Long-Term Subjective and Radiological Outcome After
Reconstruction of Kienböck’s Disease Stage 3 Treated
by a Free Vascularized Iliac Bone Graft
Rohit Arora, MD, Martin Lutz, MD, Christian Deml, MD, Dietmar Krappinger, MD,Robert Zimmermann, MD, Markus Gabl, MD
Purpose Various vascularized bone grafts are used for surgical treatment of Kienböck’s disease. Long-term resultsof free vascularized iliac bone grafts for treatment of Kienböck’s disease are not reported in the literature. Thepurpose of this study is to report the over-10-year results and to compare them with the 5-year results to determinewhether the favorable intermediate-term results were maintained.
Methods Eighteen patients with Lichtman stage III were treated with free vascularized iliac bone grafting and followed upfor a mean period of 13 years. Assessment included active range of wrist motion, grip strength, level of pain measured usingthe visual analog scale (VAS), and patient disability and functional outcome measured by the Disability of the Arm, Shoulder,and Hand (DASH) questionnaire as well as the Green and O’Brien score. Radiological evaluation included Ståhl index, Youmcarpal height index, radioscaphoid angle (RSA), radiolunate angle (RLA) and integration of the free vascularized bone graft.The long-term results were compared with both the preoperative condition and the 5-year results.
Results Postoperative x-rays showed definite osseointegration of the vascularized bone graft in 89% (16/18). Theaverage flexion-extension arc, the wrist deviation arc, pain, and grip strength improved considerably after surgery,and the results were maintained for a long period. Pronation and supination were not restricted in pre- andpostoperative range of motion. The mean DASH score at final follow-up was 8.4 points. The Green and O’Brien scoreshowed 50% excellent, 31% good, and 19% fair results.The average Ståhl index and the average Youm index, improved postoperatively and could be maintained for over 10years follow-up. Two patients presented with a resorption of the bone graft, with ongoing radiologic progression ofLichtman stage, reduced range of motion, and high pain level.
HE EXACT ETIOLOGY OF KIENBÖCK’S disease stillremains unclear. However, it is generallydocumented that in the course of this disease the
clerosis of the carpal lunate progresses to lunate collapse andsteoarthritis of the wrist.1–3 Various methods of treatmentave been described for Kienböck’s disease, indicated by theeverity of the symptoms. Treatment options range fromonservative measurements4 to surgical interventions. Toiminish pathological load transmission on the lunate, jointeveling procedures as radial shortening5 or ulnarengthening6 are described, whereas intercarpal arthrodesis,7
roximal row carpectomy,8 and silicone implant arthroplastyre preferred as salvage procedures in a more progressedtage.9 In the earlier stages of the disease, reconstructiverocedures can be indicated to revascularize the alteredecrotic lunate. In the recent literature, reports about the
176 VASCULARIZED BONE GRAFT FOR KIENBÖCK’S DISEASE
ompartmental vascularized bone grafts,11 or the vascularizeds pisiform transfer12 can be found, describing early andntermediate results. Three- to 5-year outcomes forevascularization of the lunate in Kienböck’s disease haveeen reported,10,11 whereas we could find only a feweports describing long-term results of more than 10 years ofascularized os pisiform for reinforcement of the lunate inienböck’s disease.12,13 None of the long-term follow-up
tudies report on the same patients.Since 1994, we performed reconstruction of the fractured
unate in stage III of Kienböck’s disease by use of a freeascularized iliac bone graft and external fixation, with aean follow-up time of 5 years.14 The purpose of this study
s now to investigate retrospectively the radiological andlinical long-term results in these patients to evaluate theourse of the disease.
