrist function. Three patients showed excellent subjective satisfaction, and three were good. All patients showed radiographic bone union and no further progression of lunate necrosis. The presurgical carpal height ratio was similar to the value at last follow-up, and there was no radiographic carpal bone collapse. For two cases of Lichtman stage IIIA, the slight degenerative arthritis at the lunocapitate joint observed preoperatively did not change. Skin necrosis and pin track infection were not observed.
CONCLUSION
The 4+5 extensor compartmental vascularized bone graft is a reliable procedure for Lichtman stage II and IIIA patients with Kienbock's disease, as it achieved not only pain relief and improvement of range of motion but also maintenance of the intercarpal bone relationship on radiographs, with relatively few complications.

Keyword

lunate; Kienbock's disease; avascular necrosis; 4+5 extensor compartmental vascularized bone graft

MeSH Terms

Bone Transplantation
Carpal Bones
Female
Follow-Up Studies
Hand Strength
Humans
Joints
Male
Necrosis
Osteoarthritis
Osteonecrosis
Patient Satisfaction
Range of Motion, Articular
Skin
Track and Field
Transplants
Wrist
Wrist Joint

Figure

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  Figure 1 The carpal height ratio was calculated by dividing the carpal height (B) by the length of the 3rd metacarpal bone (A) (Normal: 0.54±0.03).

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  Figure 2 A bone graft centered 11 mm proximal to the radiocarpal joint and overlying the fourth ECA (4 ECA) that includes the nutrient vessels. Necrotic bone is removed with a burr or curettes, leaving a shell of intact cartilage and subchondral bone through a dorsal opening. The lunate is gently expanded to normal. The anterior interosseous artery (AIA) is ligated proximal the fourth and fifth ECAs (5 ECA). Graft elevation is completed.

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  Figure 3 Preoperative antreroposterior (A), lateral (B) radiographs and MR images (C, D) of a 21-year-old man, Lichtman's stage II Kienböck's disease and neutral ulnar variance (Carpal height ratio=0.52). Three years and four months after the operation, antreroposterior (E) and lateral (F) radiographs (Carpal height ratio=0.53).

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  Figure 4 Preoperative antreroposterior (A), lateral (B) radiographs and MR images (C, D) of a 49-year-old woman, Lichtman's stage IIIA Kienböck's disease and neutral ulnar variance (Carpal height ratio=0.47). Two years and ten months after the operation, antreroposterior (E) and lateral (F) radiographs (Carpal height ratio=0.47).

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