Abstract
Objective Moritomo et al introduced partial capitate osteotomy as a treatment modality for early stages of Kienböck's disease. This technique maintains articular contact between the capitate and the scaphoid. We added hamate-shortening osteotomy in addition to partial capitate shortening in cases of lunate type II. The purpose of this study was to evaluate intermediate-term results of partial capitate shortening, investigate the influence of the stage of the disease on the outcome, and assess the clinical and radiological outcomes of adding hamate osteotomy in cases of type II lunate.
Patients and Methods A total of 17 consecutive patients (3 women, 14 men) with early stages of Kienböck's disease were prospectively reviewed using the aforementioned technique. Eight patients were in stage II and nine patients were in stage IIIA according to the Lichtman classification system. Clinical outcome measures included pain visual analog score, grip strength and range of motion as a percentage of the unaffected side, and assessment using the Patient-Rated Hand and Wrist Evaluation (PRHWE) and the modified Wrightington Hospital Wrist Score (MWHWS). Radiological outcome measures included healing of the osteotomy site, Stahl index, radioscaphoid angle, and progression of the disease.
Results Follow-up period averaged 72 months. All cases of isolated capitate osteotomy and combined capitate and hamate osteotomies united fully. Clinical results revealed significant improvement in pain, grip strength and extension, and PRHWE and MWHWS values. Wrist flexion did not change postoperatively. Patients with stage II showed better overall results and significant MWHWS improvement.
Conclusion At the intermediate term, partial capitate with/without hamate shortening is an effective modality for the treatment of patients with early stage Kienböck's disease. Stage II patients showed better results than stage IIIA patients in terms of pain, flexion, grip, PRHWE, and MWHWS. Adding hamate osteotomy may improve the functional results for type II lunate; however, a larger sample is needed to elicit statistical significance.
Level of Evidence This is a Level IV, therapeutic study.
Keywords: capitate shortening, hamate osteotomy, Kienböck's disease, lunate unloading, type II lunate
Hultén 1 stated that compression of the lunate by the relatively longer radius would predispose to avascular necrosis (AVN). Joint leveling procedures were therefore developed to correct the ulnar variance and reduce the stress on the lunate. Clinically, both radial shortening and ulnar lengthening are equally effective in reducing pain and increasing range of movement (ROM) and grip strength, and may allow revascularization of the lunate in Lichtman's stages II and IIIA. The only documented difference between radial shortening and ulnar lengthening is that the latter is associated with higher rates of nonunion. 2
To avoid the complications and technical pitfalls of radial shortening osteotomy in addition to inappropriateness for patients with positive ulnar variance, Almquist 3 in 1986 described an alternative procedure to reduce lunate pressure: a capitate-shortening osteotomy associated with capitate–hamate fusion (CSCHF).
Moritomo et al 4 in 2004 introduced partial capitate shortening to avoid carpal collapse following CSCHF. They assumed that the scaphoid–capitate joint should be preserved to maintain carpal alignment.
Type II lunate, which has a separate hamate facet, is present in 45 to 73% of the population according to Viegas et al's study. 5 It is speculated that capitate shortening alone may not ensure adequate decompression of type II lunate. Hamate shortening could be added for presumably better distal unloading in these cases.
The purpose of this study was threefold: first, to assess the intermediate-term results of partial capitate osteotomy as described by Moritomo et al 4 ; second, to investigate the influence of the stage of the disease on the outcome; and, third, to assess the clinical and radiological outcome of adding hamate osteotomy in cases with type II lunate.
Case Presentation
A 32-year-old right-handed male patient, who was manual worker, presented with wrist pain, limited hand grip, and wrist ROM 6 months ago with no history of inciting trauma ( Fig. 1 ).
Fig. 1.
