The Use of the 4 5 Extensor Compartmental Vascularized Bone Graft for the Treatment of Kienböck s Disease

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1 The Use of the 4 5 Extensor Compartmental Vascularized Bone Graft for the Treatment of Kienböck s Disease Steven L. Moran, MD, William P. Cooney, MD, Richard A. Berger, MD, PhD, Allen T. Bishop, MD, Alexander Y. Shin, MD, Rochester, MN Purpose: The use of vascularized bone grafts for the treatment of Kienböck s disease may prevent ongoing lunate collapse and provide relief of wrist symptomatology. This study examines our experience with the use of the 4 5 extensor compartmental artery (ECA) bone graft for the treatment of Kienböck s disease. Methods: A retrospective review was performed of all patients having pedicled vascularized bone grafts for Kienböck s disease between 1991 and Only those patients who had reconstruction with a 4 5 ECA graft were included in the study. Presurgical and postsurgical measurements included range of motion, grip strength, and pain evaluation. Measurements of the radiolunate angle, radioscaphoid angle, Ståhl s index, and carpal height ratio were taken from presurgical and final follow-up radiographs. Postsurgical magnetic resonance imaging scans were also examined to verify revascularization of the lunate. Statistical analysis was performed using Student s t test. A chi-square test was used to evaluate the effects of lunate revascularization on radiographic progression of disease. Twenty-six 4 5 ECA vascularized bone grafts were performed as treatment for Kienböck s disease. The average patient age was 32 years. At the time of surgery 12 patients were graded as stage II, 10 as IIIA, and 4 as IIIB. Mean follow-up time was 31 months. Results: At a mean follow-up of 3 months, motion improved from 68% to 71% of the unaffected side, grip strength improved from 50% to 89% of the unaffected side, and 92% of patients had significant improvement in their pain. Satisfactory results were seen in 85% of patients based on the Lichtman outcome score. Seventy-seven percent of patients showed no further collapse on postsurgical radiographs. Sixty-five percent of patients had follow-up magnetic resonance imaging scans at a mean of 20 months after surgery. Seventy-one percent of patients showed evidence of revascularization with improvement in the T2 and/or T1 signal. Conclusions: The 4 5 ECA bone graft provides a reliable alternative for the treatment of Kienböck s disease and may aid in lunate revascularization. (J Hand Surg 2005;30A: Copyright 2005 by the American Society for Surgery of the Hand.) Key words: Kienböck s disease, avascular necrosis, vascularized bone graft, lunate. From the Department of Orthopedic Surgery, Division of Hand Surgery and the Division of Plastic Surgery, Mayo Clinic, Rochester, MN. Received for publication December 2, 2003; accepted in revised form October 11, No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Steven L. Moran, MD, Mayo Clinic, 200 First St SW, Rochester, MN Copyright 2005 by the American Society for Surgery of the Hand /05/30A $30.00/0 doi: /j.jhsa The Journal of Hand Surgery

2 Moran et al / 4 5 Extensor Compartmental VBG in Kienböck s Disease 51 Although multiple treatment options have been proposed for avascular necrosis of the lunate (Kienböck s disease) a consensus on treatment has not been reached. The difficulty in establishing a set treatment algorithm for Kienböck s disease is in part due to our incomplete understanding of the disease s etiology; however; it has been established that avascular necrosis of the lunate leads to a predictable pattern of lunate collapse with progression to radiocarpal and midcarpal arthritis. 1 3 Treatment modalities depend typically on the duration of the patient s symptoms, the Lichtman/Ståhl stage of the disease, and the surgeon s preference and experience. Treatment options have included lunate excision, lunate replacement, pisiform or fascia interposition, unloading procedures, capitate shortening, and a variety of intercarpal arthrodeses Salvage procedures for advanced lunate changes with arthrosis have included proximal row carpectomy and complete wrist arthrodesis. 