Arthroscopic Debridement and Arthrolysis for the Treatment of Advanced Kienböck's Disease: 18-Month and 5-Year Postoperative Results

Abstract

Background  Salvage procedures, such as proximal row carpectomy, limited or total wrist arthrodesis, and wrist replacement, are generally preferred to treat advanced Kienböck's disease. However, these procedures are particularly aggressive and may have unpredictable results and potentially significant complications.

Questions/Purpose  This study aimed to present the short- to mid-term clinical and functional results of arthroscopic debridement and arthrolysis in the management of advanced Kienböck's disease.

Patients and Methods  Fifteen patients in whom Lichtman Stages IIIA to IIIC or IV Kienböck's disease was diagnosed and treated by arthroscopic wrist debridement and arthrolysis were included in this retrospective study. The mean age was 30 years (range: 21–45). The mean follow-up period duration was 36 months (range: 18–60). The Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS), wrist range of motion (ROM), and grip strength were measured preoperatively and then again at the final follow-up visit.

Results  The mean DASH and VAS scores improved from 41 (range: 31–52) and 7.1 (range: 6–8) preoperatively to 13 (range: 8–21) and 2 (range: 0–3; p  < 0.001) at the final follow-up visit, respectively. The mean wrist flexion and extension values increased from 32 (range: 20–60 degrees) and 56 degrees (range: 30–70 degrees; p  = 0.009) preoperatively to 34 (range: 10–65 degrees; p  = 0.218) and 57 degrees (range: 30–70 degrees; p  = 0.296) at the final follow-up appointment, respectively, although these findings were statistically insignificant. The mean strength of the hand grip increased from 22.7 (range: 9–33) to 23.3 (range: 10–34; p  = 0.372).

Conclusion  Arthroscopic debridement and arthrolysis may improve wrist function and quality of life due to the preserved ROM and hand grip strength after short- to mid-term follow-up periods despite the radiographic progression of Kienböck's disease.

Level of Evidence  This is a Level IV, retrospective case series study.

Kienböck's disease is characterized by avascular necrosis of the lunate that may proceed to sclerosis and collapse of the bone, wrist instability, and ultimately, end-stage arthrosis. Although considered a rare clinical entity, the disease often requires surgical treatment due to symptoms of progressive wrist pain and loss of function. ¹ The Lichtman et al's classification is currently the most widely used classification system in staging and directing treatment of patients with Kienböck's disease. ² It has evolved with time and now includes Stage IIIC, which can be defined as a complete coronal plane split regardless of the lunate or wrist morphology. ³

Despite a multitude of available treatment options, management of Kienböck's disease remains a considerable challenge, even in the best hands. As the etiology of the disease is still inadequately understood, no clear consensus has defined the most suitable treatment. ⁴ Nonetheless, as a general approach, preservation treatments, such as immobilization, joint-leveling, or revascularization procedures, may be applied in the early stages of the disease where the lunate remains viable without degeneration (Lichtman Stages I and II). In contrast, salvage procedures, such as proximal row carpectomy, limited scaphotrapeziotrapezoid or scaphocapitate arthrodesis or total wrist arthrodesis, and wrist replacement, are mostly reserved for the late stages that are complicated by the collapse of the lunate and subsequent degeneration of the wrist (Lichtman Stages III and IV). ^{2 5} Nonetheless, salvage procedures are particularly aggressive and can lead to unpredictable results and potentially significant complications. ^{6 7 8}

Over the past few decades, the use of arthroscopy has gained popularity in the diagnosis and treatment of Kienböck's disease. Wrist arthroscopy, a minimally invasive procedure, offers the advantages of lower morbidity, accelerated recovery, increased wrist motion, and eventual higher patient satisfaction. ⁹ To avoid major salvage procedures, we have consecutively performed arthroscopic synovectomy, irrigation, debridement, and arthrolysis as a minimally invasive alternative treatment for patients with advanced stages of Kienböck's disease (Lichtman Stages IIIA–IIIC and IV) for the past several years.

This study aimed to present the short- to mid-term clinical and functional results of arthroscopic debridement and arthrolysis in the management of advanced Kienböck's disease.

Patients and Methods

The medical records of 21 consecutive patients diagnosed with Lichtman Stages IIIA to IIIC or IV Kienböck's disease ² and treated by arthroscopic wrist debridement and arthrolysis from 2013 to 2018 at our institution were retrospectively reviewed. All patients were assessed based on the eligibility criteria (inclusion and exclusion) presented in Table 1 . After excluding 6 patients (1 was lost to follow-up, 1 had inadequate medical records, and 4 underwent a salvage procedure after the index operation), the remaining 15 patients (9 men, 6 women; 15 wrists) who met the inclusion criteria were included in the study and invited to a final follow-up examination. The approval of the Institutional Review Board was obtained prior to data collection, and informed consent was provided by all participants.