ATIENTS AND METHODSetween 1994 and 2002, 40 patients with Kienböck’sisease stage III were treated by revascularization of theunate with a small free vascularized iliac crest bone graft.mong those cases, 18 patients with minimum 10 years of
ollow-up were included in this study. Five-year follow-upesults of these patients were already reported by Gabl etl.14 The same patients (13 men, 5 women) were evaluatedor final follow-up at an average of 12.7 � 2.1 years (range0–14 years) after surgery in this retrospective study. Meange at the time of surgery was 30 years (range 17–41 years).leven right and 7 left hands were treated, and theominant wrist was affected in 9 patients. Before surgery, allatients complained of wrist pain, decreased grip strength,nd/or reduced wrist motion during their daily activity andork. No patient had previous surgical treatment. Using
tandard posteroanterior, lateral wrist radiographs andomputerized tomography (CT), we classified the patientsefore surgery as Lichtman stage IIIA (n � 15), or stage
TABLE 1: TheModifiedWrist Function Score of Green a
IIB (n � 3). No radiological signs of wrist osteoarthritis p
JHS �Vol A, F
ere found in any patient before surgery. No additionalrocedures for permanently unloading the lunate wereerformed accompanying the revascularization.
SSESSMENTunctional Assessment
resurgical and postsurgical functional assessment includedeasurement of active range of wrist extension, flexion,
adial, and ulnar deviation using a goniometer. Grip poweras measured with a dynamometer (Jamar; Therapeuticquipment, Clifton, NJ). Wrist pain was evaluated using theisual analog scale (VAS 0: no pain, VAS 100: severe pain).inal results of range of motion were compared to thereoperative and 5-year results and to the contralateral side.ostoperative functional subjective outcome was measuredy the DASH questionnaire15 (range: 0–100, with 0 for bestesult), and the combination of subjective and objectiveutcomes was assessed using the Green and O’Brien score16
range, 100–0, with 100 for the best result) at the finalollow-up (Table 1).
adiologic Assessment
adiographic assessment with standard posteroanterior andateral pre and postoperative x-rays of the wrist wereerformed. Final results were compared with thereoperative and 5-year results. Radiographic assessmentsnd measurements included the Ståhl index (longitudinaleight of lunate in relation to the highest dorsopalmarimension), the Youm carpal index (length of thirdetacarpal in relation to carpal height), the RSA, the RLA,
nd integration of the free vascularized bone graft (noadiolucent rim around the graft and trabecular reaching theim of the lunate). Changes of Ståhl index and Youm carpaleight ratio were evaluated to verify the progression ofisease (carpal collapse) during the follow-up course.17
hanges of radioscaphoid angle were evaluated to assess
’Brien8
15 20 25
ityain
Mild, regular, nonotable effecton activity
Mild,occasional
No pain
70–99 100–140 �140
50–74 75–90 Normal
Light duties dueto wrist pain
Normal duties,somemodifications
Nolimitations
nd O
activno p
almar rotation of the scaphoid. Changes of radiolunate
ebruary
aPwvim
btotc
2ftare
S
Mfr(SdOudfd�
RAf1rgr
P
XiTIdatfl8Pawot
1s(
Vp51
VASCULARIZED BONE GRAFT FOR KIENBÖCK’S DISEASE 177
ngle were evaluated to assess the position of the lunate.18
ostoperative magnetic resonance imaging (MRI) scansere available for 11 of 18 patients (61%) to assess theiability of the graft. Bone revascularization was defined asmprovement in T1 and/or T2 signal and normalization ofarrow signal.19
The assessor of the radiological outcome (C.D.) waslinded to the functional outcome but not to the method ofreatment. Functional outcome was assessed by anrthopedic specialist physiotherapist who was not blinded tohe method of treatment because the palmar-located scarsould be easily observed.
The details of the surgical procedure were described in002 by Gabl et al.14 The period of immobilizationollowing surgery was based on protocol. The K-wire andhe external fixator were removed 9 weeks after surgery andbelow-elbow cast was applied for another 4 weeks. After
emoval of the plaster cast, assisted active and passive wristxercises were initiated.
