Abstract
Purpose
Lunate excision is a treatment option for advanced-stage Kienböck disease; however, its effects on wrist mobility and stability remain insufficiently understood. This study aimed to biomechanically compare the wrist kinematic changes following lunate excision alone and proximal row carpectomy (PRC), focusing on dart-throwing motion (DTM), circumduction, and midcarpal stability.
Methods
Ten freshly frozen cadaveric upper limbs were mounted on a custom apparatus after isolating and tensioning the flexor carpi radialis, flexor carpi ulnaris, extensor carpi radialis, and extensor carpi ulnaris tendons. The simulated active DTM was produced by sequentially loading the flexor carpi ulnaris and extensor carpi radialis tendons, whereas wrist circumduction motion was generated through passive multidirectional traction. The range of DTM and circumduction motions was recorded using an electromagnetic tracking system. Each specimen was tested under the following three conditions: intact wrist, lunate excision, and PRC. Carpal stability was evaluated by measuring passive translations of the distal carpal row in four directions.
Results
Lunate excision alone and PRC significantly reduced the arc of the simulated DTM, averaging 83% and 40% of that in the intact condition, respectively. In contrast, the circumduction range was relatively preserved, with significant differences observed only in selected directions. Dorsal instability increased after lunate excision, whereas PRC was associated with increased volar instability.
Conclusions
Lunate excision alone preserved DTM more effectively than PRC.
Clinical relevance
Although lunate excision alone can maintain functional wrist motion, it may lead to carpal instability.
Key words: Biomechanics, Circumduction, Dart-throwing motion, Lunate excision, Proximal row carpectomy
Blanco and Lawton1 reported long-term outcomes of lunate excision for advanced stages of Kienböck disease. However, this procedure has been limited in use because of concerns regarding the disruption of the proximal carpal row, which can lead to scaphotriquetral widening, proximal migration of the capitate, and subsequent carpal collapse. Thus, additional procedures such as scaphocapitate fusion, scaphotrapeziotrapezoid fusion, and proximal row carpectomy (PRC) are more commonly performed. Recent advancements in arthroscopic techniques allow lunate excision while preserving as much ligamentous and structural continuity of the proximal carpal row as possible,2, 3, 4, 5, 6 potentially mitigating adverse effects on carpal alignment.
Dart-throwing motion (DTM) plays a critical role in daily wrist function and is primarily generated by the midcarpal joint.7 Recent cadaveric biomechanical studies have examined wrist motion patterns such as DTM and circumduction.8, 9, 10 However, the effects of lunate excision on DTM and circumduction have not been well elucidated. In addition, its effects on carpal stability remain unclear. This study aimed to investigate the biomechanical effects of lunate excision and PRC on DTM and circumduction range of motion and to assess carpal instability using cadaveric models. We hypothesized that lunate excision alone would not reduce the range of wrist motion compared to wrists with PRC. Another hypothesis was that carpal instability occurs after both procedures.
Materials and Methods
The experimental setup and loading conditions were based on a previous cadaveric wrist biomechanics study,9 which reproduced physiological wrist motion using comparable load magnitudes.
Specimen preparation
Ten freshly frozen cadaveric upper limbs (six individuals; mean age, 75 years) were used. None of the donors had any history of wrist trauma. After overnight thawing at room temperature, the skin and subcutaneous tissues were removed. The following tendons were dissected and looped with nonabsorbable sutures: the flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and extensor carpi radialis longus and brevis (ECRL/B). The ECRL and ECRB tendons were sutured to form a single unit. The wrist joint capsule, intrinsic and extrinsic ligaments, and the interosseous membrane were preserved.
Degenerative changes in the midcarpal joint were ruled out by using wrist radiography and direct inspection during the experiment. Ligament integrity was visually confirmed from the dorsal aspect before joint inspection, and all intrinsic and extrinsic ligaments were preserved during preparation. Ligament integrity was visually confirmed from the dorsal aspect before joint inspection, and all intrinsic and extrinsic ligaments were preserved during preparation.
Experimental setup
Each specimen was mounted on a custom-designed testing apparatus with the forearm positioned in neutral rotation, maintained by 1.8-mm K-wires inserted transversely through the radius and ulna. The flexor tendons were directed toward the medial epicondyle and the extensor tendons toward the lateral epicondyle (Fig. 1A).
Figure 1.
Experimental setup for simulating wrist motion. A Custom-made jig used to fix the cadaveric forearm in a neutral position. B Tendon loading system with floating pulleys simulating resting muscle tone. C Setup for simulating passive circumduction motion using perpendicular traction applied to a wooden rod inserted into the third metacarpal and capitate canals.