Table 1. Eligibility criteria for inclusion and exclusion of the study participants.

Inclusion criteria	Exclusion criteria
• A diagnosis of Kienböck's disease • Lichtman Stage IIIA, IIIB, IIIC, or IV • Complete medical records and radiographic images • Being willing to participate in the study	• Lost to follow-up • Inadequate medical records • Patients who underwent a salvage procedure • Being unwilling to participate in the study

All patients included in the study presented with unilateral Kienböck's disease. The mean age of the patients was 30 years (range: 21–45). The mean follow-up duration was 36 months (range: 18–60). The underlying conditions were a history of major trauma to the wrist in two patients and repetitive microtrauma associated with occupation in the remaining participants ( Table 2 ).

Table 2. Demographic characteristics of the study participants.

Number of patients	15
Gender (female/male)	6/9
Age (y), mean (minimum–maximum)	30 (21–45)
Follow-up (mo), mean (minimum–maximum)	36 (18–60)
Lichtman Stage	IIIA → 5 IIIB → 5 IIIC → 3 IV → 2
Bain and Begg's arthroscopic classification	Grade 1 → 2 Grade 2a → 5 Grade 2b → 3 Grade 3 → 3 Grade 4 → 2
Dominant: nondominant hand	12/3
Underlying conditions	Trauma → A fall on the outstretched hand ( n  = 1)  Traffic accident ( n  = 1) Wrist overuse → Jackhammer use ( n  = 1)  Cashier ( n  = 1)  Secretary ( n  = 2)  Track driver ( n  = 2)  Steel factory worker ( n  = 1)  Furniture factory worker ( n  = 1)  Recreational sporting activities ( n  = 5)

The initial diagnosis was established clinically and radiographically following a standardized physical examination and routine X-ray evaluation of the hand using both anteroposterior and lateral views. The diagnosis was then confirmed by magnetic resonance imaging or computed tomography in all patients. The stage of disease was categorized according to Lichtman et al's classification system.

The most common symptom was mechanical pain in the wrist that was aggravated by physical activity. The pain posed considerable difficulties to each patient not only during recreational activity but also when performing household and occupational tasks. The physical examination revealed diffuse tenderness at the wrist in all patients.

Based on the senior author's preference and experience, all the patients initially underwent nonoperative treatment, including activity modification, nonsteroidal anti-inflammatory medication, and orthoses, for a minimum of 3 months. None of the patients benefited from the nonoperative treatment modalities, so the wrist arthroscopy was performed.

Clinical Evaluation and Outcome Measures

The Disabilities of the Arm, Shoulder, and Hand (DASH) score, ¹⁰ visual analog scale (VAS), wrist range of motion (ROM), and grip strength were measured in all patients both preoperatively and then again at the final follow-up appointment.

The DASH score is a validated functional outcome measure used to evaluate overall upper-extremity disability, and it includes a 30-item disability/symptom scale with final scores ranging from 0 (no disability) to 100 (the most severe disability). ^{10 11} The VAS was used to evaluate changes in pain intensity. The VAS score utilized in this study is a modified and simplified measure in which the pain intensity experienced during daily activities is rated on a scale of 0 to 10, where 0 indicates no pain and 10 indicates the worst pain imaginable. ^{12 13} Passive ROM of the wrist (flexion and extension) was measured using a universal standard goniometer as described previously. ¹⁴ Grip strength was assessed using a Jamar dynamometer (Clifton, NJ) and the mean of three obtained maximum values. Carpal ligament instability was examined based on the Watson's scaphoid shift test at the final follow-up.

Arthroscopic Technique and Findings

Each operation was performed by the same surgeon, who was specialized in arthroscopic wrist surgery. After the induction of general anesthesia, the patient was placed in the supine position, and wrist arthroscopy was performed based on a standardized procedure. ¹⁵ A pneumatic tourniquet was applied to the upper arm, and the hand was suspended in traction of 7 to 10 pounds using a traction towel. The 1–2, 3–4, and 6R portals were alternately used as both working and viewing portals. The radiocarpal joint was initially visualized with a 2.4-mm, 30-degree arthroscope (Arthrex, Naples, FL) and then debrided properly to remove loose synovial tissue, radiocarpal septa, loose bodies, chondral flap, and interosseous ligament (if a partial or total tear presented) using a radiofrequency ablation probe (ArthroCare, Sunnyvale, CA) or an oscillating shaver (Arthrex). Diagnostic arthroscopy revealed radiocarpal synovitis in all patients. Fragmentation of the lunate was noted in most patients; therefore, only osteochondral flaps (if present) were removed from the lunate facet without performing any decompression to avoid increasing fragmentation.

