Vascularized Bone Grafts from the Dorsal Wrist for the Treatment of Kienböck Disease

Abstract

Previous literatures described various methods of treatment for Kienböck disease depending on the patient characteristics, the severity of the symptom, and radiological staging. 1-8 Treatment options range from conservative measurements to surgical interventions. 9-12 Several authors advocated a biomechanical approach to reduce load transmission on the necrotic lunate, [13][14][15][16][17][18][19] and good clinical results have been reported in joint leveling procedures such as radial shortening or ulnar lengthening 20-22 and in radial or ulnar wedge osteotomy. 23,24 Hori et al 25 introduced a biological approach of revascularization for necrotic bones based on their experimental results. Since then, there have been several donor sites available for vascularized bone graft in the treatment of AbstractPurpose The objective of this article is to evaluate functional and radiological outcomes of vascularized bone grafts for stage 2 and 3 Kienböck disease. The outcomes of three different donor sites via dorsal approach of the wrist were compared. Pearls and pitfalls in surgical technique were discussed. Methods There were 28 patients who underwent vascularized bone grafts, including the extensor fourth and fifth compartmental artery graft of distal radius in 8 patients, the first and second supraretinacular intercompartmental artery graft of distal radius in 12 patients, and the second dorsal metacarpal neck graft in 8 patients. Average age was 32 years, and radiological grading according to Lichtman classification was stage 2 in 8 patients, stage 3A in 10 patients, and stage 3B in 10 patients. Temporary pinning fixing the midcarpal joint was conducted for 10 weeks postoperatively. Results Follow-up periods averaged 70 months. Pain reduced in 27 patients, and visual analog scale for pain of pre-and postoperative level averaged 59 and 18. Range of wrist flexion and extension motion improved from 87 to 117 degrees, and average grip strength improved from 21 kg preoperatively to 33 kg postoperatively. Carpal height ratio had almost no change from 0.52 to 0.53. Fragmentation of necrotic bone healed in 7 of the 14 cases. Comparative analyses of functional and radiological outcomes between three donor sites found no significant difference. Conclusion Three different vascularized bone grafts from the dorsal wrist and hand area demonstrated favorable and comparable functional outcomes. It was technically important to elevate vascular bundle with surrounding retinaculum or fascia, to include sufficient periosteum, and to insert the vascularized bone as the cortex aligned longitudinally.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients

“…Four articles approximately 4+5 ECA for Kienböck's disease (stages II, III) and one article for scaphoid nonunion met inclusion criteria and were included in the study. 5,[36][37][38] In total there were 54 patients with Kienböck's disease. The mean follow-up in these studies was 45 months (20-70 months).…”

Long-term results of vascularized os pisiform transfer for advanced Kienböck disease after follow-up for at least 15 years

“…The current techniques for regenerating vascular flow, termed vascularized bone grafting methods, are the mainstream therapies for advanced Kienböck disease. [2,3] Multiple short-term [4] or mid-term [5] clinical trials have reported the usefulness of vascularized bone grafting in patients with advanced Kienböck disease; meanwhile, few long-term clinical results are available, [6] with follow-up no longer than 15 years. Since the first report of Saffar [7] on Kienböck disease treatment with vascularized os pisiform transferring (VOPT), the procedure has become a useful approach for treating Kienböck disease affecting the wrist, due to its ability to relieve pain, improve grip strength, and enhance the range of motion.…”

The free vascularized lateral femoral trochlea osteochondral graft: a reliable alternative for Stage III Kienböck’s disease

“…We believe that compromised vascularization of the lunate is the most important pathogenetic factor in Kienbo ¨ck's disease. This is addressed by techniques using local or free vascularized corticocancellous bone grafts (Arora et al, 2008, Daecke et al, 2005a, 2005bMatsumoto et al, 2018;Moran et al, 2005;Nakagawa et al, 2016;Tsantes et al, 2019;von Maydell and Bru ¨ser, 2008;Ye et al, 2020). Vascularized bone grafts alone do not allow reconstruction of a joint surface, especially the radiolunate cartilage.…”