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Comparison of Clinical and Radiological Outcome of Radial Shortening and Capitate Shortening in the Early Stages of Kienbock Disease

Dariush Nazari, Amir R. Kachooei, Amin Rezaeian, Ali Birjandinejad, Amir Shahriar Ariamanesh, Mona Meybodi and Ali Moradi^{* *}Correspondence: Ali Moradi, Department of Orthopedics, Mashhad University of Medical Sciences, Mashhad, Iran, Email:

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Introduction

Pest first described lunate Avascular Necrosis (AVN) [1] and Kienbock described the radiological collapse of the lunate [2]. Since then, lunate AVN is called Kienbock disease. In a retrospective review of wrist imaging of 51,071 patients in a single-center study, Kienbock disease prevalence was found 0.27% in the United States [3]. Various surgical techniques are described for the management of Kienbock disease, and RSO is the most popular surgery due to its less interference with wrist motion [4].

In this study, we aimed to compare the outcomes of RSO and CSO, in the early stages of Kienbock disease. Our main questions were failure rate, assessing radiological changes observed in postop in comparison to pre-op, assign functional score on the basis of patient- and physician-rated questionnaires, and determining wrist range of motion and grip strength in each study group.

Materials and Methods

Participants

In a retrospective cohort study, we included all wrists with the diagnosis of Kienbock disease based on clinical and radiological findings at an academic medical center from September 2019 to May 2020. Informed consent was obtained from all individual participants included in the study.

We included patients diagnosed with Kienbock disease and a minimum follow-up of 6 months. We invited the patients for physical and radiographic examination. Antero-posterior and lateral views of the affected wrist were obtained, and the patients completed outcome questionnaires. The related ethical committee has approved the study, but the code number is removed due to blinding issues. This study was performed in line with the principles of the Declaration of Helsinki, and the reporting of this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Clinical examination

We assessed bilateral wrists' range of motion using a standard orthopedic goniometer. Grip strength was measured bilaterally using a grip meter (Jaymar Engineering, Los Angeles, CA, USA) while the patient was in a sitting position, 90 degrees elbow flexion, and neutral forearm rotation. We repeated every measurement three times, and the highest measurement was recorded in kilograms. Relative grip strength was measured in percentage compared to the unaffected side.

Questionnaires

To assess the functional outcome of the wrists at the latest followup, we used the validated versions of the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) [5] and Patient-Rated Wrist Evaluation (PRWE) [6], and Modified Mayo Wrist Score [7] questionnaires.

Radiologic staging

We determined the lunate osteonecrosis stage using Lichtman- Stahl classification on preoperative and the final radiographic wrist views [8].

Surgical techniques: Surgical techniques were based on the surgeon’s preference.

Radial Shortening Osteotomy (RSO): We performed a longitudinal volar skin incision on the radial side of the flexor carpi radialis tendon. After releasing the tendon sheet, FCR was retracted to the ulnar side to protect the median nerve. Then, 3 millimeters osteotomy was done, fixed by a 3.5 mm six-hole stainless steel straight dynamic compression plate (Synthes com, Zuchwil, Switzerland). Patients had a long arm splint for two weeks, and strengthening and range of motion exercises were gradually initiated after six weeks [4].

Capitate Shortening Osteotomy (CSO): A 3-centimeter incision was made over the dorsal of the wrist at the level of the capitate. A 2 mm transverse osteotomy was made in the capitate with a small sagittal saw, and the bone segment was removed. The capitate was osteotomized at the level of the middle and distal thirds to avoid violating the radiocarpal ligament insertions. Distal and proximal fragments were re-approximated and fixed by one or two headless Herbert screws (Zimmer, Warsaw, IN, USA) under fluoroscopic imaging. Patients had a short arm splint for two weeks, and rehabilitation programs including muscle strengthening and motion improvement were initiated after four weeks.

Failure rate

Reoperation and Mayo wrist score below 65 (equal to the poor level in Mayo wrist score) at the follow-up visit was considered a failure [9].

Statistical analysis

All data were analyzed using SPSS statistical software. We used Chi-square to compare the categorical outcome data and Paired Independent Samples T-test to compare the continuous outcome data. We also assigned 95% confidence interval (95% CI) for failure rate of each procedure.