11 More recently procedures have been developed to replace the diminished intraosseous blood supply of the lunate through the use of arteriovenous pedicles and vascularized bone grafts (VBGs) In 1965 Roy-Camille 16 presented one of the earliest reports of a vascularized pedicled bone graft using the scaphoid tubercle on an abductor pollicis brevis muscle pedicle. Beck and others reported the use of a pisiform vascularized pedicle graft in the treatment of Kienböck s disease. Saffar 20 modified Beck s technique, basing the pisiform graft on the oblique dorsal branches of the ulnar artery. The pedicled pronator quadratus muscle bone flap has also been described for lunate avascular necrosis with promising results Since these initial reports other techniques have evolved using vascularized grafts from the distal radius as described by Sheetz and Shin et al These grafts are harvested and placed through a single dorsal incision, providing significant surgical benefit over previous procedures that violate the palmar radiocarpal ligaments. The most common of these grafts used for the treatment of the lunate is based on the 4 5 extensor compartmental artery (ECA). Retrograde flow from the 5th ECA is directed in an orthograde direction into the fourth ECA by ligation of the posterior branch of the anterior interosseous artery. The advantages of this technique are (1) the large diameter of the pedicle, (2) the long pedicle length, and (3) the pedicle s ulnar location in the wrist, which allows for arthrotomy without risking injury to the vessels. Pedicled grafts may facilitate revascularization and remodeling of the avascular lunate. Vascularized bone grafts produce minimal bone necrosis, which results in less bone remodeling; this in turn maintains bone mass and diminishes osteopenia after transfer. 27,28 Anatomic studies suggest that the vascular variability of the lunate may be a predisposing factor in the development of Kienböck s disease. 29,30 Revascularization of the lunate by using vascularized grafts may help to reverse the disease process, prevent ongoing lunate collapse, and provide relief of wrist symptomatology. This study examines our experience with 4 5 ECA bone graft for the treatment of avascular necrosis of the lunate. Materials and Methods A retrospective review was performed of all patients having vascularized bone grafts for Kienböck s disease. Chart review and patient evaluations were performed. Presurgical and postsurgical evaluation included range of motion and grip strength measured with a dynamometer (Jamar, Clifton, NJ). Pain was evaluated in accordance with the modified Mayo wrist scoring system. Postsurgical complications were noted. Measurements of ulnar variance, radiolunate angle, radioscaphoid angle, scapholunate angle, Ståhl s index determined on lateral radiographs, and carpal height ratio were taken from presurgical and final follow-up radiographs. 31,32 This information was used to stage wrists according to the method of Ståhl as modified by Lichtman. 31,33 Lichtman outcome scores and Mayo wrist scores were tabulated at the last follow-up examination. 31,34 Changes in carpal height ratio and Ståhl s index were evaluated to verify progression of disease during the follow-up course. Postsurgical magnetic resonance imaging (MRI) scans were also examined to verify revascularization of the lunate. 35,36 Evidence for bone revascularization was judged by a radiologist as improvement in T1 and/or T2 signal and normalization of marrow signal. Gadolinium contrast was used in the most recent MRIs (2001 to present) to visualize the vascular pedicle and blood flow to the lunate. 37 Statistical analysis was performed using Student s t test to compare presurgical and postsurgical values. A chi-square test was used to evaluate the effects of lunate revascularization on radiographic progression of disease.

