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Reconstruction of the proximal carpal row with tendon graft for advanced Kienböck’s disease

Kienböck’s disease (KD) or osteonecrosis of the lunate may lead to chronic wrist pain, impaired grip strength and limited wrist motion, with arthritis. There remains a lack of consensus regarding the optimal treatment, especially for Lichtman stages III and IV disease. Thus, this study proposes a novel procedure for advanced Kienböck’s disease through the reconstruction of the proximal carpal row to antagonize the flexion and pronation tendency of the scaphoid and maintain the carpal height and alignment.

Two bone tunnels were drilled in the scaphoid and triquetrum, respectively. To antagonize the flexion and pronation tendency of the scaphoid, a distally based extensor carpi radials longus (ECRL) graft was harvested and passed through the scaphoid tunnel from anterior to posterior. On the dorsal side, the tendon graft was brought through the prefabricated tendon ball and continued to pass through the triquetrum tunnel from the anteroradial to the posteroulnar side. Once through the triquetrum tunnel, the graft was brought back over the dorsum of the wrist to the scaphoid with the ball fixed in situ. The inclusion criteria were patients with Lichtman stage IIIB, IIIC and IV KD who were treated with lunate excision, tendon ball interposition arthroplasty and proximal carpal stabilization with ECRL tendon graft in our hospital between 2015 and 2021. The exclusion criteria were patients with previous surgery to the wrist, pancarpal arthritis and clinical follow-up of less than 12 months. The pain level was recorded using a visual analogue scale (VAS). Range of motion (ROM) of the wrist was recorded and grip strength measured using an electronic hand dynamometer. Radiographic measurements were also recorded.

In total, 16 patients were included and the mean follow-up was 25 months. Pain improved from 5.6 preoperatively to 1.3 postoperatively on a 10-point visual analogue scale. Mean wrist motion improved by 17.8°and grip strength compared with the non-operative side increased by 22.1% on average. Radiographic outcomes demonstrated correction of scaphoid flexion and carpal height ratio.

The normal carpal proximal row is effectively restored in antagonizing the flexion of the scaphoid and maintaining the carpal height. The novel procedure through reconstruction of the carpal proximal row may be an alternative wrist salvage procedure for the treatment of advanced Kienböck’s disease.

Kienböck’s disease, reconstruction of the proximal carpal row, tendon graft, carpal stabilization, lunate necrosis