Results

In total, 23 patients 23 wrists were included in this study. Of these, 17 patients underwent a single operation, and six patients underwent two or more procedures for the recalcitrant pain. In patients with a single procedure, ten patients underwent radial shortening osteotomy (RSO group) and seven patients underwent Capitate Shortening Osteotomy (CSO group) (Table 1).

Table 1: Demographic, radiologic, clinical, and outcome data of patients with kienböck disease.

Six (46.2%) patients in RSO and seven (70%) patients in CSO were classified as failure because of either reoperation or poor Mayo wrist score below 65. Failure rates were 0.46 (95% CI: 0.19- 0.75) and 0.7 (95% CI: 0.37-0.93) for RSO and CSO, respectively. Because the mean follow-up intervals were different between the groups, we estimated the failure rates as 1.16% and 2.59% per year for RSO and CSO, respectively.

Radiologically, one patient in each group of RSO (out of ten) and CSO (out of seven) progressed to a higher stage in comparison to the pre-operation radiographs as shown in Table 1. In the RSO group, the stage was improved in 6 wrists while 3 had no changes. The stage was improved in 3 wrists in the CSO group while three remained unchanged as shown in Table 1.

Pain score in the Mayo wrist questionnaire (score 25 for the least pain and score 0 for the worst pain) was significantly lower in the RSO group (19 (SD 4.6)) in comparison to the CSO (13 (SD 7.0)) group (P=0.037) as shown in Table 1.

Clinically, we found a significantly lower range of motion in flexion and extension when comparing operated wrist with the other side in the RSO group (53(SD 15) vs. 75(SD 21) in extension, P=0.031; 53(SD 17) vs. 75(SD 14) in flexion, P=0.008) as shown in Table 1. Additionally, we calculated the arc of motion as the sum of wrist flexion and extension, and we found comparable results in both groups (106 in RSO and 107 in CSO, P=0.97).

The operated side's mean grip strength was significantly lower than the other side in both groups (22 (SD 7.2) vs. 32 (SD 9.8) kg; P<0.001). However, it was only statistically different in the RSO group (25 (SD 6.9) vs. 34 (SD 11) kg; P=0.005) as shown in Table 1.

We also found six patients with more than one procedure for their Kienbock disease (Table 2). Three patients were initially treated using RSO, of whom two underwent CSO and one underwent lunate excision and capitate lengthening. The other three patients were initially treated using the CSO, all of whom underwent Arthroscopic lunate decompression (ALD) for the second surgery. One patient underwent three procedures due to recalcitrant pain, including the CSO followed by the ALD and finally wrist arthrodesis. We compared patients who underwent a single procedure (RSO or CSO) with patients who underwent one or more surgeries (Table 3). We found a significantly limited range of motion in wrist flexion, extension, and the arc of motion between the two groups (P=0.05, P=0.016, and P=0.17, respectively). Moreover, the relative range of motion in wrist flexion and the arc of motion were significantly different (P=0.03 and P=0.05, respectively). Although we found statistically significant lower grip strength in the re-operation group compared to other groups (17 (SD 5.3) vs. 24 (SD 7) kg, P=0.035), relative grip strength was not significantly different between the groups (P=0.269). Demographic data and outcome questionnaires did not show a significant difference between primary and reoperation groups (P>0.05).

Table 2: Characteristics of patient’s with more than one procedure for their Kienbock disease.

Table 3: Comparison of patient’s outcomes after primary procedures and re-operation.

Discussion

We tried to evaluate all patients with Kienbock disease managed with any of the RSO and CSO procedures at least six months after their last operation (Mean follow-up of 46 months). Overall, 23 patients were included in our study, out of which 6 had more than one operation. Pain score in the Mayo wrist questionnaire was significantly lower in the RSO group than the CSO group. We found a significantly limited range of motion and grip strength compared to the contralateral side in the RSO group. Only wrist flexion was significantly limited compared to the other side in CSO group. Significantly limited wrist range of motion was observed in patients with re-operation for their Kienbock disease.

Failure rate

We evaluated the failure rate of the two standard procedures in Kienbock patients. As follow-up periods differed significantly, we calculated failure rates as 1.16% and 2.59%, for RSO and CSO, respectively. Gay et al. found an 18% (2 patients out of 11) failure rate due to persistent pain who required revision surgery in their series of patients after capitate shortening osteotomy (mean follow-up=67.4 months); both underwent revision surgery due to persistent pain [10]. Reported a 25% (4 out of 16) failure rate after RSO in 25-year follow-up; one underwent silicone implant arthroplasty, one had wrist fusion and the other two patients had disabling pain in the follow-up [11].