3 52 The Journal of Hand Surgery / Vol. 30A No. 1 January 2005 within the septum separating the fourth and fifth extensor compartments. The fifth ECA is traced proximally to its origin from the anterior interosseous artery where the fourth ECA is also identified and traced distally (Fig. 3). A bone graft centered 11 mm proximal to the radiocarpal joint and overlying the fourth ECA to include the nutrient vessels is outlined (Fig. 4). Once the graft is marked a capsulotomy is performed to expose the joint. The lunate then is inspected. If the cartilage shell of lunate is not compromised or fragmented vascularized bone grafting is feasible. Necrotic bone is removed with a burr or curettes with both direct visualization and an image intensifier, leaving a shell of intact cartilage and subchondral bone through a dorsal opening. The lunate is expanded gently to normal dimensions if collapsed using a small, bluntended spreader (Fig. 5). The anterior interosseous artery is ligated proximal to the fourth and fifth ECA. Graft elevation is completed and the tourniquet is deflated to verify blood flow to the graft (Fig. 6). Cancellous bone graft is packed into the lunate followed by insertion of the vascularized bone graft, Figure 1. Location of the 2,3 ECA (2,3 ECA), fourth ECA (4 ECA), and fifth ECA (5 ECA) pedicles in relation to the radiocarpal joint. The 4 5 ECA graft allows for capsulotomy without injury to the vascular pedicle. L, lunate; S, scaphoid; ICSRA, intercompartmental supraretinacular artery. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved. Surgical Technique The surgical technique for the use of vascularized dorsal radius bone grafts has been described previously ,38 We have found the fourth and fifth ECA graft to be best in the treatment of Kienböck s disease. Although the distal fourth ECA can be used as its pedicle the fifth ECA is preferred, connected to the fourth ECA via their common origin (Fig. 1). This combined fourth and fifth ECA pedicle is ideal because of the large diameter of the fifth ECA and the great length of the combined pedicle. Harvesting the fourth ECA fifth ECA graft requires identification of the fifth ECA by opening the fifth dorsal extensor compartment (Fig. 2). The fifth ECA and venae comitantes are visualized on the radial aspect of the compartment lying adjacent to or partially Figure 2. Harvesting the fourth ECA fifth ECA graft requires identification of the fifth ECA by opening of the fifth dorsal extensor compartment. EDC, extensor digitorum communis; EDM, extensor digiti minimi. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved.

4 Moran et al / 4 5 Extensor Compartmental VBG in Kienböck s Disease 53 Figure 5. Necrotic bone is removed with a burr or curettes, leaving a shell of intact cartilage and subchondral bone through a dorsal opening. The lunate is gently expanded to normal. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved. Figure 3. The fifth ECA (5 ECA) is traced proximally to its origin from the anterior interosseous artery where the fourth ECA (4 ECA) also is identified and distally traced. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved. which orients the pedicle vertically with the cortical surface arranged in a proximal distal orientation to strut and maintain lunate height during revascularization (Fig. 7). Internal fixation is unnecessary provided the lunate is not fractured and the graft is shaped carefully and impacted into the bone. A temporary external fixator or scaphocapitate pins are placed at the completion of the case to Figure 4. A bone graft centered 11 mm proximal to the radiocarpal joint and overlying the fourth ECA that includes the nutrient vessels is outlined. Once the graft is marked a capsulotomy is performed to expose the joint. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved. Figure 6. The anterior interosseous artery is ligated proximal the fourth and fifth ECAs. Graft elevation is completed and the tourniquet is deflated to verify blood flow to the graft. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved.

5 54 The Journal of Hand Surgery / Vol. 30A No. 1 January 2005 time was 31 months (range, months). Twenty patients had temporary fixation placed at the time of the vascularized bone graft procedure to prevent excessive force on the lunate during the initial stages of revascularization. Twelve patients had midcarpal pinning and 8 were placed in an external fixator. Pins and fixators were left in place for 6 to 8 weeks in all patients. Figure 7. Cancellous bone graft is packed into the lunate followed by insertion of the vascularized bone graft. Printed with permission from the Mayo Foundation for Medical Education and Research. All rights reserved. unload the lunate during the initial stages of revascularization and are removed at 6 to 8 weeks. Contraindications for the procedure are complete collapse of the lunate, midcarpal arthritis, radiocarpal arthritis, or marked destruction of cartilaginous shell of the lunate. Over an 11-year period ( ) 55 pedicled vascularized bone grafts were performed as the primary treatment for Kienböck s disease. Of these vascularized grafts 30 were found to be 4 5ECA grafts. Two of the 30 patients were excluded from the study because they had a permanent