tatistical Analysis
ean and SD were calculated for the parameters of age,ollow-up time, range of motion, DASH score, andadiological results and parameters. SPSS for Windows 12.0SPSS, Chicago, Illinois) was used for statistical analysis. Atudent’s t-test was performed when samples were normallyistributed and the homogeneity of variances was assured.therwise, a nonparametric Mann-Whitney U test was
sed. The Kolmogorov-Smirnov test was performed toetermine whether the distributions differed significantlyrom a normal distribution. The Levene test was used foretermination of the homogeneity of variances. A p value of
TABLE 2: Summary of Mean (Range) Clinical Results: Co
Final Follow-Up Evaluation
Before Surgery
Graft integrated (n�16)
Arc of flexion/extension (°) 80 (55–105)
Arc of ulnar/radial deviation (°) 35 (20–50)
Grip strength (Kp) 89 (50–90)
Pain (points) 64 (35–85)
Graft nonintegrated (n�2)
Arc of flexion/extension (°) 65 (60–70)
Arc of ulnar/radial deviation (°) 37 (30–45)
Grip strength (Kp) 40 (30–50)
Pain (points) 65 (60–70)
Kp, Kilo pond.*Significantly increased over preoperative value (p�.05).†Significantly decreased over preoperative value (p�.03).**Significantly decreased over preoperative value (p�.05).
.05 was considered to be statistically significant. n
JHS �Vol A, F
ESULTSfter a mean time of 60 months (range 48–84 months) the
ree vascularized iliac bone graft showed osseointegration in6 of 18 patients (89%). In 2 patients, the graft fractured andesorbed.14 The outcome measure of range of motion andrip strength is shown in Table 2, and the radiologicalesults are shown in Table 3.
atients With Incorporation of the Graft
-rays showed definite osseointegration of the vascularizedliac bone graft in 16 patients (89%) at the 5-year follow-up.his status remained unchanged over the 10-year follow-up.
n these patients, the average flexion-extension arc, the wristeviation arc, and the grip strength increased considerablyfter surgery, but there were no notable changes betweenhe 5-year and 10-year results. At final follow-up, theexion-extension arc averaged 73%; the wrist deviation arc,6%; and the grip strength, 76% of the uninjured side.ronation and supination were not limited in preoperativend postoperative range of motion. The increase in totalrist range of motion and grip strength at the 5-year andver-10-year follow-up did reach statistical significance (t-est; p�.05).
The mean DASH score at final follow-up was 8.4 �6.7 points (range 0–42 points). The Green and O’Briencore showed 8 excellent (50%), 5 good (31%), and 3 fair19%) results.
The average pain level at final follow-up, measured byAS, decreased significantly, from 64 points (range 35–85oints) before surgery to 5 points (range 0–15 points) at the-year follow-up (t-test; p�.01), and to 7 points (range 0–9 points) at the average 13-year follow-up. There were no
rison Between Preoperative, 5 Years Postoperative, and
5-Year Follow-UpEvaluation
At Over-10-Year Follow-UpEvaluation
96 (80–120)* 98 (75–130)*
47 (40–65)* 45 (45–70)*
110 (40–140)* 108 (30–140)*
5 (0–15)† 7 (0–20)†
60 (50–65) 45 (40–50)**
38 (35–40) 25 (15–35)**
50 (30–70) 35 (30–40)
45 (40–50) 80 (70–90)*
mpa
At
otable changes between the 5-year and over-10-year
ebruary
rffpf1
ibRarpio(
t
hua
prwmeci
P
Itan
iseas
178 VASCULARIZED BONE GRAFT FOR KIENBÖCK’S DISEASE
esults. Only one patient who was painless at the 5-yearollow-up evaluation experienced mild pain at the finalollow-up. Two patients (13%) had to change their previousrofession due to prolonged pain during work at the 5-yearollow-up. This status remained unchanged until the over-0-year examination.
The Ståhl index and the Youm carpal height indexmproved after surgery, but there were no notable changesetween the 5-year and over-10-year results. The RSA andLA showed no notable postoperative changes at 5-year
nd over 10-year follow-up. None of the radiological valueseached statistical significance comparing pre- andostoperative measurements (t-test; p�.06). In patients withntegration of the graft, there was no radiologic progressionf Lichtman’s stage at 5-year and over-10-year follow-upFig. 1).