At the next stage, arthrolysis was performed to remove adhesions in the radiocarpal joint and release the dorsal and volar radiocarpal ligaments as well as the capsule of the wrist joint from the radial attachments. Finally, the mid-carpal joint was examined through the ulnar and radial portals, and carpal instability was routinely tested by inserting a probe into the lunotriquetral (LT) and scapholunate (SL) intervals. The status of the LT and SL ligaments was noted. A partial SL ligament tear was identified in 9 patients, while 5 had a total SL tear, 5 had a partial LT tear, and 10 had a total LT tear. Debridement was performed, and then, the articular surfaces of the lunate, capitatum, and distal radius were carefully inspected.

Postoperative Rehabilitation Protocol

All patients underwent a similar rehabilitation protocol. Passive ROM exercises of the wrist began immediately postoperatively. Between 1 and 6 weeks after the operation, active ROM was progressively allowed. Strengthening exercises and hand ergotherapy were implemented 6 weeks postoperatively under the supervision of a physiotherapist.

Results

Figure 1 illustrates the pre- and postoperative changes for each outcome measure in each patient.

Fig. 1.

Pre- and postoperative comparative results of each participant. DASH, Disabilities of the Arm, Shoulder, and Hand; ROM, range of motion; VAS, visual analog scale.

The mean DASH score improved from 41 (range: 31–52) preoperatively to 13 (range, 8–21) at the final follow-up visit ( p  < 0.001), and the mean VAS score improved from 7.1 (range: 6–8) to 2 (range: 0–3; p  < 0.001) ( Table 3 ).

Table 3. Preoperative and final follow-up clinical outcomes of the patients.

Variables	Preoperative	Postoperative	p -Values
DASH, mean (minimum–maximum)	41 (31–52)	13 (8–21)	<0.001
VAS, mean (minimum–maximum)	7.1 (6–8)	2 (0–3)	<0.001
Wrist ROM (deg), mean (minimum–maximum)
Flexion	32 (20–60)	34 (10–65)	0.218
Extension	56 (30–70)	57 (30–70)	0.296
Hand grip strength (kg)	24.5 (12–33)	25.1 (10–34)	0.372

Abbreviations: DASH, Disabilities of the Arm, Shoulder, and Hand; ROM, range of motion; VAS, visual analog scale.

The mean amount of wrist flexion and extension increased from 32 (range: 20–60 degrees) and 56 degrees (range: 30–70 degrees; p  = 0.009) preoperatively to 34 (range: 10–65 degrees; p  = 0.218) and 57 degrees (range: 30–70 degrees; p  = 0.296) at the final follow-up appointment, respectively, although the difference was statistically insignificant. The mean strength of hand grip increased from 22.7 (range: 9–33) to 23.3 (10–34), but this change did not reach significance ( p  = 0.372) ( Table 3 ).

At the final follow-up visit, the radiological examination revealed that three patients classified as Stage IIIA prior to surgery had progressed to Stage IIIB, two patients with Stage IIIB had moved on to Stage IIIC, and one patient with Stage IIIC was reclassified with Stage IV disease. Additionally, none of the patients had carpal instability based on the Watson's test at the final follow-up examination.

Complications

Based on the Bain and Begg's arthroscopic classification system, ¹⁶ two patients were identified as grade 1, five patients as grade 2a, three patients as grade 2b, three patients as grade 3, and two patients as grade 4. One patient experienced neuropathic pain secondary to iatrogenic injury to the superficial branch of the radial nerve, which resolved 1 year postoperatively. No other complications were noted, and none of the included wrists had undergone a revision procedure during the follow-up period. However, four patients who underwent a salvage procedure after the index operation due to persistent wrist pain were excluded from the study. Of these four patients, one patient with an intact lunate facet and articular surface of the capitatum (Lichtman Stage IIIA) underwent proximal row corpectomy 1 year postoperatively. While scaphocapitate arthrodesis was performed in another patient with lunate facet degeneration (Lichtman Stage IIIB) 6 months postoperatively, total wrist fusion was performed in the remaining two patients with severe wrist arthrosis (Lichtman Stage IV) 4 and 9 months after the index operations, respectively.