unloading procedure (1 radial shortening, 1 capitate shortening) at the time of vascular graft placement. Two additional patients were excluded because they had had previous surgical procedures for the treatment of Kienböck s disease. Of the 26 patients with isolated 4 5 ECA grafts, 12 were women and 14 were men. The dominant hand was involved in 19 patients. Average patient age was 32 years (range, years). Symptoms had been present for an average of 14 months (range, 1 36 months). Fifteen patients were classified as ulna neutral, 1 as ulna positive, and 10 as ulna negative. The diagnosis of Kienböck s disease was established with plain film radiographs in 26 patients, trispiral tomograms in 14 patients, and MRI in 10 patients. At the time of surgery 12 patients were classified as Lichtman grade II, 10 as grade IIIA, and 4 as grade IIIB. Plain films and presurgical tomograms showed fractures within 19 of the 26 lunates. Mean follow-up Results Twenty-four patients reported an improvement in their pain after surgery. Wrist flexion-extension arc improved from 68% to 71% of normal after surgery. Average flexion-extension arc after surgery was 94 with an average of 50 of extension and 44 of flexion. Wrist deviation improved from 66% of normal before surgery to 77% after surgery. The average wrist deviation arc was 45 with an average of 14 of radial deviation and 31 of ulnar deviation after surgery. The improvements in wrist range of motion did not meet clinical significance. Postsurgical grip strength improved significantly from 50% of the normal hand before surgery to 89% after surgery (p.001). Twenty patients showed no radiographic progression of disease or collapse after surgery. Average change in carpal height index was with an overall final average carpal height ratio of 0.46 (normal 0.54). Average change in Ståhl s index was 0.02 with an overall final Ståhl s index of Neither of these values was significant. Six patients had radiographic evidence of further lunate collapse and progression of Lichtman radiographic stage. Two patients progressed from stage II to stage IIIA, 1 progressed from stage II to stage IV, 1 progressed from stage IIIA to IIIB, 1 progressed from stage IIIA to stage IV, and 1 progressed from stage IIIB to stage IV. Seventeen of the 26 patients had follow-up MRIs at a mean of 20 months after surgery (range, 9 38 months). Twelve of these 17 showed evidence of revascularization with improvement in T2 and/or T1 signal and normalization of marrow signal. Normalization of T2-weighted values was seen first at 3 to 6 months. This was followed by normalization of T1- weighted values at 18 to 20 months (Fig. 8). Complications occurred in 2 patients, and both were related to pin track infections. Reconstructive failures occurred in 2 patients, who required fusions for persistent wrist pain. Satisfactory results were seen in 22 patients, based on the Lichtman scoring system. The 4 unsatisfactory results were caused by persistent pain in 2 patients,

6 Moran et al / 4 5 Extensor Compartmental VBG in Kienböck s Disease 55 Figure 8. (A) Lateral image of lunate with T2-weighted image showing avascular lunate before surgery. (B) Same lunate 18 months after surgery with significant improvement in signal, decreased edema, and return of trabecular structure. loss of greater than 10 of presurgical motion in 1 patient, and the recovery of less than 60% of normal grip in 1 patient. Twenty-four of the 26 patients had adequate follow-up data to be ranked on the modified Mayo wrist score. The average Mayo wrist score was 77 (range, ). According to the Mayo wrist scores 6 patients had an excellent result, 6 had a good result, 9 had a fair result, and 3 had a poor result. Grading was affected more adversely by changes in range of motion and grip strength than in pain levels and functional status. There were no significant differences in postsurgical motion, grip strength, Lichtman outcome scores, or Mayo wrist scores between early Kienböck s (stage II) and later-stage Kienböck s disease (stages IIIa and IIIb). The use of temporary external fixation and pinning did not affect postsurgical outcome significantly and were not found useful in predicting good or excellent results. Patients who had evidence of revascularization on MRI had significantly higher Mayo wrist scores (mean scores, 63 vs 85, p.003) and a higher rate of returning to work when compared with patients who had no evidence of revascularization on postsurgical MRIs. There was also a significantly higher chance for further lunate collapse with progression of the Lichtman/Ståhl classification if the lunate showed no signs of revascularization after surgery (p.05). Discussion The intuitive solution for avascular necrosis of the lunate is to re-establish a new blood supply within the lunate. This approach has been used successfully for femoral head avascular necrosis and avascular proximal pole fractures of the scaphoid Hori et al 12 implanted the dorsal metacarpal vascular pedicle directly into the lunate of 9 patients and found evidence for revascularization of the lunate. In 1993 Tamai et al 43 reported improvement in pain and grip strength in 50 of 51 patients after implantation of a vascular bundle into the lunate. These studies provided the preliminary