In comparison to the 5-year radiographs, we noticed that
TABLE 3: Summary of Mean (Range) Radiological Result
and Final Follow-Up Evaluation
Before SurgeryA
Graft integrated (n�16)
Ståhl index 0.31 (0.28–0.34)
Youm index 0.52 (0.48–0.55)
Radioscaphoid angle (°) 47.6 (43.2–50.6)
Radiolunate angle (°) 7.2 (6.7–7.9)
Graft nonintegrated (n�2)
Ståhl index 0.33 (0.22–0.43)
Youm index 0.51 (0.49–0.53)
Radioscaphoid angle (°) 51.7 (49.6–53.7)
Radiolunate angle (°) 7.5 (6.7–8.3)
*No significant changes over preoperative value (p�.05).†Significantly decreased over preoperative value (p�.03).
FIGURE 1: A 38-year-old man with stage IIIB d
he postoperatively improved Ståhl index and Youm carpal e
JHS �Vol A, F
eight index could be maintained over the 10-year follow-p time. No evidence of radiographic deterioration was seenfter 5 years of follow-up (Fig. 2).
For 9 of the 16 patients (56%) with incorporated graft, aostoperative MRI was available and showed evidence ofevascularization with normalization of T1 and/or T2eighted values of the incorporated graft at a mean of 19onths (range 4–32 months) after surgery. Patients with
vidence of revascularization on MRI had significantly highorrelation with a long-term improvement in the Ståhlndex (p�.03).
atients With No Incorporation of the Graft
n those 2 patients (11%) who presented with resorption ofhe bone graft, the average flexion-extension arc, theverage wrist deviation arc, and the average grip strength didot improve after surgery. At final follow-up, the flexion-
mparison Between Preoperative, 5 Years Postoperative,
-Year Follow-UpEvaluation
At Over-10-Year Follow-UpEvaluation
42 (0.39–0.49)* 0.40 (0.38–0.47)*
54 (0.5–0.56)* 0.54 (0.5–0.56)*
.2 (46.3–51.4)* 50.4 (47.1–51.9)*
.9 (6.2–7.4)* 7.0 (6.5–7.3)*
28 (0.19–0.36)* 0.18 (0.11–0.24)†
45 (0.43–0.47)* 0.39 (0.31–0.47)†
.3 (46.6–49.9)* 49.4 (47.7–51.1)*
.2 (6.4–7.9)* 7.2 (6.4–7.9)*
e. A Posteroanterior radiograph. B CT scan.
s: Co
t 5
0.
0.
49
6
0.
0.
48
7
xtension arc averaged 39%; the wrist deviation arc, 51%;
ebruary
asarmpt5pafwO
ab4pALppdhoo
C
Irnin
DVo
sulIrm
icrebaymato9ttIptdsoplounai
dwtgiaghaAe3eL
Itorc
F
sp
VASCULARIZED BONE GRAFT FOR KIENBÖCK’S DISEASE 179
nd the grip strength, 38% of the uninjured side. There wastatistically significant worsening of active range of motionnd grip strength between the 5-year and over-10-yearesults (p�.03). The average pain level at final follow-up,easured by VAS, decreased from 65 points (range 60–70
oints) before surgery to 45 points (range 40–50 points) athe 5-year follow-up, and then increased to 80 points (range0–100) at the over-10-year follow-up. Both of theseatients had to change their previous professions due to painnd restricted range of motion. Both patients denied anyurther treatment. The mean DASH score at final follow-upas 57 points (range 48–66 points). The Green and’Brien score showed poor results for both patients.The Ståhl index and the Youm index did not improve
fter surgery, and there was considerable deteriorationetween the 5-year and over-10-year results (Fig. 3 and Fig.). The RSA and the RLA showed no notableostoperative changes at 5-year and over-10-year follow-up.t 5-year follow-up, the first patient had progressed fromichtman’s stage IIIA to stage IV, and the second patientrogressed from stage IIIB to stage IV. For both patients, aostoperative MRI was available, and neither of thememonstrated evidence of revascularization. Both patientsad postoperative lunate collapse with ongoing progressionf radiographic changes and deterioration of clinicalutcome until the final follow-up.
omplications
n total, minor complications occurred in 2 patients (11%),elated to pin track infection from external fixation, but didot require further treatment. There were no instances ofnfection, hernia formation, or lateral femoral cutaneouserve injury at the donor site over the iliac crest.