Discussion

In advanced stages of Kienböck's disease, preservation treatments, such as immobilization, joint leveling, or revascularization, typically fail, and patients are frequently impaired in terms of daily living and work-related activities to a great extent. ¹⁷ These patients are complicated by the progressive collapse and fragmentation of the lunate; they have traditionally been treated by major salvage procedures, including proximal row corpectomy, limited scaphotrapezoid or scaphocapitate arthrodesis, or total wrist arthrodesis, to relieve pain and restore function. ² Although these procedures can now be performed via arthroscopic or arthroscopic-assisted methods to reduce patient morbidity, the success rates vary considerably in the literature, and the procedures may induce several potential complications, including loss of motion in the wrist joint, a prolonged recovery time, nonunion, persistent pain, and eventual premature osteoarthritis. ^{18 19 20}

Despite the inevitable progression of the disease, we attempted to benefit from several advantages the arthroscopic technique has over proximal row carpectomy and limited fusion procedures. We consecutively performed arthroscopic wrist debridement and arthrolysis in patients with Stages IIIA to IIIC and IV Kienböck's disease. Our primary goal with this treatment approach was to relieve the pain's intensity as well as improve or at least preserve wrist ROM and muscle strength. In our case series, three patients reported complete relief of pain; of these patients, one exhibited decreased ROM, one maintained ROM, and one experienced improved ROM and hand grip strength. The remaining 15 patients reported substantial relief in their pain and showed slightly improved or maintained ROM. Our results indicated that arthroscopic debridement and arthrolysis were effective at providing pain relief but were not completely sufficient at improving ROM and grip strength.

Unlike most degenerative diseases of the wrist, Kienböck's disease predominantly presents in young and middle-aged groups (as in our study) and thus imposes a substantial quality of life and socioeconomic burden on patients with physically demanding hobbies and professions. ²¹ We considered that significant improvement in the DASH score, which is a validated, disease-specific functional and quality-of-life score, ¹⁰ corresponded to higher rates of returning to work and also with enhanced quality of life in our cohorts. Moreover, even extended maintenance without significant improvement in ROM and grip strength may be considered favorable results in the working age population.

Arthroscopic debridement has been used as an alternative treatment for some rheumatological disorders ²² and late stages of SL advanced collapse ^{23 24} in the field of wrist and hand surgery. However, to the best of our knowledge, only one previous study evaluated the role of arthroscopic debridement in the management of advanced Kienböck's disease. In 1999, Menth-Chiari et al ¹⁵ used an approach similar to ours to perform arthroscopic debridement of the necrotic lunate and degenerative intrinsic ligaments in eight patients with Stages IIIA and IIIB Kienböck's disease. The authors found arthroscopic debridement to be effective for pain relief, which was consistent with our findings. However, they reported significantly improved ROM and grip strength in all of their patients despite the radiographic progression of the disease during the follow-up period, which lasted from 6 to 42 months. This finding was contradictory to our results.

Although mechanical wrist pain is typically the chief complaint associated with Kienböck's disease, restriction of motion (especially in flexion) is another cause of impairments in quality of life and functioning, as seen in our case series. In an effort to improve wrist ROM, we routinely perform arthrolysis in addition to arthroscopic debridement to release the radiocarpal ligaments and joint capsule of the wrist from the volar and dorsal radial attachments. To our knowledge, our study is to first introduce arthroscopic arthrolysis as a part of treatment for Kienböck's disease. Some surgeons ^{25 26} have recently performed this relatively new technique for posttraumatic wrist stiffness and determined selective resection of the dorsal and volar wrist joint to be useful at improving wrist flexion and extension. Contrary to previous findings, we observed no significant improvement in wrist flexion/extension postoperatively. Previous studies mostly consisted of patients with wrist stiffness secondary to a distal radius fracture. Given the progressive nature of Kienböck's disease, arthroscopic arthrolysis is not likely to be able to improve the wrist ROM in patients who have already reached the advanced stages of the disorder. Nonetheless, unlike most degenerative diseases of the wrist, Kienböck's disease predominantly presents in young and middle-aged groups, so even extended maintenance without significant improvement in ROM and grip strength may be considered favorable results.

It is also worth noting that carpal instability may develop due to the degeneration and avulsion of the ligaments during the natural process of Kienböck's disease and may be predominantly hidden by wrist rigidity. Accordingly, arthrolysis can uncover a hidden carpal instability, and its clinical manifestations may become apparent following the proecdure. ²⁷ None of the patients in our case series experienced such a complication, which may be due to the fact that we could not achieve a significant improvement in wrist ROM. Additionally, we assessed carpal instability using the Watson's test, but diagnostic arthroscopy is the gold standard test for identifying carpal instability. Therefore, a second-look arthroscopy may have revealed evidence of carpal instability.

Finally, several limitations of this study must be considered. The major limitations were its retrospective nature, limited sample size, and short- to mid-term follow-up period duration. Another limitation was the lack of a control group. Further prospective studies are needed to confirm these results.

Conclusion

Arthroscopic debridement and arthrolysis may improve wrist function and quality of life by preserving ROM and hand grip strength despite the radiographic progression of Kienböck's disease. With lower complication rates, this arthroscopic procedure should be considered in the treatment armamentarium for patients with advanced Kienböck's disease as it may delay salvage procedures by a significant amount of time.