Content of this journal is licensed under a Abstract
Objective:
This study aimed to compare the clinical and radiological results of scaphocapitate fusion (SCF) and capitohamate fusion (CHF) combined with lunate excision in advanced Kienböck’s disease.
Methods:
Patients over 18 years of age who were in stages IIIB-IIIC according to the Lichtman classification, and who had at least 1 year of follow-up, were included in the study. All patients had unilateral disease. Patients were divided into 2 groups according to whether they had CHF or SCF. The range of motion (ROM) and grip strength of the operated and contralateral active wrist joint were measured. Radiological evaluation of the severity of the disease was determined preoperatively using Lichtman staging. Preoperative and postoperative carpal height ratios (CHRs) were measured on anteroposterior radiographs. The presence of osteoarthritis was evaluated. Functional outcome was assessed using the Disability of the Arm, Shoulder, and Hand (DASH) and Visual Analogue Scale (VAS) scores.
Results:
The mean age of the 27 patients (12 CHF and 15 SCF) was 32.5 years. There was no statistically significant difference between the 2 groups in terms of demographic characteristics, Lichtman stages, and mean follow-up time. No difference between the groups regarding ROM, grip strength, VAS, and DASH scores could be found. The preoperative and postoperative CHRs were compared, and no difference was found between the groups.
Conclusion:
Although SCF has some advantages over CHF regarding joint ROM and clinical scores, no difference was found between the groups (clinically and radiologically). Both SCF and CHF combined with lunate excision seem to be effective in the treatment of advanced Kienböck’s disease in the mid-term.
Level of Evidence:
III, Therapeutic study.
Keywords: Capitohamate fusion, Kienböck’s disease, Limited carpal fusion, Lunate excision, Scaphocapitate fusion
Highlights
Both SCF and CHF combined with lunate excision demonstrated comparable clinical and radiological outcomes in the mid-term treatment of advanced Kienböck disease.
No statistically significant differences were found between the two groups in terms of range of motion, grip strength, VAS, and DASH scores.
SCF showed slightly better joint motion and clinical scores, but overall, both techniques proved to be reliable and effective treatment options for advanced stages of Kienböck disease.
Introduction
Kienböck’s disease consists of avascular necrosis of the lunate, and its treatment varies according to the patient’s clinical complaints and radiological stage.1 In advanced stages of Kienböck’s disease, in which revascularization is not possible, various salvage procedures, such as lunate excision, limited carpal fusion, proximal row carpectomy, or total wrist fusion, are recommended in the literature.2-8
It has been reported that good results can be obtained simply with lunate excision.7-11 The disadvantage of this technique is the long-term deterioration of wrist kinematics due to proximal migration of the capitate.8,11 In advanced-stage Kienböck patients, the aim is to protect wrist kinematics by preventing proximal migration of carpal bones using limited carpal fusion techniques, with or without excision of the lunate, and by creating an alternative columnar pathway for loading forces.12-17 The most commonly used procedures for limited carpal fusion are scaphotrapeziotrapezoid (STT) arthrodesis and scaphocapitate fusion (SCF). Capitohamate fusion (CHF) has been suggested to prevent proximal capitate migration in the treatment of Kienböck’s disease.12-14,16
This is the first study in the literature comparing the patients who underwent lunate excision with scaphocapitate and capitohamate fusion in advanced Kienböck’s disease. It is hypothesized that there is no difference in the clinical and radiological results between the CHF and SCF groups with lunate excision.
Material and methods
Thirty-two patients who were operated on for Kienböck’s disease in 4 different clinics between 2015 and 2020 were evaluated retrospectively (13 patients with CHF and 19 patients with SCF). Patients who were over 18 years of age, were in stages IIIB-IIIC according to the Lichtman classification, underwent SCF or CHF after lunate excision, and who had at least 1 year of follow-up were included in the study. All patients had unilateral disease. Patients with a history of bilateral hand and wrist fractures or a previous operation for Kienböck’s disease were excluded. Twenty-seven patients who met the inclusion criteria and attended the last follow-up were included in the study.
The main reason for presentation to the outpatient clinic was wrist pain in all patients. All patients underwent standard radiographs and magnetic resonance imaging for diagnosis. Radiological evaluation of the severity of the disease was conducted preoperatively using Lichtman staging.18 Preoperative and postoperative carpal height ratios (CHRs) were measured on an anteroposterior radiograph as described by Youm et al.19 The presence of osteoarthritis and smoking was evaluated.