( A ) Preoperative X-ray (anteroposterior [AP] view: stage II, positive ulnar variance, and lunate type I). ( B,C ) MRI (magnetic resonance imaging) T1- and T2-weighted images (showing decreased signal intensity). ( D ) Intraoperative field view of miniscrew fixating capitate osteotomy. ( E ) Postoperative X-ray (AP view). ( F ) Postoperative X-ray (lateral view). ( G ) Wrist X-ray (AP view) showing early signs of lunate revascularization.
Radiographs revealed Kienböck’s disease stage IIIA, positive ulnar variance, and lunate type I. Isolated partial capitate shortening was performed and fixed with 1 miniscrew. Full union of the capitate was achieved after 6 weeks, and then removable splint was applied and rehabilitation started. He returned to his manual work 3 months after the surgery with good satisfaction. At his final follow-up; VAS, PRHWE, MWHWS, grip, and ROM (flexion and extension in comparison to the contralateral side) were 1, 5, 85, 80%, 44%, and 50%, respectively.
He had Kienböck's disease stage IIIA, positive ulnar variance, and lunate type I. Isolated partial capitate shortening was performed and fixed with a miniscrew. Full union of the capitate was attained after 6 weeks, and then removable splint was applied and rehabilitation started. He returned to his manual work after 3 months with good satisfaction. At his final follow-up, VAS, PRHWE, MWHWS, grip, and ROM (flexion and extension in comparison to the contralateral side) were 1, 5, 85, 80%, 44%, and 50%, respectively.
Patients and Methods
Prospective case series study comprised 20 patients with stage II and IIIA Kienböck's disease in whom partial capitate with/without hamate osteotomy was performed in our institute between December 2011 and August 2013. There were no exclusion criteria regarding sex or age (only skeletally mature patients were included). Three cases were excluded because of lost to follow-up, leaving 17 patients with complete follow-up. The average age of patients was 31 years (range: 17–52 years). Of the 17 patients, 3 were females and 14 were males. Eight patients were in stage II, and nine were in stage IIIA. Twelve patients had lunate type I and 5 had type II. Four patients had positive ulnar variance, seven patients had neutral ulnar variance, and six had negative ulnar variance. The dominant hand was affected in 12 patients, and the nondominant hand was affected in 5 patients. Six patients were smokers, and eight sustained injury from work-related causes. All patients had given informed consent, and the study protocol was approved by the Institutional Review Board of our university.
Clinical outcome measurement included a thorough analysis of pain using the visual analog scale (VAS), 6 assessment of wrist motion using a goniometer, and assessment of grip strength using Jamar dynamometer (second handle position from inside). Range of motion and grip strength were expressed as a percentage of the range of motion or the strength of the uninvolved side. The ability to perform different daily activities including work performance were analyzed using the Patient-Rated Hand and Wrist Evaluation (PRHWE) 7 and the modified Wrightington Hospital Wrist Score (MWHWS).
Wrightington Hospital wrist scoring system 8 was modified so that the motion parameter was transferred to the objective measurements, and we modified its scores to be a maximum of 20 when the range of motion is equal to the opposite side and 5 when it is stiff and less than the functional range, with 5 degrees increments for each grade in-between. Additionally, we considered the overall rating (total of subjective and objective scores) to be ranked excellent if it is within 91 to 100, good 80 to 90, fair 65 to 79, and poor if less than 65.
Radiologically, the patients were evaluated by plain X-ray (posteroanterior and lateral views) of the wrist preoperatively for the assessment of stage of disease according to the Lichtman classification, 9 ulnar variance, lunate type, radioscaphoid angle, and Stahl index. 10 Postoperatively, X-rays were evaluated to assess healing of the osteotomy site and progression of disease. Healing of the osteotomy was defined by osseous bridging in more than 50% of the opposing bony surfaces. Progression of the disease was judged by comparison of the radioscaphoid angle in the lateral view, Stahl index, and appearance of arthritic changes. Radioscaphoid angle > 60 degrees denotes progression to stage IIIB with carpal collapse. Decrease of Stahl index denotes lunate collapse. All patients were scanned preoperatively by magnetic resonance imaging (MRI).
