A 40-Year Retrospective Evaluation of Vascularized Bone Grafting for Kienböck Disease.

Purpose: Kienböck disease is characterized by lunate osteonecrosis with progressive carpal collapse. The relative benefit of revascularization compared to other surgical options remains uncertain. The purpose of this investigation was to compare long-term radiographic, functional, and patient-reported outcomes of revascularization techniques to alternative surgical procedures for the treatment of early- and late-stage Kienböck disease.

Methods: A retrospective cohort of patients who underwent surgery for Kienböck disease from 1976 to 2023 was identified. Only patients with at least 24 months of follow-up were included in the study. The patients were grouped by index surgical procedure and disease severity: early-stage defined as Lichtman stage I-IIIA and late-stage defined as stage IIIB-IV. Demographic, functional, and radiographic data; postoperative Disability of the Shoulder, Arm and Hand (DASH) scores; and postoperative Patient-Rated Wrist Evaluation (PRWE) scores were obtained. Patient outcomes were compared between the different surgical techniques, accounting for disease severity. Hazard ratio and survival analyses were performed to evaluate predictors of unplanned return to the operating room or conversion to a salvage procedure after revascularization.

Results: A total of 195 patients were included in the primary analysis. Compared to other procedures, patients undergoing revascularization were younger. Additionally, patients undergoing revascularization or offloading procedures had lower proportions of late-stage disease. For patients with early-stage disease, wrist range of motion, relative grip strength, and postoperative Stahl indices were comparable or higher after revascularization and DASH scores were comparable or lower than other procedures. Patients undergoing revascularization and joint leveling procedures had similar rates of reoperation, which were higher than those seen with scaphocapitate fusion or proximal row carpectomy.

Conclusions: In early-stage Kienböck disease, revascularization procedures resulted in comparable or better patient-reported scores than other interventions. There were no benefits noted for revascularization over other procedures in late-stage disease. Revascularization should be reserved for patients with early-stage disease.

Type of study/level of evidence: Therapeutic IV.