Patients were divided into 2 groups according to the CHF and SCF surgical technique. In all patients, the operation was performed under a tourniquet using a dorsal incision in both groups. First, the entire lunate was excised, and a synovectomy was performed. Then, the cartilage surfaces between the capitate and hamate in the CHF group (Figures 1A and B CHF preoperative Figure 1C and D CHF postoperative images) and between the scaphoid and capitate in the SCF group (Figure 2A and B SCF preoperative Figure 2C and D SCF postoperative images) were removed with a thin osteotome, and fixation was performed using a 3.5 mm headless cannulated screw that provided compression. Bone grafting was not used in any patients. In both groups, the arm was immobilized using a short splint for 3 weeks. At the end of the third week, a physiotherapist initiated the passive wrist movement, and a night splint was used. The splint was removed at the end of the sixth week. Then, passive and active wrist movements were permitted under the supervision of an experienced hand physiotherapist.
Figure 1.
(A) Capitohamate fusion preoperative anteroposterior radiograph, (B) Capitohamate fusion preoperative lateral radiograph, (C) Capitohamate fusion postoperative anteroposterior radiograph, (D) Capitohamate fusion postoperative lateral radiograph.
Figure 2.
(A) Scaphocapitate fusion preoperative anteroposterior radiograph, (B) Scaphocapitate fusion preoperative lateral radiograph, (C) Scaphocapitate fusion postoperative anteroposterior radiograph, (D) Scaphocapitate fusion postoperative lateral radiograph.
At the last follow-up, the range of motion (ROM) (degrees) of the operated and contralateral wrist joint was measured using goniometry. Patient-reported disability was evaluated using the Disability of the Arm, Shoulder, and Hand (DASH) and Visual Analogue Scale (VAS) scores (0: no pain, 10: most severe pain). Grip strength (kg) was measured using a Jamar dynamometer (Model SH 5001, Saehan Corporation, Masan, South Korea).
A pre-study power analysis based on previous data determined a sample size of at least 5 patients for each group to reach the desired power of > 0.8. Grip strength percentage to the normal side was the primary outcome for the 2 means t-test power analysis.20
The Shapiro–Wilk test was applied to determine the distribution of the data. Parametric and non-parametric data were evaluated using the Student’s t-test and Mann–Whitney U-test. Categorical data were evaluated using Fisher’s exact test. Parametric and non-parametric data were evaluated with the paired sample t-test and the Wilcoxon test within groups. A value of P < .05 was considered statistically significant.
Results
There were 12 patients who underwent CHF and 15 patients who underwent SCF. The mean age of the 27 patients was 32.5 years (range: 18-64 years). The demographic characteristics of the patients and the Lichtman stages are given in Table 1. There was no statistically significant difference between the 2 groups in terms of demographic characteristics, Lichtman stages, and mean follow-up time (Table 1). All patients in both groups returned to work.
Table 1.
Demographic data of patients
| Variables | Capitohamate fusion (n = 12) |
Scaphocapitate fusion (n = 15) |
P |
|---|---|---|---|
| Gender Female Male |
3 9 |
7 8 |
.424 |
| Age (years) | 31.3 ± 12 | 33.5 ± 12.5 | .649 |
| Mean follow-up (months) | 56 ± 20.5 | 46 ± 17.4 | .182 |
| Side Right Left |
7 5 |
8 7 |
.795 |
| Dominant side Right Left |
12 0 |
12 3 |
.231 |
| Dominant side affected Yes No |
7 5 |
9 6 |
>.999 |
| Lichtman stage IIIB IIIC |
6 6 |
7 8 |
.863 |
There was no statistically significant difference between the 2 groups regarding functional results, such as VAS, DASH scores, joint ROM, and grip strength (Table 2). Grip strength on the affected side was 70.9% in the SCF group and 67% in the CHF group compared to the contralateral side. No difference was found between the pre- and postoperative values in the groups (P > .05). The mean preoperative CHRs values were 0.45 ± 0.030 for the CHF group and 0.45 ± 0.038 for the SCF group, and postoperative CHRs were 0.44 ± 0.032 for the CHF group and 0.45 ± 0.029 for the SCF group. There was no difference between the groups in terms of CHR values (P > .05).
