A capitate osteotomy and capitometacarpal fusion in a patient with Kienböck’s disease
L.N.T. Oerlemans1 A.A.M. Paters2 E.E.J. Raven3 1 Department of Orthopaedics, Isala Clinics, The Netherlands 2 Department of Orthopaedics, Medical Spectrum Twente, The Netherlands 3 Department of Orthopaedics, Gelre Hospital, The Netherlands Correspondending author: dr. E.E.J. Raven, e.raven@gelre.nl
Several surgical procedures have been proposed to slow the progression of osteonecrosis and secondary carpal deterioration in Kienböck’s disease. Treatment choice must be based on a number of variables, including stage of the disease, wishes and activity level of the patient, anatomic variation of the ulna and preference of the treating surgeon. In this case report we describe a patient with Kienböck’s disease with neutral ulnar variance; the positive result after a capitate osteotomy and capitometacarpal fusion suggests that a capitate-metacarpal fusion is a surgical option for this condition.
Introduction Kienböck’s disease presents with a disease process of osteonecrosis of the lunate. The exact aetiology is not well known. A history of trauma and certain morphological variations, like a negative ulnar variance, are common in patients with Kienböck’s disease. The disease starts with decreased blood flow to the lunate. This leads to microfractures and in later stages to degeneration and instability if ligaments also become involved. Patients normally present with pain and in later stages with dysfunction and instability. Kienböck’s disease develops progressively and appears mainly unilaterally between ages 20 and 40. A shorter ulna is assumed to be a provoking cause or, conversely, the course of progression by increased pressure on the lunate1-6. Surgery can be considered depending on the stage of the disease using the Lichtman classification (table 1), which is based on radiographs and MRI7. Using this classification, treatment options depend on the integrity of the lunate, carpal collapse, or radiocarpal osteoarthritis. Treatment options include unloading the lunate (i.e., radial osteotomy, capitate osteotomy), revascularizing the lunate or a salvage procedure (i.e., proximal row carpectomy). In its early stages the disease can be reversed by revascularization and lunate-unloading procedures. For example, a fourth plus fifth extensor compartment artery vascularized bone graft can be an effective technique to facilitate healing avascular necrosis8. In patients with a shorter ulna, a radial shortening osteotomy could reduce the force coming from the radius to the wrist in the early stages9. If there is a neutral ulna, capitate shortening, capitate-hamate fusion or distal capitate shortening with capitometacarpal fusion are options4,10. When diagnosing the disease in its end stages (Lichtman stages 3B-4), possible salvage procedures are proximal row carpectomy, scaphocapitate or scaphotrapezio-trapezoid-capitate arthrodesis, and arthroplasty. Based on a systematic review, none of these surgical treatments is superior to another for Kienböck’s disease10.
Patient A 21-year-old, right-dominant female was seen as an outpatient due to pain in her right wrist during hockey and sailing. There was no clear trauma of the wrist. The wrist was sometimes swollen during painful periods. During physical examination the wrist was not swollen, and the patient had pain upon pressure on the dorsal wrist and a painful Watson test, without click. Wrist pronation-supination was 80/0/80 (R) and 90/0/90 (L), dorsal-palmar flexion 30/0/30 (R) and 80/0/80 (L), ulnar and radial deviation 20/0/20 (R) and 30/0/30 (L). Grip strength was 20 kg (R) and 33 kg (L) (Jamar Dynamometer, Therapeutic Instruments, USA). X-ray of the right wrist showed height loss and some sclerosis of the lunate, suspicious for Kienböck’s disease Lichtman stage 2 (figure 1). The wrist X-ray also showed a neutral wrist, meaning equal length of the radius and ulna. MRI showed avascular necrosis of the lunate (figure 2).
First, a shared decision was made to start conservative treatment by wearing a wrist brace continuously. After one year there was increased pain and dysfunction of the right wrist. X-ray showed further deterioration of the lunate (Lichtman stage 3A). The decision was made to perform a capitate osteotomy with capitometacarpal fusion in this patient with neutral ulnar variance whose Kienböck’s disease had progressed to Lichtman stage 3A. The decision was based on unloading the lunate on the distal side; by combining the procedure with capitometacarpal fusion, we assume the fusion rate was higher. Intervention A capitate osteotomy and capitometacarpal fusion were performed (using an axillary brachial plexus block). A dorsal incision was made located at CMC-3 after X-ray localization. The joint was exposed. Resection of the distal part of the capitate and resection of the proximal part of the third metacarpal was done with an oscillating saw. A locking T-plate was used placing two screws in the capitate and two in the third metacarpal bone (figure 3). A stable fixation was achieved. After the intervention a soft cast was applied for six weeks.
Comparison Unfortunately, there is little evidence to support any treatment for Kienböck’s disease because the aetiology remains poorly understood10. Radial shortening osteotomy is considered to be a good procedure in patients with negative ulnar variance9. In patients with a neutral ulna, surgical intervention options are resection arthroplasty of the lunate11, denervation surgery12, silicone implant13, revascularization14,15 and different types of fusions12,16-19. For these interventions, studies report 55-88% success rates after 3 to 11 years follow-up9. A known surgical intervention is the capitate-hamate fusion, which also prevents secondary proximal migration of the capitate. However, this intervention alone is not effective enough as it doesn’t reduce load transmission to the lunate. Werber et al. showed significant load reduction of the lunate after capitate shortening, which is also seen in this case report; this suggests that a capitate-metacarpal fusion is a surgical option for Kienböck’s disease with neutral ulnar variance20. Outcome Six weeks after surgery the soft cast was removed, and the patient started dedicated hand physiotherapy. Normal hand function was restored, pain was significantly reduced, and she resumed her sports activities without pain. The symptomatic plate was removed one year after the primary procedure. X-ray showed consolidation of the capitometacarpal fusion (figure 4).
Figure 4. PA wrist X-Ray 4 years postoperatively: complete fusion of the capitate with the third metacarpal bone.
Before intervention and one year after intervention she submitted the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire21, where a higher score reflects more disability. Her pre-intervention score was 48.3 points [0-100], dropping to 11.7 points post-intervention. The clinically significant improvement since the minimal clinically important difference (MCID) was 10.83 points21. The patient is playing field hockey and sailing small boats again. Pre-intervention she scored 68.8 points in the DASH sports module, post-intervention 37.5 points. At final follow-up the range of motion for dorsal-palmar flexion was 60/60. To conclude, in this case report of our patient with Kienböck’s disease stage 3A and neutral ulnar variance a capitate osteotomy with capitometacarpal fusion resulted in an improvement in DASH score and range of motion at follow-up. Capitate osteotomy with capitometacarpal fusion could be considered as a possible treatment for patients with Kienböck’s disease from stage 3A if the patient has a neutral ulnar variance. Disclosure statement Authors have no conflict of interest to declare.
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