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Functional and Radiographic Disease Progression in Nonoperatively Managed Kienböck Disease
Brent R DeGeorge1, Sagar S Chawla1, Laura Lewallen1
1From the Department of Plastic and Orthopedic Surgery, University of Virginia; the Department of Orthopaedics and Sports Medicine, University of Washington; and the Department of Orthopedic Surgery, Mayo Clinic.
Insights
Nonoperative treatment for Kienböck disease improves pain and grip strength, despite radiographic progression. This study followed patients nonoperatively, finding significant functional gains over time.
Area of Science:
- Orthopedics
- Hand Surgery
- Radiology
Background:
- Kienböck disease affects the lunate bone in the wrist.
- Nonoperative management is an option for Kienböck disease.
- Understanding the natural history of nonoperative Kienböck disease is crucial.
Purpose of the Study:
- To describe the natural history of Kienböck disease in patients treated nonoperatively.
- To evaluate outcomes of nonoperative Kienböck disease management.
Main Methods:
- Retrospective study of patients with Kienböck disease treated nonoperatively (1999-2014).
- Inclusion criteria: >1 year follow-up, serial wrist radiographs, clinical exams.
- Radiographic review included Lichtman stage, carpal index, Stahl index, ulnar variance, and intercarpal angles.
Main Results:
- 25 patients (25 wrists) with average follow-up of 3.9 years (clinical) and 5.2 years (radiographic).
- Significant decrease in pain, increase in modified Mayo wrist scores and grip strength.
- Radiographic progression observed: increased Lichtman stage, scapholunate angle, radioscaphoid angle; decreased carpal index, PA lunate ratio, Stahl index.
- Smoking history correlated with increased radiographic disease progression.
Conclusions:
- Nonoperative management of Kienböck disease leads to significant patient-reported improvements in pain and function.
- Radiographic evidence of disease progression is common despite clinical improvement.
- Further research into risk factors like smoking is warranted.
Background:
The purpose of this study was to describe the natural history of Kienböck disease among patients who elected to proceed with nonoperative treatment.
Methods:
The authors performed a retrospective study of all patients treated nonoperatively for Kienböck disease within their institution from January 1, 1999, to December 31, 2014. Inclusion criteria included follow-up greater than 1 year, serial posteroanterior and lateral wrist radiographs, and clinical examination. Posteroanterior/lateral radiographs were independently reviewed at initial presentation and at final follow-up, including Lichtman stage, carpal index, Stahl index, ulnar variance, and intercarpal angles.
Results:
Twenty-five patients with 25 wrists were included (mean age, 50.2 years), with an average length of clinical follow-up of 3.9 years and a mean length of radiographic follow-up of 5.2 years. There was no significant difference in range of motion; however, patient-reported pain was significantly decreased, and modified Mayo wrist scores and grip strength were increased. Lichtman stage, scapholunate angle, and radioscaphoid angle were increased; and carpal index, posteroanterior lunate ratio, and Stahl index were decreased across the study period. The mean progression in Lichtman stage was 0.5 stage/year with a range of 0 to 1.6 stages/year throughout the study period. There was no significant difference in Lichtman stage progression based on stage at presentation. A history of smoking was associated with increased radiographic disease progression.
Conclusion:
The present study demonstrates that among patients with Kienböck disease managed nonoperatively, the majority of patients significantly improve over time with respect to pain, grip strength, and Mayo wrist score, despite radiographic progression of disease.
Clinical Question/Level Of Evidence:
Risk, IV.