Surgical Technique
The patients were treated with partial capitate shortening osteotomy according to the technique of Moritomo et al. 4 We added partial hamate osteotomy in two of the five cases with lunate type II (randomly selected) to ensure complete unloading of the lunate as there is a separate hamate facet in type II lunate.
The procedure was performed using regional (2 cases) or general anesthesia (15 cases). Under tourniquet control, a 3-cm longitudinal dorsal incision was made overlying the capitate. The extensor tendons of the fourth compartment were retracted, and the capsule of the midcarpal joint was exposed. Using a longitudinal dorsal incision of the capsule of the midcarpal joint and the distal part of the dorsal intercarpal ligament on the capitate, the proximal joint surface of the capitate was exposed.
Osteotomy of the capitate was performed with a sharp osteotome. The first osteotomy line was located longitudinally on the capitate ridge (which separates the articular facets opposing the lunate and the scaphoid), and the second one was located transversely 3 to 4 mm distal to the edge of the articular surface of the capitate facing the lunate perpendicular to the first cut, forming a “inverted L” shaped line. The third cut is made transverse, parallel and 2 mm distal to the second cut, and a rectangular block of the capitate is removed, is made as shown in Fig. 1D . The volar capsule and volar ligaments should be preserved because most of the capitate blood supply is derived from the volar aspect. The cut segment can be removed with a small curette in a piece-by-piece manner. The mobile segment can then be easily compressed against the more distal segment by using a curved, blunt instrument, without disturbing the articular surface.
In two of the five cases with lunate type II, additional partial hamate osteotomy was performed in the same manner as capitate osteotomy. The first osteotomy line was located longitudinally on the hamate, and the second one was located transversely 2 to 3 mm distal to the edge of the articular cartilage of the hamate opposite the lunate, forming a “reverse L” shaped osteotomy line which is composed of two straight lines crossing almost at an angle of 90 degrees (mirror image of capitate osteotomy). The second transverse cut was made parallel and 2 mm distal to the first transverse cut. The cut segment can be removed with a small curette in a piece-by-piece manner. The mobile segment was easily compressed against the more distal segment using a curved blunt instrument, without disturbing the articular surface just like capitate shortening step, and then a 0.8-mm Kirschner wire (K-wire) in one case and miniscrew in the second case were inserted through the osteotomy line for fixation.
Eight osteotomies were fixed with K-wires, 6 with miniscrews, and 3 with headless screws. The tourniquet was released, and the bleeding was controlled by cautery prior to closure of the wound.
Rehabilitation
A short-arm cast was applied, and light activity with the fingers was encouraged. Stitches were removed after 2 weeks, whereas the cast was removed approximately 6 weeks after surgery. The patients were seen every 2 weeks till healing of osteotomy site and thereafter every month to evaluate clinical improvement and any sign of lunate revascularization or collapse. Physical rehabilitation started after 6 weeks in the form of gradual ROM, grip strength, and pain control modalities.
The patients were encouraged to continue light activities for the next few months. Heavy exercises were allowed after 3 months.
Postoperative changes in VAS, the range of motion, grip strength, PRHWE, and MWHWS, as well as postoperative changes in the Stahl index and the radioscaphoid angle were compared with preoperative values using the paired-sample Student t -test. Comparison between the functional outcome of the patients with Lichtman stage II and IIIA, or patients with lunate type 2 with or without hamate osteotomy was performed using unpaired Student's t -test. Fisher's exact test was used to examine the relationship between categorical variables. The level of significance was set at p ≤ 0.05. All data analysis was calculated with statistical software SPSS, version 15 for Windows (SPSS Inc., Chicago, IL).
Results
Follow-up period averaged 72 months (range: 63–82 months). Union was achieved in all cases of isolated capitate osteotomy, and all cases of combined capitate and hamate osteotomies, within an average of 6.5 weeks (range: 6–8 weeks). Table 1 summarizes the overall functional results of all our patients 1 year postoperatively and at the final follow-up.