ISCUSSIONarious surgical procedures are recommended for treatment
IGURE 2: Posteroanterior radiographs 12 years and 4 months afterurgery, showing no evidence of further lunate collapse androgression of Lichtman stage. Carpal height could be maintained.
f Kienböck’s disease in Lichtman stage III. In the early s
JHS �Vol A, F
tage, joint-leveling procedures such as radial shortening orlnar lengthening decrease the excessive load pressure to the
unate, allowing the carpal bone to revascularize.20
ntercarpal arthrodesis unloads the lunate, permittingevascularization with the advantage of stabilizing theidcarpal joint in the later stage of the disease.21
Because the vascular anatomy and the vascularmpairment of the lunate have often been referred to as theause of avascular necrosis in Kienböck’s disease, lunateevascularization seems reasonable to treat this disease. Horit al first reported on vascular bundle implantation intoone in canines.22 Based on these investigations, Tamai etl23 reported 51 patients with an average follow-up of 2ears treated by direct implantation of the second or thirdetacarpal vessels into the lunate. Good results could be
chieved only in stage I and II of Kienböck’s disease. Inheir series, 72.5% demonstrated a radiological disappearancef sclerosis, 19.6% had an increase of osteoarthritic signs, and.8% had further fragmentation of the lunate. In stage III,he radiological improvements were not satisfying, andherefore, the authors recommended this treatment for stageII only in conjunction with joint-leveling procedures orartial carpal fusion. The authors did not use any additionalemporary fixation to prevent excessive force on the lunateuring the early stage of revascularization. Aspenburg et altated that bone revascularization leads to an increasedsteoclastic activity, which weakens the bone in the acutehase of revascularization. An external fixator prevents directoad bearing of the lunate and protects the graft untilsseointegration is achieved.24 In the presented study, wesed an external fixator for 8 weeks after surgery toeutralize compression forces that might displace the graftnd might be detrimental to the graft during thencorporation.
Moran et al11 reported 26 patients with Kienböck’sisease (stage II: n�12; stage IIIA: n�10; stage IIIB: n� 4)ith an average follow-up of 31 months. All patients were
reated with the 4 � 5 extensor compartmental artery boneraft and external fixation. Wrist flexion-extension arcmproved from 68% to 71% of the control side after surgery,nd wrist deviation improved from 66% to 77%. Postsurgicalrip strength improved from 50% to 89% of the uninjuredand. The average carpal height index was 0.46, and theverage Ståhl index was 0.41 at final examination.ccording to the Mayo wrist score, 6 patients had anxcellent result, 6 had a good result, 9 had a fair result, andhad a poor result. Six patients (23%) had radiographic
vidence of further lunate collapse and progression ofichtman stage.
In our series, from 18 patients classified as Lichtman stageII, 2 patients (11%) progressed to stage IV. As proved inheoretical studies, we consider the biomechanical propertiesf the iliac bone graft to be superior to that of the distaladius. Schnitzler et al25 demonstrated that the denseancellous structure of the iliac crest graft is mechanically
uperior to other donor sites. Bone volume and bone
ebruary
taMdobpavId
dfavup
aaa0pppwatvsp
1iafm4scRc
talbtasipl
u
diseas
F
sw
180 VASCULARIZED BONE GRAFT FOR KIENBÖCK’S DISEASE
urnover of the distal radius is lower, trabeculae are thinner,nd the cortices are only half as thick as the iliac crest.oran et al11 used a vascularized bone graft from the dorsal
istal radius to address the pathologic lunate from dorsal. Inur described procedure, the dense-structured cancellousone with its strong cortical bone from the iliac crest islaced to the palmar aspect of the lunate where the maximalxial load is applied.26 Following this concept of stability andiability, especially in the collapsed lunate stage IIIA andIIB, long-term restoration of carpal height could beemonstrated at midterm follow-up.14
Daecke et al12 reported on 23 patients with Kienböck’sisease (stage II: n�13; stage IIIA: n�6; stage IIIB: n�1;or 3 patients preoperative x-rays were missing) with anverage follow-up of 12 years. All patients were treated byascularized os pisiform transfer. Eleven patients (48%) withlnar-minus variance received an additional leveling
FIGURE 3: A 28-year-old man with Stage IIIA
IGURE 4: Posteroanterior radiographs 11 years and 7 months afterurgery, showing resorption of the bone graft and lunate collapseith ongoing progression of radiographic changes.