The tendon loading system was configured using floating pulleys to simulate the physiological force vectors. The FCR and ECRL/B loops were connected to one pulley (radial pair), and the FCU and ECU were connected to the other (ulnar pair), with a static 0.45 kg weight applied to each side to simulate the resting muscle tone (Fig. 1B). The load magnitude was selected in accordance with Viegas et al.11
Surgical procedures
Each wrist was assessed under three sequential conditions: intact, after lunate excision alone, and after PRC (Fig. 2).
Figure 2.
Schematic illustrations of surgical procedures. Sequential procedures performed on each specimen—Experiment 1: intact wrist; Experiment 2: arthroscopic lunate excision; and Experiment 3: PRC. Ligament preservation and capsular repair were performed where possible in each stage.
Lunate excision was performed using a 2.5-mm arthroscopic bur with preservation of the volar and dorsal lunate cortices to maintain ligamentous continuity of the proximal row. PRC involves open resection of the scaphoid, lunate, and triquetrum using a modified Berger-Bishop approach12 while preserving the capsuloligamentous structures. The remaining portion of the lunate was removed during PRC. After each intervention, the capsules were sutured using 4-0 Vicryl (Polyglactin 910; Ethicon).
Motion simulation and data acquisition
Motion was recorded using an electromagnetic tracking system (TrakSTAR, Ascension Technologies). The sensors were fixed to the dorsal surfaces of the capitate and third metacarpal head. A reference sensor was placed at the distal radius.
A simulated active dart-throwing condition was evaluated by applying additional load to specific tendons from a neutral wrist position. The wrist was first stabilized in neutral under baseline physiological loading (0.45 kg per tendon pair), which provided a reproducible starting position. An additional 0.225 kg load was then applied independently to either the ECRL/B tendons or the FCU tendon to induce radial-extension or ulnar-flexion displacement, respectively. The resulting direction and end-point angular deviation of the third metacarpal from neutral were recorded.
Circumduction traction was applied to a wooden rod inserted into the third metacarpal and capitate canals using a 0.1-kg load through two floating pulleys, which standardized both the direction and magnitude of the applied force (Fig. 1C). Passive circumduction motion was measured in 12 directions spaced at 30° intervals, corresponding to ulnar deviation (0°), extension (90°), radial deviation (180°), and flexion (270°). The resulting angular deviation of the third metacarpal from neutral was recorded independently at each direction. The circumduction magnitude was defined as the sum of the angular displacements measured in these directions. To facilitate comparison across conditions, this summed value was expressed as a percentage relative to the intact wrist.
During each simulated motion, the patterns were observed and recorded using fluoroscopic images. Fluoroscopic images were used to observe wrist motion and carpal alignment during the experiment.
Evaluation of carpal stability
To assess carpal stability, a 20-N traction force was applied to the capitate in four directions (dorsal, volar, radial, and ulnar). A constant traction force was applied to the capitate using a pulley-weight system. A wooden rod was inserted into the third metacarpal to serve as a positional reference for wrist alignment. During each traction test, the wrist was maintained in neutral alignment using the wooden rod and additional support jig. Translation of the third metacarpal base relative to the radius was recorded using an electromagnetic sensor. Carpal translation was calculated as the change in electromagnetic sensor coordinates between the unloaded neutral position and the position after applying the traction load.
Statistical analysis
Each of the 10 wrists from six donors (bilateral wrists from four donors and one ipsilateral wrist from two donors) was analyzed, and statistical comparisons were made. The ranges of DTM, passive circumduction, and carpal translation were compared among the three conditions using repeated-measures analysis of variance with Holm-Bonferroni post hoc correction. Circumduction motion was analyzed in 12 directions at 30° intervals around the wrist. Statistical comparisons were performed for each direction to evaluate changes in the angular range among the three conditions. Statistical significance was set at P < .05.
Pilot study and sample size estimation
We performed a pilot study to assist in sample size calculation using the initial three specimens. A sample size estimation was performed with a power set at 80% and a significance level of .05. Based on the pilot data, the expected mean difference in active DTM arc between lunate excision and PRC was 30.1° with a standard deviation of 23.3°. This analysis indicated that six specimens were required; therefore, we used 10 specimens in the present study.
Ethical approval
Ethical approval was obtained from the Research Ethics Committee of [Chiang Mai University]. Cadaveric specimens were provided by Department of Anatomy, Chiang Mai University. Informed consent for the use of these specimens in the study was obtained from each donor before death.
Results
Simulated active dart-throwing motions
The mean DTM plane in the intact wrist was oriented at 92° in the radiodorsal direction and 297° in the ulnar-volar direction. The DTM plane deviated after lunate excision and PRC compared with the intact wrist. With ECR loading, the motion vector shifted from 92°(intact) to 105° after lunate excision and to 73° after PRC. With FCU loading, the direction changed from 297° (intact) to 291° after lunate excision and to 308° after PRC. The average ranges of the DTM were 93°, 77°, and 37° in Experiments 1–3, respectively. Following lunate excision alone, the DTM arc was significantly reduced to 83% of that of an intact wrist. PRC further significantly decreased DTM to 40% of that under intact conditions (Fig. 3A).