Stage

We found no reasonable correlation between the radiographic and clinical findings whereas some patients with improved radiologic stage showed limited wrist motion and grip strength. The radiological staging did not correlate with patients’ satisfaction with the procedures. Two patients had worsened radiologic staging with Lichtman IIIA converted to IIIB [12]. Just like Watanabe et al. implicated RSO as a protective measure to Lichtman stage IV in Kienbock patients in a 21-year follow-up [9], we found no patient in stage IV in neither groups. However, Luegmair et al. found 8 of 36 patients converted stage IIIA to IV Lichtman after RSO in a 12-year follow-up [13].

Functional questionnaires

DASH score seems to be conversely correlated with follow-up duration since we found a DASH score of 19 and 21, in RSO and CSO with 57 and 20 months follow-up, found patients with RSO and CSO with 24.2 and 20 DASH scores in 3.2 and 3.1 years follow-up respectively [12], reported a DASH score of 12 in a 12-year follow-up [13], found a DASH score of 6 in patients with RSO in a 25-year follow-up [11].

The same trend was observed in Mayo wrist score. We found Mayo wrist score of 64.5 in our RSO group, while the RSO group in Luegmair et al. had a Mayo wrist score of 75 [5,13]. Reported a score of 77 in their cohort with a mean 7-year follow-up [4].

Range of motion

We found a significantly limited range of motion in wrist flexion and extension in the RSO group. Limited wrist range of motion was previously reported in several cohorts with mid-term followup for RSO [4,12,14] and CSO [10,12,15]. In a recent systematic review of 172 wrists with RSO procedure over ten years of follow-up, the mean wrist arc of motion was comparable to our results (107.4 (SD 10) vs. 106 degrees) [16]. In a long-term study, extension and flexion were 93% and 76% of the unaffected side [11]. Although wrist flexion was also limited in our study, only wrist extension was significantly lower in the involved side compared to the other side in CSO group.

Grip strength

Afshar et al. found grip strength 70.1% and 75.2% of the unaffected side in RSO and CSO groups [12]. Additionally, in RSO, grip strength in Rodrigues-Pinto et al. was 73% [11,14]. was 95% of the contralateral side [11], found 63% [15], and Gay et al. reported 72% of unaffected side grip strength in CSO [10]. Similar to these studies, we found grip strength was also diminished compared to the other side in RSO and CSO (75.3% and 71.69%, respectively). Although the literature shows that wrist motion and grip strength have improved after either of the procedures, all patients with Kienbock disease should be cautious about a diminished range of motion and grip strength. Neither of these procedures could take them back to unaffected side values.

Multiple operation results

Ultimately, three patients in each RSO and CSO group underwent re-operation due to residual pain and disability. However, residual pain in one patient with CSO and then ALD resulted in wrist arthrodesis. All these patients had worsened radiologic stage, and most of them are experiencing some degree of wrist pain and disability in daily activities. These patients were usually excluded in previous studies or reported as a failure. We assigned them into a separate group to further evaluate their condition after revision surgery. All but one had a poor result in Mayo score (<65 points). Additionally, all of them had a worse radiologic stage compared to before operation, and all but one was in stage IIIB Lichtman-Stahl. However, we found no statistically significant difference in radiologic stage in the re-operation group compared to patients in RSO and CSO groups.

Conclusion

Due to patient’s limitations for the follow-up, we could not include all patients in the current study. Also, patient’s preoperative ranges of motion and grip strength were not complete for all patients to be used for comparison. Therefore, we used the contralateral side for the comparison. The low sample size is an inevitable issue due to the low prevalence and rarity of Kienbock disease while, at the same time, not all are candidates for surgery.

In this limited study, we found none of the methods of RSO and CSO could retrieve complete wrist function. No significant difference between the two groups in terms of clinical findings, patient’s function, satisfaction, and success rate was found. RSO had slightly superiority in term of pain management. In conclusion, we evaluated three different Kienbock disease procedures with a mean 46 months follow-up. We found no significant difference in functional, satisfaction, or radiologic properties between RSO and CSO procedures. However, patients who underwent RSO had lower pain scores among others.

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