Scapho-luno-capitate fusion with proximal lunate articular surface preservation for management of grade IIIA Kienböck’s disease: a prospective case series

Shams et al. Journal of Orthopaedics and Traumatology (2023) 24:23 https://doi.org/10.1186/s10195-023-00703-9 ORIGINAL ARTICLE Journal of Orthopaedics and Traumatology Open Access Scapho‑luno‑capitate fusion with proximal lunate articular surface preservation for management of grade IIIA Kienböck’s disease: a prospective case series Ahmed Shams1, Mohamed Ahmed Samy1, Mohamed Kamal Mesregah1*   and Ahmed Abdelazim Abosalem1 Abstract Background Kienböck’s disease is idiopathic lunate avascular necrosis, which may lead to lunate collapse, abnormal carpal motion and wrist arthritis. The current study aimed to assess the outcomes of treating stage IIIA Kienböck’s disease by a novel technique of limited carpal fusion via partial lunate excision with preservation of the proximal lunate surface and scapho-luno-capitate (SLC) fusion. Materials and methods We conducted a prospective study of patients with grade IIIA Kienböck’s disease managed with a novel technique of limited carpal fusion comprising SLC fusion with preservation of the proximal lunate articular cartilage. Autologous iliac crest bone grafting and K-wires fixation were used to enhance the osteosynthesis of the SLC fusion. The minimum follow-up period was 1 year. A visual analog scale (VAS) and the Mayo Wrist Score were utilized for the evaluation of patient residual pain and functional assessment, respectively. A digital Smedley dynamometer was used to measure the grip strength. The modified carpal height ratio (MCHR) was used for monitoring carpal collapse. The radioscaphoid angle, scapholunate angle, and the modified carpal-ulnar distance ratio were used for the assessment of carpal bones alignment and ulnar translocation of carpal bones. Results This study included 20 patients with a mean age of 27.9 ± 5.5 years. At the last follow-up, the mean range of flexion/extension range of motion (% of normal side) improved from 52.8 ± 5.4% to 65.7 ± 11.1%, P = 0.002, the mean grip strength (% of normal side) improved from 54.6 ± 11.8% to 88.3 ± 12.4%, P = 0.001, the mean Mayo Wrist Score improved from 41.5 ± 8.2 to 81 ± 9.2, P = 0.002, and the mean VAS score reduced from 6.1 ± 1.6 to 0.6 ± 0.4, P = 0.004. The mean follow-up MCHR improved from 1.46 ± 0.11 to 1.59 ± 0.34, P = 0.112. The mean radioscaphoid angle improved from 63 ± 10º to 49 ± 6º, P = 0.011. The mean scapholunate angle increased from 32 ± 6º to 47 ± 8º, P = 0.004. The mean modified carpal-ulnar distance ratio was preserved and none of the patients developed ulnar translocation of the carpal bones. Radiological union was achieved in all patients. Conclusions Scapho-luno-capitate fusion with partial lunate excision and preservation of the proximal lunate surface is a valuable option for treating stage IIIA Kienböck’s disease, with satisfactory outcomes. Level of evidence Level IV. Trial registration Not applicable. *Correspondence: Mohamed Kamal Mesregah Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Shams et al. Journal of Orthopaedics and Traumatology (2023) 24:23 Page 2 of 7 Keywords Kienböck’s disease, Lunate avascular necrosis, Limited carpal fusion, Iliac crest graft, Scapho-luno-capitate fusion, K-wires Introduction Kienböck’s disease is characterized by lunate avascular necrosis with rare spontaneous healing, which may lead to lunate collapse, abnormal carpal motion, and degenerative wrist arthritis [1, 2]. There is still no clear cause for Kienböck’s disease, but a number of intrinsic and extrinsic factors have been proposed [1, 3]. Several studies suggested that lunate osteonecrosis occurs due to increased intraosseous pressure from intraosseous venous thrombosis as a result of anatomical, biological, inflammatory, immune, or coagulation disorders [4, 5]. Males between the ages of 20 and 40 are most commonly affected by this disease [6]. Kienböck’s disease is clinically suspected when there is dorsal wrist pain over the lunate that is sometimes combined with reduced range of motion and weak grip strength [7]. Plain X-rays and magnetic resonance imaging (MRI) are required for diagnosis [8, 9]. The Lichtman classification [10] is widely used to classify this disease, with stage IIIA being lunate fragmentation and collapse with decreased carpal height. Kienböck’s disease is treated according to its stage at the time of presentation, with no gold standard treatment option [11, 12]. Stage IIIA can be treated with lunate excision to remove the source of pain and limited carpal fusion, including scapho-trapezio-trapezoid (STT), scapho-capitate (SC), and capito-hamate (CH) arthrodesis to modulate the load transmission through the carpus bone [13–16]. The procedure of lunate excision and SC fusion was first reported by Pisano et al. [17], with a proposed biomechanical hypothesis of a reduction of axial loading through the radio-lunate and luno-capitate joints and an increase of axial loading through the radio-scaphoid joint; which may lead to osteoarthritis [18]. In the current study, we sought to assess the functional and radiological outcomes of the management of stage IIIA Kienböck’s disease by a novel technique of limited carpal fusion through partial lunate excision with preservation of the proximal surface of lunate and scapho-luno-capitate (SLC) fusion. Our proposed hypothesis is that this technique can offer more balanced axial load transmission through the radio-lunate and radio-scaphoid joints. Materials and methods Patient selection This prospective study included 20 patients with grade IIIA Kienböck’s disease treated with a novel technique of limited carpal fusion comprising SLC fusion with preservation of the proximal lunate articular cartilage, from March 2018 to March 2021 in a University Hospital. Written consent was taken preoperatively from all patients. Our institutional review boards (IRB) and ethics committee approved the study. The minimum follow-up period was 1 year. The inclusion criteria were patients from 20 to 60 years old with Lichtman grade IIIA Kienböck’s disease. Patients with other Kienböck’s disease grades, damaged proximal lunate (...truncated)