Figure 3.
Changes in wrist range of motion following surgical procedures: A Simulated active DTM was significantly reduced after lunate excision and further after PRC. B Passive circumduction motion was generally preserved after lunate excision and PRC. ∗P < .01, ∗∗P < .001.
Fluoroscopic motion imaging showed smooth movements of the midcarpal and radiocarpal joints in intact and lunate- excised wrists. After the PRC procedure, the specimens demonstrated joint margin impingement between the dorsal contour of the capitate and distal radius (Video S1, available online on the Journal’s website at https://www.jhsgo.org).
Passive circumduction motion
The overall circumduction magnitude, calculated as the sum of directional ranges, was 102% (range, 93%–110%) after lunate excision and 108% (range, 83%–130%) after PRC relative to the intact condition (Fig. 3B). There was no significant difference between these three conditions. Direction-wise analysis demonstrated that passive circumduction changed significantly in specific directions after lunate excision and PRC. Significant differences were detected at 180° among all stages, at 210° between lunate excision and PRC, and at 300° between intact and PRC (all P < .05) (Table 1).
Table 1.
Angular Deviation in Passive Circumduction Motion
| Direction | Intact | Lunate excision | PRC |
|---|---|---|---|
| 0° (ulnar deviation) |
41.8°±3.7° | 44.1°±3.1° | 42.1°±9.8° |
| 30° | 42.6°±2.7° | 45.8°±3.4° | 47.1°±9.6° |
| 60° | 54.8°±5.0° | 56.7°±4.4° | 54.7°±11.5° |
| 90° (extension) |
67.1°±8.3° | 67.3°±8.9° | 69.3°±14.8° |
| 120° | 46.6°±10.8° | 51.1°±8.8° | 53.5°±15.2° |
| 150° | 30.8°±9.0° | 33.6°±6.8° | 38.2°±10.8° |
| 180° (radial deviation) |
22.3°±8.0°＊,# | 24.6°±6.5°＊,† | 28.9°±6.2°#,† |
| 210° | 24.2°±6.5° | 24.4°±5.4°† | 30.1°±6.2°† |
| 240° | 33.8°±7.6° | 32.5°±5.7° | 39.9°±9.6° |
| 270° (flexion) |
66.5°±14.4° | 64.6°±16.0° | 60.3°±19.2° |
| 300° | 77.5°±15.7°# | 71.9°±12.1° | 64.6°±18.0°# |
| 330° | 55.1°±5.0° | 55.7°±5.7° | 51.6°±10.4° |
Values are reported as mean ± standard deviation.
Statistically significant (P < .05) between ∗: intact and lunate excision, #: intact and PRC.
Lunate excision and PRC.
Fluoroscopic observations revealed that several specimens in the PRC had a rolling-back motion pattern during passive ranges of motion (Video S2, available online on the Journal’s website at https://www.jhsgo.org).
Carpal stability
Lunate excision alone resulted in a significant increase in dorsal translation compared with that in the intact wrist. PRC significantly increased volar translation relative to both intact and lunate excision conditions (Fig. 4). Carpal dislocations were not observed in any specimen.
Figure 4.
Carpal translation distance under traction in four directions. Displacement of the third metacarpal base relative to the distal radius under 20 N traction in the dorsal, radial, volar, and ulnar directions. ∗P < .05, ∗∗P < .01, ∗∗∗P < .001.
Discussion
This study demonstrated that both lunate excision alone and PRC markedly reduced the range of simulated active DTM, while preserving passive circumduction. Lunate excision maintained DTM more effectively than PRC, preserving approximately 83% and 40% of baseline values, respectively. Given the essential role of DTM in activities of daily living, these findings suggest that lunate excision may better maintain functional wrist performance than PRC. The mean DTM range was 77° for lunate excision alone and 38° for PRC. Garg et al13 assessed wrist kinematics during seven functional tasks and introduced the concept of kinematic path length, which quantifies the angular extent of a curved wrist motion path. The reported kinematic path lengths ranged from 20° to 61°. When these values are used as reference requirements for daily activities, the present finding of a reduced DTM arc following PRC suggests that functional demands may not be fully met in clinical settings. Previous biomechanical studies have also evaluated wrist motion after PRC. DeBottis et al14 reported that PRC substantially alters wrist kinematics and reduces functional motion arcs compared with the intact wrist. These findings are comparable with the present results, demonstrating a marked reduction in simulated active DTM after PRC.