rocedure for radial shortening. Range of motion increased i
JHS �Vol A, F
fter surgery and reached 80% of the uninjured side. Theverage grip strength was 84% of the contralateral hand. Theverage carpal height was 0.53, the average Ståhl index was.37, and the average RSA was 54° at final follow-up. Thereoperative Lichtman stage remained unchanged in 11atients (55%), improved in 3 (15%), and progressed in 6atients (30%). The mean DASH score at final follow-upas 15.3 points. The carpal height ratio, the Ståhl index,
nd the RSA of the uninjured side were not presented inhis series. In the case of ulnar-minus variance, theascularized os pisiform transfer was combined with radialhortening. In 64% of these cases, carpal collapse could berevented.
In the presented study, the late follow-up of more than0 years after core revascularization of the collapsed lunaten stages IIIA and IIIB showed a good functional, radiologic,nd subjective outcome. The performed procedure using aree vascularized bone grafting from the iliac crest enabled aean recovery to 98° of wrist flexion-extension arc and to
5° of wrist deviation arc. Assessment of radiological resultshowed an average Ståhl index of 0.4 and an average Youmarpal height index of 0.54 at final follow-up.adiologically, the initial restoration of the carpal height
ould be maintained for an average of 13 years.No additional surgery in order to diminish pressure to
he lunate was required. The advantage of the palmarpproach is to directly address the biomechanically mostoad-bearing part of the lunate and to place and shape theone graft most properly. This approach requiresranssection of the palmar ligaments, but leaving the ulnarnd radial insertions of the long radiolunate ligament and thecaphocapitate ligament intact. We observed no carpalnstability in the long-term follow-up. Probably theeriosteum of the graft enhances formation of a stable tissueayer as it covers this ligamentous complex.
Our findings indicate that reconstruction of the lunatesing a vascularized corticocancellous bone graft from the
e. A Posteroanterior radiograph. B CT scan.
liac crest can restore and maintain carpal height. This graft
ebruary
hltd
foupmora
cis
R
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
VASCULARIZED BONE GRAFT FOR KIENBÖCK’S DISEASE 181
as been found to be strong enough to carry the appliedoads for a long period of time. It also proved beneficial toailor the graft adequately, especially to the long sagittaliameter of the lunate.27
Free vascularized iliac bone grafting and external fixationor Kienböck’s disease stage III is a reasonable treatmentption. The final results at an average of 13 years of follow-p, compared with the reported 5-year results14 of the sameatients, confirmed that the favorable 5-year results wereaintained over the long term. Patients with incorporationf the graft showed good clinical and radiological long-termesults, and progression of the disease seems to be stabilizedfter 5 years.
The restoration of carpal height, prevention of carpalollapse, minor donor site morbidity, no evidence of carpalnstability, and long-lasting pain relief justify this long-tanding procedure.
EFERENCES
1.Alexander AH, Lichtman DM. Kienbock’s disease. OrthopClin North Am 1986;17:461–472.
2.Beckenbaugh RD, Shives TC, Dobyns JH, Linscheid RL.Kienbock’s disease: the natural history of Kienbock’s diseaseand consideration of lunate fractures. Clin Orthop Relat Res1980;149:98–106.
3.Kristensen SS, Thomassen E, Christensen F. Kienbock’sdisease—late results by non-surgical treatment. A follow-upstudy. J Hand Surg 1986;11B:422–425.
4.Keith PP, Nuttall D, Trail I. Long-term outcome ofnonsurgically managed Kienbock’s disease. J Hand Surg2004;29A:63–67.
5.Weiss AP, Weiland AJ, Moore JR, Wilgis EF. Radialshortening for Kienbock disease. J Bone Joint Surg 1991;73A:384–391.
6.Tillberg B. Kienboeck’s disease treated with osteotomy tolengthen ulna. Acta Orthop Scand 1968;39:359–369.
7.Watson HK, Monacelli DM, Milford RS, Ashmead D IV.Treatment of Kienbock’s disease with scaphotrapezio-trapezoid arthrodesis. J Hand Surg 1996;21A:9–15.