Table 1. Summary of the functional results at 1 year and the final FU.
| Preoperative | 1-y FU | Final FU | |
|---|---|---|---|
| Pain (VAS) | 7.12 | 3.4 ( p < 0.01) | 1.41 ( p < 0.001) |
| Flexion | 60.12% | 60.4% ( p = 0.78) | 59.82% ( p = 0.93) |
| Extension | 49.85% | 66.8% ( p < 0.001) | 66.76% ( p < 0.001) |
| Grip | 47.12% | 61.9% ( p < 0.05) | 75% ( p < 0.01) |
| PRHWE | 61.91 | 39.3 ( p < 0.001) | 20 ( p < 0.001) |
| MWHWS | 50.29 | 63.2 ( p < 0.001) | 80 ( p < 0.001) |
Abbreviations: FU, follow-up; MWHWS, modified Wrightington Hospital Wrist Score; PRHWE, Patient-Rated Hand and Wrist Evaluation; VAS, visual analog score.
According to the grading of VAS performed by Jensen et al, 11 preoperatively, three patients had mild pain, nine had moderate pain, and five had severe pain. At the final follow-up, three patients were pain-free and 14 patients had mild pain with strenuous activity.
When comparing the results between patients with stage II and stage IIIA, the mean age for stage II patients was 31.4 years (range: 17–52 years), whereas the mean age for stage IIIA patients was 30.7years (range: 22–40 years). This difference did not reach significance ( p = 0.86). The average length of follow-up was 70 months for stage II patients and 73.2 months for stage IIIA patients ( p = 0.92). In stage II patients, eight had negative ulnar variance, five had neutral ulnar variance, and two had positive ulnar variance, whereas in stage IIIA patients, five had negative ulnar variance, three had neutral ulnar variance, and one had ulnar positive variance. There was no difference in the distribution of ulnar variance between the two stages according to Fisher's exact test ( p = 1). Patients with stage II had better results than patients with stage IIIA regarding pain VAS, flexion, grip, PRHWE, and MWHWS. However, these values were not statistically significant except for MWHWS score ( p < 0.05).
On comparing the results of isolated capitate shortening osteotomy and combined capitate and hamate shotening osteotomies in type II lunate in terms of VAS, PRHWE, MWHWS, grip, and ROM (flexion and extension in comparison to the contralateral side); cases of isolated capitate shortening osteotomy achieved 3.5, 33, 55, 67%, 60%, and 72%, respectively, in comparison to combined capitate and hamate shortening osteotomy cases which showed average postoperative values of 3, 25, 73, 73%, 63%, and 78%.
Comparing both 1 year and the final follow-up results revealed significant improvement in VAS from 3.4 at 1 year to 1.4 at the final follow-up ( p < 0.001) and in handgrip from 61.9% at 1 year to 75% at the final follow-up ( p < 0.001). PRHWE score at 1 year was 39.3, which improved to 20 at the final follow-up ( p < 0.001). MWHWS score at 1 year follow-up was 63.2, which improved to 80 at the final follow-up ( p < 0.001). ROM did not change at 1 year and the final follow-up ( p = 0.67 for flexion, p = 1 for extension)( Table 1 ).
Stahl index and radioscaphoid angle did not change significantly postoperatively. Mean preoperative Stahl index was 0.44 ± 04 and postoperative Stahl index was 0.43 ± 02, whereas mean radioscaphoid angle changed from 49 ± 2 degrees preoperatively to 51 ± 3 degrees postoperatively. These changes were not statistically significant ( p = 0.64), ( p = 0.52) successively.
Complications
One patient developed screw back-out, requiring removal (during the removal procedure, we surprisingly found fibrocartilage completely covering the articular osteotomy step). In one case unintended completion of the transverse limb of the capitate waist osteotomy happened (in this patient, the horizontal limb osteotomy was performed before the vertical one), on follow-up of this case AVN of the capitate was detected throughout the whole follow-up period. One case deteriorated from stage IIIA to IIIB, this was type I lunate for which isolated capitate shortening osteotomy was done.