evidence for the potential success of revascularization procedures for Kienböck s disease. In the present series vascularized bone grafts provided significant pain relief in 92% of patients, with significant improvement grip strength. Only 23% of patients had radiographic evidence of continued collapse after the procedure and there were only 2 reconstructive failures. These results are comparable to joint leveling procedures. In a study by Weiss et al 8 a radial osteotomy was performed in 30 wrists of 29 patients. They reported that a majority of patients did not progress from stage III to stage IV. Range of motion in their series averaged 32% of extension and 27% of flexion compared with the uninjured side and grip strength averaged 49% of the uninvolved side. Quenzer and Trail et al 44,45 have also reported on long-term results of radial shortening osteotomies. In their series of 68 patients followed up for 52 months pain improved in 93% and grip strength improved in 76% but motion was limited again to 60% to 65% of the uninvolved side. Garcia-Elias et al 46

7 56 The Journal of Hand Surgery / Vol. 30A No. 1 January 2005 reviewed wedge osteotomy in 20 patients. They had 13 good to excellent results, 6 fair results, and 1 poor result. A 10-year follow-up study on closing wedge osteotomy by Wada et al 32 found progression of radiographic disease in 8 of 13 patients. In our series MRI evidence for revascularization was a significant predictor for reconstructive success. Patients with evidence of revascularization on postsurgical MRIs obtained good to excellent results as judged by the Mayo wrist score and all returned to their previous employment. Sowa et al 36 also noted better clinical results in patients with increased T2 signals after surgery for Kienböck s disease. Radial shortening osteotomy may also promote some indirect lunate revascularization; however, only one third of the patients in the study by Weiss et al 8 had radiographic evidence of revascularization at an average of 4 years after surgery. Little substantial change in radiocarpal height or Ståhl s index occurred during the follow-up period, suggesting that lunate decompression and expansion with VBGs may prevent future lunate collapse. Yajima and Tamai 47 also found no significant change in lunate height in two thirds of patients after vascular bundle implantation. Ongoing lunate collapse could result possibly from the surgical procedure because trabecular strength is lost during the bone revascularization process. 48 Aspenburg et al 48 believe that the initial stages of bony healing increase the osteoclast response, which may lead to the initial weakening of the bone. In this study we did not find a significant correlation between carpal distraction and reconstructive success; however, we still have concerns that early loads directed through the lunate after surgery may be detrimental to the bone graft and ongoing revascularization. We believe that some form of unloading procedure is necessary during the initial phases of bony healing. Our clinical results after VBG implantation in stage IIIB Kienböck s disease appear promising. Although improvement in Ståhl s index and carpal height were minimal there were signs of revascularization on MRI in 3 of the 4 patients. Although there were only 4 patients in this group the average Mayo score was 80 and all experienced significant improvement in their pain. Not all reports of VBG have been positive. Straw et al 49 reported only a 27% success rate with pedicled vascularized grafts for the treatment of scaphoid nonunions. Vascularized bone graft procedures can be demanding technically and there is a learning curve with the procedure. Kinking of the pedicle or damage to the vessels during insertion into the bone can lead to devitalization of the graft. Technical error or pedicle injury during the procedure could have contributed to the 29% of lunates that failed to revascularize in this study. Vascularized bone grafting from the dorsal distal radius is an effective method to treat Kienböck s disease. The procedure requires less extensive dissection, does not require transection of the palmar stabilizing radiocarpal ligaments, and is easier technically than previously described VBG procedures. In the ulna-neutral or -positive variant this procedure is a particularly attractive option. When this procedure is performed we believe the lunate should be protected from direct loading to facilitate the revascularization process. Despite the inability to improve carpal height in the long term clinical results have been excellent, suggesting that vascularized grafting will continue to play a role in treatment of Kienböck s disease. References 1. Kristensen SS, Thomassen E, Christensen F. 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9 58 The Journal of Hand Surgery / Vol. 30A No. 1 January 2005 optimum correcting angle. Chir Main 1998;17(4): Yajima H, Tamai S. Treatment of Kienbock s disease with vascular bundle implantation. Fukuoka, Japan: Japanese Orthopedic Association, 1992: Aspenberg P, Wang JS, Jonsson K, Hagert CG. Experimental osteonecrosis of the lunate. Revascularization may cause collapse. J Hand Surg 1994;19B: Straw RG, Davis TRC, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg 2002;27B: