Treatment of Kienbock’s Disease with Capitohamate Arthrodesis: Pain Relief with Minimal Morbidity

Author(s): Oishi SN, Muzaffar AR and Carter PR

Source: Plastic and Reconstr Surg 109: 1293-1300, 2002

Summary:

The etiology and optimal treatment of Kienbock’s disease has yet to be conclusively determined.  The author’s report on 45 consecutive wrists with Kienbock’s (stage I-III) treated with capitohamate fusion.  These were reviewed retrospectively at an average follow-up of 32 months (range, 4-107 months).   All patients had “persistent pain” pre-operatively and the average age at surgery was 31 years (12-64 years).  Fifty-five percent of individuals had ulnar minus variance.  Fusion was performed with a Herbert screw and iliac crest autograft.  Results revealed union in all cases, and 96% of patients with longer than two-year follow-up were either pain free or improved by self-reported pain scales.  Wrist range of motion was unchanged at follow-up while grip strength significantly improved. 

A variety of “successful” surgical procedures have been described for Kienbock’s disease, including joint leveling, angular osteotomies to the radius (both increasing and decreasing radial inclination), simple partial thickness osteotomy of the radius, limited carpal fusions (incorporating the scaphoid), capitate shortening with capitohamate fusion and now capitohamate fusion alone.  It is clear that we simply do not understand the pathophysiology of this condition and the factors, which determine limitation of function and pain. Several studies suggest that pain may ultimately resolve without surgery over an extended period of time.  Others describe a subset of individuals with the condition who are asymptomatic in which the condition is found incidentally (Clin Ortho 395: 121-7, 2002). 

This study reports on intercarpal fusion between the capitate and hamate, two bones that are relatively linked to begin with.  The proposed mechanism of this procedure is that stabilization of the capitate does not allow it to migrate proximally, thereby unloading the lunate.  This hypothesis is not supported by biomechanical studies.  In reality, this fusion does not make much sense.  Practically, however, it may be that any operation that alters the vascular pattern to the wrist may affect the symptoms associated with this poorly understood condition.

 


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