Discussion
This study reports the intermediate-term results of treating Kienböck's disease with partial capitate shortening using Moritomo's technique. This prospective study included 17 consecutive patients who had stage II or IIIA disease. At the final follow-up (mean of 72 months), 3 patients became totally pain-free and 14 had mild pain with strenuous activities. Mean VAS was 1.4. In the study of Citlak et al, 12 they performed partial capitate shortening in seven patients with early stage of Kienböck's disease. Their patients were followed-up for a median of 38 months (range: 15–46 months). The Lichtman stage changed in one patient from IIIA to IIIB and in another from II to IIIA. The mean preoperative VAS was 8.2 (range: 7–10) and the postoperative VAS was 3.1 (range: 1–5). The mean time to return to work was 5.5 months (range: 1.5–12 months). In the study by Gay et al, 13 11 cases with neutral ulnar variance in early stage disease were treated with isolated capitate shortening osteotomy fixed with staples. After a mean of 67.4 months follow-up, the mean VAS was 1.7. In Rodrigues-Pinto et al's 2 study on radial shortening performed on 18 patients with stage II or III, 12 patients were asymptomatic and 6 reported mild pain (mean follow-up was 10.3 years).
Grip strength improved significantly to reach 75% of the strength of the unaffected side ( p < 0.01). In Citlak et al's 12 study, the mean grip strength in the operated hands was 73% (range: 26–100%). In Rodrigues-Pinto et al's 2 series, mean grip strength reached 73.2% of the contralateral strength. Gay et al 13 documented improvement of grip strength by 25% of the unaffected side, with no mention of preoperative value. Waitayawinyu et al 14 reported on the results of capitate shortening osteotomy with vascularized bone grafting to treat 14 patients with stage II and IIIA. There was improvement in grip strength from 58 to 78% of the unaffected side. It is speculated that these differences may be due to differences in hand-dominance distribution among different series or due to differences in follow-up periods between these studies. According to Tang and Imbriglia, 15 it takes more than 2 years for grip strength to reach its plateau level. However, what is inferred from the results of previous studies (including this study) is that the postoperative grip strength of the operated hand is expected to be less than that of the contralateral side at the intermediate-term follow-up.
Wrist flexion did not change postoperatively, whereas extension improved from 49.85 to 66.76% of the contralateral side ( p < 0.001). Schuind et al 16 demonstrated that dorsal approach may result in less wrist flexion. Rock et al 17 reported that the improvement in the wrist ROM averaged 15 degrees in the flexion–extension arc. In Gay et al's 13 series, flexion–extension arc did not change following surgery. In Rodrigues-Pinto et al's 2 study, the mean ROM improved from 76.8 degrees preoperatively to 100.5 degrees ( p < 0.001). Compared with the unaffected side, mean extension was 71.4% and flexion was 79.4%. In the study of Waitayawinyu et al, 14 the average arc of flexion–extension was 78% of contralateral motion, with 4% less than preoperative values. Statistical significance of these changes was not all specified; however, they stated that surgery had a minimal effect on wrist motion. Given these defects in previous reports, it may be difficult to compare our results to these reports. However, it may be implied that the absolute ROM in our patients is comparable to that reported in these studies. Table 2 presents a summary of the results of published studies of capitate shortening osteotomy.
Table 2. Summary of different studies reporting results of capitate osteotomy.
