Mir Xavier, Barrera-Ochoa Sergi, Lluch Alex, Llusa Manuel, Haddad Sleiman, Vidal Nuria, Font Jordi
Hand Surgery Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
Tech Hand Up Extrem Surg. 2013 Jun;17(2):72-9. doi: 10.1097/BTH.0b013e31827f452a.
Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.
对于晚期月骨无菌性坏死（Lichtmann IIIB至IV期），通常建议采用诸如近排腕骨切除术或部分关节固定术等重建手术。本研究的目的是评估一种针对晚期月骨无菌性坏死的替代性手术技术：月骨切除并用带蒂血管化舟骨移植替代，同时进行部分桡舟关节固定术。该手术的主要优点是在不影响诸如疼痛等主要临床结果的情况下保留活动度。通过替换失活的月骨，我们旨在维持腕中关节的活动范围，并防止因腕骨塌陷和手腕骨关节炎导致的疾病进展。在2002年至2008年期间，13例平均年龄为41岁（范围为25至57岁）的患者接受了该技术手术。手术操作包括3个关键步骤。首先，切除月骨；然后，用旋转后的舟骨填充所形成的间隙，将其用作带蒂血管化自体移植物；最后，进行部分桡舟关节固定术。在末次随访时，接受干预的患者均无静息痛，6例患者能够进行不受限制的日常活动。术后屈伸活动度的平均值为70度（范围为55至90度），为对侧手臂活动度的44%（范围为38%至54%），仅比同一只手腕术前活动度少16%（范围为14%至19%）或25度（范围为18至30度）。握力提高了30%以上（范围为24%至36%）。术后平均随访4年时，13例患者中有12例在新舟头关节水平没有骨关节炎或软骨下骨塌陷的影像学证据。在随访评估中，DASH评分的平均值为14分（范围为6至20分）。与传统技术相比，患者的功能能力有显著改善，取得了良好的效果。没有腕骨塌陷且功能结果良好，令人鼓舞。