Several factors may explain the decreased DTM. First, both procedures altered the DTM plane. The plane deviation observed after lunate excision and PRC under ECRL/B and FCU traction likely produced a mismatch between the motion path and joint morphology.15 Second, PRC eliminates the intercalated proximal row, predisposing the reconstructed radiocapitate joint to contour mismatch and impingement. Blankenhorn et al16 reported that radial deviation after PRC is limited by abutment between the trapezoid and radial styloid, which may similarly restrict the DTM in the present study.
In contrast, passive circumduction remained preserved, likely due to altered contact mechanics. Capitate contact has been shown to shift dorsally and ulnarly during flexion and volarly and radially during extension,17 suggesting a swinging rotation of the distal carpal row around the radius after PRC. Passive circumduction also produced a characteristic “rolling-back” motion, in which the capitate elevates while pivoting around an impingement fulcrum. This mechanism may preserve passive circumduction despite reduced active DTM, consistent with clinical observation by Singh et al,18 who reported that active circumduction area after PRC is reduced to approximately 30% of the contralateral side. Although statistically significant differences were detected in certain directions, the magnitude of these changes was small. Therefore, the clinical relevance of these directional differences in passive circumduction remains uncertain.
Previous biomechanical studies consistently show that PRC produces elevated radiocapitate contact pressures and abnormal motion patterns due to the nonanatomic articulation between the capitate and the lunate fossa.17,19,20 Although PRC preserves multiplanar wrist motion better than limited carpal fusion,8 these alterations still reduce the dart-throwing arc and disrupt radial–ulnar deviation coupling. Wolff et al21 demonstrated that PRC limits the DTM arc to approximately 60% of normal, reflecting impaired multiplanar kinematic integrity. In contrast, the present study demonstrated that isolated lunate excision preserved a larger DTM arc and produced smoother capitate kinematics without the dorsal radiocapitate impingement characteristic of PRC. Although proximal migration of the capitate after lunate excision remains a concern, recent biomechanical and 3-dimensional in vivo studies following arthroscopic lunate excision indicate that such midcarpal disruption can be prevented.4, 5, 6 We therefore consider isolated lunate excision a reasonable intermediate option before proceeding to PRC in advanced Kienböck disease.
Lunate excision resulted in significant dorsal translation of the capitate, likely due to loss of dorsal osseous restraint, whereas PRC produced greater volar translation. The curvature mismatch between the capitate head and lunate fossa,20 combined with ligament relaxation, may facilitate translational motion between the capitate and radius. Because carpal instability is multifactorial—arising from bone alignment, capsuloligamentous integrity, and neuromuscular control—it may result in pain and functional limitations, and eventually secondary osteoarthritis. Although rare, volar carpal dislocation has been reported after PRC,22 emphasizing that instability remains a clinical concern. While simplified, this cadaveric model provides biomechanical evidence that partial carpal excision may increase the risk of translational instability.
This study has several limitations. First, as a cadaveric investigation, biological responses such as scar formation, capsular remodeling, and muscle tone could not be assessed, and the long-term effects of lunate excision cannot be determined. Repetitive loading and in vivo studies are necessary to clarify these aspects and validate the present findings. Second, certain aspects of the experimental setup may have influenced the observed kinematics. The ECRB and ECRL tendons were sutured together to standardize extension force, which may not fully replicate their independent biomechanical contributions. In addition, the transverse pin between the radius and ulna prevented proximal migration of the radius under loading, and thus, dynamic changes in ulnar variance could not be reproduced. Furthermore, the experimental configuration may not have fully replicated the physiological radial-extension component of in vivo DTM. Passive circumduction was assessed once per condition without formal repeatability testing, which may have introduced measurement variability. Differences in capsular handling between lunate excision and ligament-sparing PRC may also have influenced capsular tension and carpal stability. Third, all specimens were obtained from elderly donors. Although no gross or radiographic degenerative changes were observed, age-related cartilage alterations cannot be completely excluded.
In conclusion, lunate excision alone preserved simulated active DTM more effectively than PRC. Although both procedures maintained passive circumduction, each was associated with translational instability, underscoring the need for continued monitoring and careful surgical selection in advanced Kienböck disease.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
Acknowledgments
The authors thank Editage for English language editing, and all the staff of the Department of Anatomy, Chiang Mai University, for their valuable assistance in this study.
Supplementary Data
Fluoroscopic motion imaging showed smooth movements of the midcarpal and radiocarpal joints in intact and lunate-sectioned wrists. After the PRC procedure, the specimens demonstrated joint margin impingement between the dorsal contour of the capitate and distal radius.
Fluoroscopic observations revealed that several specimens in the PRC had a rolling-back motion pattern during passive ranges of motion.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Fluoroscopic motion imaging showed smooth movements of the midcarpal and radiocarpal joints in intact and lunate-sectioned wrists. After the PRC procedure, the specimens demonstrated joint margin impingement between the dorsal contour of the capitate and distal radius.
Fluoroscopic observations revealed that several specimens in the PRC had a rolling-back motion pattern during passive ranges of motion.