Table 2.
Comparison of clinical and functional results
| Variables | Capitohamate fusion (n = 12) | Scaphocapitate fusion (n = 15) | P |
|---|---|---|---|
| VAS score | 2.2 ± 1.2 | 1.6 ± 1.1 | .148 |
| DASH score | 10.4 ± 7.1 | 8.3 ± 7.2 | .451 |
| Hand grip contralateral side (˚) | 39.6 ± 8.4 | 35.6 ± 4.6 | .130 |
| Hand grip affected side (˚) | 25.6 ± 4.7 | 24.8 ± 7.0 | .739 |
| Flexion contralateral side (˚) | 71.6 ± 3.8 | 70.0 ± 11.9 | .798 |
| Flexion affected side (˚) | 46.6 ± 14.3 | 50.6 ± 14.3 | .454 |
| Extension contralateral side (˚) | 70.0 ± 0.0 | 69.3 ± 2.5 | .371 |
| Extension affected side (˚) | 43.3 ± 14.9 | 50.3 ± 15.4 | .253 |
| Ulnar deviation contralateral side (˚) | 20.0 ± 0.0 | 20.0 ± 1.8 | >.999 |
| Ulnar deviation affected side (˚) | 12.9 ± 5.4 | 13.0 ± 5.2 | .955 |
| Radial deviation contralateral side (˚) | 20.0 ± 0.0 | 19.6 ± 1.2 | .371 |
| Radial deviation affected side (˚) | 12.9 ± 5.4 | 13.0 ± 5.6 | .979 |
Values are presented as mean ± SD.
DASH, Disability of the Arm, Shoulder, and Hand; VAS, Visual Analogue Scale.
Complete union was achieved in all cases, with a median time of 3 months in both groups (SCF median: 2.5-3.5, CHF median: 2.25-3.75). Osteoarthritis was found at a rate of 16.7% in the CHF group and 20% in the SCF group. Smoking was 60% for SCF and 66.6% for CHF. It was determined that smoking was a variable that did not make a difference between the groups.
Discussion
None of the current treatments of Kienböck’s disease algorithms address the indications for CHF. In this study, both CHF and SCF combined with lunate excision in patients with Kienböck stage IIIB-IIIC were associated with satisfactory clinical and radiological results in the mid-term.
Lunate excision alone is seldom indicated for the treatment of Kienböck’s disease because of further proximal migration of the capitate and stress concentration on the scaphoid.21 Limited arthrodesis, such as SCF, STT, CHF, performed with lunate excision, aim to prevent proximal migration of the capitate and carpal collapse.16,22-27 Scaphocapitate arthrodesis is a well-known fusion technique. In the normal wrist joint, the hamate is surrounded by strong ligaments and bound to the triquetrum and the fifth and fourth metacarpals. Its proximal migration is prevented, especially by the triquetrum. For this reason, fusion of the capitate to the hamate also prevents proximal migration of the capitate. Additionally, CHF is associated only with the distal carpal row. If CHF fails, proximal row carpectomy is still an option because the proximal articular surface of the capitate is intact.