8.Lin HH, Stern PJ. “Salvage” procedures in the treatment ofKienbock’s disease. Proximal row carpectomy and total wristarthrodesis. Hand Clin 1993;9:521–526.
9.Stark HH, Zemel NP, Ashworth CR. Use of a hand-carvedsilicone-rubber spacer for advanced Kienbock’s disease.J Bone Joint Surg 1981;63A:1359–1370.
0.Leung PC, Hung LK. Use of pronator quadratus bone flapin bony reconstruction around the wrist. J Hand Surg 1990;15A:637–640.
1.Moran SL, Cooney WP, Berger RA, Bishop AT, Shin AY.The use of the 4 � 5 extensor compartmental vascularizedbone graft for the treatment of Kienbock’s disease. J HandSurg 2005;30A:50–58.
2.Daecke W, Lorenz S, Wieloch P, Jung M, Martini AK.
Vascularized os pisiform for reinforcement of the lunate in
JHS �Vol A, F
Kienbock’s Disease: an average of 12 years of follow-upstudy. J Hand Surg 2005;30A:915–922.
3.Daecke W, Lorenz S, Wieloch P, Jung M, Martini AK.Lunate resection and vascularized os pisiform transfer inKienbock’s disease: an average of 10 years of follow-up studyafter Saffar’s procedure. J Hand Surg 2005;30A:677–684.
4.Gabl M, Lutz M, Reinhart C, Zimmerman R, Pechlaner S,Hussl H, et al. Stage 3 Kienbock’s disease: reconstruction ofthe fractured lunate using a free vascularized iliac bone graftand external fixation. J Hand Surg 2002;27B:369–373.
5.Macdermid JC. Development of a scale for patient rating ofwrist pain and disability. J Hand Ther 1996;9:178–183.
6.Green DP, O’Brien ET. Open reduction of carpaldislocations: indications and operative techniques. J HandSurg 1978;3A:250–265.
7.Youm Y, Mcmurthy RY, Flatt AE, Gillespie TE.Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexion-extension. J Bone Joint Surg1978;60A:423–431.
8.Linscheid RL, Dobyns JH, Beabout JW, Bryan RS.Traumatic instability of the wrist. Diagnosis, classification,and pathomechanics. J Bone Joint Surg1972;54A:1612–1632.
9.Sowa DT, Holder LE, Patt PG, Weiland AJ. Application ofmagnetic resonance imaging to ischemic necrosis of thelunate. J Hand Surg 1989;14A:1008–1016.
0.Schiltenwolf M, Martini AK, Mau HC, Eversheim S, BrocaiDR, Jensen CH. Further investigations of the intraosseouspressure characteristics in necrotic lunates (Kienbock’sdisease). J Hand Surg 1996;21A:754–758.
1.Sauerbier M, Trankle M, Erdmann D, Menke H, GermannG. Functional outcome with scaphotrapeziotrapezoidarthrodesis in the treatment of Kienbock’s disease stage III.Ann Plast Surg 2000;44:618–625.
2.Hori Y, Tamai S, Okuda H, Sakamoto H, Takita T,Masuhara K. Blood vessel transplantation to bone. J HandSurg 1979;4A:23–33.
3.Tamai S, Yajima H, Ono H. Revascularization proceduresin the treatment of Kienbock’s disease. Hand Clin 1993;9:455–466.
4.Aspenberg P, Wang JS, Jonsson K, Hagert CG.Experimental osteonecrosis of the lunate. Revascularizationmay cause collapse. J Hand Surg 1994;19B:565–569.
5.Schnitzler CM, Biddulph SL, Mesquita JM, Gear KA. Bonestructure and turnover in the distal radius and iliac crest: ahistomorphometric study. J Bone Miner Res 1996;11:1761–1768.
6.Iwasaki N, Minami A, Miyazawa T, Kaneda K. Forcedistribution through the wrist joint in patients with differentstages of Kienbock’s disease: using computed tomographyosteoabsorptiometry. J Hand Surg 2000;25A:870–876.
7.Biddulph SL. Bone donor site. Iliac crest or distal radius?