| Study | Year of publication | No. of patients | Procedure | FU | ROM | Grip (% improvement) | VAS | Stahl index | Time to union |
|---|---|---|---|---|---|---|---|---|---|
| Waitayawinyu et al 14 | 2008 | 14 | Capitate shortening with VBG | NA | Flexion–extension arc 4% less | 20% | Not mentioned | Not changed | 6.8 wk |
| Andre et al | 2009 | 11 | Isolated capitate shortening | NA | Not changed | 25% | Improved to 1.7 | Not changed | Not mentioned |
| Afshar et al | 2010 | 9 | Isolated capitate osteotomy | NA | Improved | Not mentioned | Improved | Not changed | 6 wk |
| Citlak et al 12 | 2014 | 7 | Partial capitate shortening | 38 mo | Not mentioned | Improved to 73% of the unaffected side | Improved from 8.2 to 3.1 | Not mentioned | |
| This study | 2018 | 17 | Partial capitate shortening | 72 mo | Extension improved 15% Flexion 1% less |
Improved to 65% | Improved from 7.1 to 1.4 | Not changed | 6.5 wk |
Abbreviations: FU, follow-up; NA, not available; ROM, range of movement; VAS, visual analog score; VBG, vascularized bone graft.
Waitayawinyu et al 14 performed complete capitate and hamate osteotomies when both of them articulate with the lunate and triquetrum as a single unit or if an incongruous hamate–lunate articulation was noted during capitate osteotomy. We added partial hamate osteotomy to partial capitate shortening in two out of five cases with lunate type II; the other three cases of type II underwent classic isolated partial capitate shortening. We assumed that this will adequately unload lunate when it articulates with the hamate in addition to the capitate.
The results were better in the combined hamate and capitate osteotomy group in all parameters except flexion range. However, no statistical significance can be calculated because of a small number of cases. Larger sample is needed to state confidently if adding hamate osteotomy in these patients could improve the clinical outcome. It is worth noting that Kataoka et al 18 recently published their results of a biomechanical study on the effect of partial capitate shortening in a cadaveric model. They stated that the radiolunate joint mean pressure significantly decreased by approximately 50% irrespective of the lunohamate articulation status.
We tried to find a relation between the stage of the disease and the clinical outcome. Stage II patients had a tendency for better results than stage IIIA patients in terms of VAS, wrist flexion, grip, and PRHWE. Only values for MWHWS were statistically significant. These results were comparable to the results of Waitayawinyu et al. 14
Unintended complete capitate osteotomy was performed in one case. In this case, we started with the horizontal limb before the vertical limb. After this case, decision to start with the vertical limb was taken and proved to be safer.
No AVN of the capitate occurred after partial capitate osteotomy. Posterior approach may be safer as blood supply of the capitate comes mainly from the volar side according to Gelberman et al. 19 Also, the main blood supply coming from the body to the head is not completely violated with this partial osteotomy.
There is a concern that by conducting partial capitate osteotomy, we create an intra-articular step that may lead to arthritic changes. In this study with intermediate follow-up period (mean: 72 months), we did not find arthritic change; moreover, in case we needed to explore and remove a prominent screw, we found fibrocartilage covering the osteotomy site of the capitate head.
It was found that pain, as reflected by VAS, and functional outcome, as reflected by both PRHWE and MWHWS, showed progressive improvement from 1 year postoperatively till the final follow-up. Also, grip strength progressively improved, which is consistent with the conclusion of Tang and Imbriglia 15 that it takes more than 2 years for grip strength to reach its plateau level. ROM did not change after one year, which means it reaches its plateau level earlier.
This study has, however, some limitations. First, this is not a randomized controlled study. No control group was assigned randomly to radial shortening or complete capitate osteotomy; therefore, no definitive statement on treatment differences can be made. Second, measurement bias could have been introduced as the observer who collected and analyzed functional and radiological data was not masked to the study and data of the patients. Third, the number of patients with lunate type II was small to delineate definitely the benefit (if any) of adding hamate osteotomy in this group. Fourth, no assessment was performed for revascularization of the lunate postoperatively.
Based on the intermediate-term results of this study, it is concluded that partial capitate with\without hamate shortening is effective for the treatment of patients with stage II and IIIA Kienböck's disease. Patients with stage II disease showed a tendency for better results. Motion is maintained, pain improved, grip strength increased, and overall function is improved by time. The procedure is minimally invasive and technically easy.
Conflict of Interest None declared.
Ethical Approval
This research has been approved by the Ethical Review Committee of the Faculty of Medicine, Ain Shams University.
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