Advanced stage Kienböck’s disease is usually characterized by pain and limitation of movement in the wrist. Pain is caused by ischemia or pathological fracture of the lunate in the early stages of the disease. In stage IIIB and more advanced stages, it originates from the sequestered lunate with concomitant synovitis.10,16 Kawai et al8 achieved satisfactory results, including symptom regression, in 18 patients who underwent simple lunate excision and were followed for an average of 11 years. In another recent study on stage IIIB and IIIC Kienböck’s patients, Tahta et al16 performed CHF by excising the lunate, which they defined as a pain generator—in all patients—and reported a significant reduction in pain. It is also thought that the pain relief is related to lunate excision and synovectomy.16,24,28
In some studies with Kienböck’s patients treated with CHF, successful results were reported radiologically and functionally without excision of the lunate.12-14 Oishi et al13 presented their experience with CHF in 45 wrists. They reported that 93% of the patients had no or less pain after surgery, preserved wrist ROM, and increased grip strength. Inoue reported that after performing CHF on 8 patients, all patients returned to normal activities without pain and increased grip strength.14
In another study by Luegmair et al,28 it is noteworthy that the pain was greater in stage IV cases in which the lunate was preserved and SCF was performed. In contrast, many studies have reported that the pain was relieved by 90% when SCF was performed, even when the lunate was not excised or was only partially excised.25,28,29 Collon et al30 did not recommend resection of the lunate because they believed that would make the surgery more complex and that the purpose of SCF is to reduce the load on the lunate anyway. However, Charre et al26 combined lunate excision with SCF in patients with an average follow-up of 10.7 years. The authors recommended this method as a reliable and permanent solution, with results that are more functional and result in better grip strength compared to all other SCF studies in which the lunate was not excised, with minimal pain and 90% patient satisfaction.26
In the literature, it has been reported that CHR decreased after lunate excision, the capitate migrates proximally, and that the carpal alignment is characterized by bones rearranged by the palmar flexion of the scaphoid.8,11 In studies in which SCF was performed, the CHR generally decreased in the postoperative follow-up. For instance, Rhee et al25 reported that scaphocapitate arthrodesis with lunate excision significantly reduced the mean CHR in advanced Kienböck’s disease; however, symptomatic carpal collapse was not evident until a mean follow-up of 5 years.25 In other studies in which SCF was performed, the CHR was reported to be 0.48 preoperatively and 0.47 and 0.45 postoperatively.26,28 In the literature, in patients with CHF undergoing surgery, the mean CHR did not change.13,14,16 In this study, no significant difference was found in terms of CHR in both groups. In this study, there was a similarity in terms of CHR in both groups. This result showed that both methods were effective in preventing carpal migration after lunate excision.
In this study, when the patients’ wrist ROM was compared with the contralateral side as a percentage, the SCF group performed better than the CHF group in all movements. The grip strength was 70.9% of the contralateral side in the SCF group and 67% of the contralateral side in the CHF group. Although postoperative grip strength was similar between the 2 groups, there was less loss of strength in the SCF group compared to the contralateral side. Although the functional assessment between the 2 groups was not statistically significant, the SCF group had better DASH and VAS scores.
Limitations
The most obvious limitation of this study is that it is retrospective and was conducted in multiple clinics. Therefore, surgical techniques and procedures were applied according to the surgeons’ personal experience and preferences, and postoperative evaluations were made by different surgeons. In addition, the lack of preoperative evaluation is another limitation, and this limitation was tried to be minimized by comparing it with the opposite wrist. However, despite the relatively small number of patients, the patient sample was sufficiently large and homogeneous to compare the 2 surgical treatment techniques.
In conclusion, both SCF and CHF combined with lunate excision seem to be effective in the treatment of advanced Kienböck’s disease in the mid-term. Although SCF has some advantages over CHF regarding joint ROM and clinical scores, no difference was found between the groups (clinically and radiologically). Both groups were similar in terms of clinical and radiological findings. However, a larger patient cohort and a longer follow-up period are needed to confirm these outcomes.
Funding Statement
The authors declared that this study has received no financial support.
Footnotes
Ethical committee approval was received from the Ethics Committee of Tokat Gaziosmanpasa University School of Medicine (Approval No.: 20-KAEK-277; Date: November 25, 2020). Informed consent was obtained from the patients who agreed to take part in the study.
Ethics Committee Approval: Ethical committee approval was received from the Ethics Committee of Tokat Gaziosmanpaşa University School of Medicine (Approval No.: 20-KAEK-277; Date: November 25, 2020).
Informed Consent: Informed consent was obtained from the patients who agreed to take part in the study.
Peer-review: Externally peer-reviewed.
Author Contributions: Conception – T.O., E.C.Z., I.M.S.; Design – T.O., H.E., K.Y.; Supervision – I.M.S., C.A.; Resources – E.C.Z., I.M.S.; Materials – T.O., C.A., I.M.S.; Data Collection and/or Processing – T.O., H.E., K.Y.; Analysis and/or Interpretation – T.O., H.E., K.Y.; Literature Search – T.O., I.M.S.; Writing – T.O., I.M.S.; Critical Review – T.O., E.C.Z., I.M.S.
Acknowledgements: The authors would like to thank Professor Mehmet Yıldız for sharing his patients’ data for this study.
Declaration of Interests: The authors have no conflict of interest to declare.
Data Availability Statement:
The data that support the findings of this study are available on request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.