| Avascular necrosis of the lunate is a progressive, debilitating disease process that can lead to chronic pain and dysfunction, but the reason is still unclear. Robert Kienb?ck, an Austrian radiologist, first descirbed the pattern,pathogenesis and treatment options for this disease in detail in 1910. Because of his contribution, this entity is called Kienb?ck disease. The most influenced people between the years of 15-40 and is mostly unilateral. Although the anatomy, etiology, imaging, and treatment of the disease has made great progress, but the diagnosis and treatment of the Kienb?ck disease is still a challenging thing for orthopaedic surgeons. Although there are many treatment options, but so far there is no unified method.Until now, the pathogenic mechanism of the Kienb?ck disease is still unclear. Anatomical factors, mechanical, vascular and traumatic factors have been implicated. So the lesions may be the result of multifactors. Among the factors considered in its etiology, negative variance ulnar is one of the most frequently mentioned and studied. There is controversy opinion in the association of Kienb?ck disease and negative ulnar variance. In the literature,the association of Kienb?ck disease and ulnar variance seems to vary between different nationalities and countries. The purpose of this study is to compare the X-ray of the wrist of the patients with Kienb?ck disease from the normal population to find out whether there was a relationship between ulnar negative variance and Kienb?ck disease in the people of south-central province of Hebei.For stage Ⅱto Ⅲ Kienb?ck disease, the most commonly used methods are attempts to unload the pressure, improve the blood supply, and maintain the shape of the lunate. However, the optimal treatments for stage Ⅱto Ⅲcontinue to elude investigators. New method was attempted to treat patients with Kienb?ck disease in stage Ⅱto Ⅲ by using balloon kypholasty system and the effect of this new method was assessed.Intraosseous ganglia(IOG) are cystic defects of the bone and it is the most common bone tumour in the carpal bones. The pathogenesis of IOG is still uncertain. For the painful intraosseous ganglia, surgery is needed to excise the tumour. The traditional method is to excise the painful IOG with open curettage by autogenous cancellous bone graft to fill the empty cavity. But this method may destroy the structure of the wrist and lead to dysfunction postoperation. The minimally invasive technique of percutaneous bone cement injection was used to treat the intraosseous ganglia of the wrist bones and obtained satisfactory therapeutic results.PartⅠ The analysis of the relationship between ulnar negative variance and Kienb?ck disease by wrist X-ray in the people of south-central province of HebeiObjective:To compare the X-ray of the wrist of the patients diagnosed with Kienb?ck disease from the normal population to find out whether there was a relationship between ulnar negative variance and Kienb?ck disease in the people of south-central province of Hebei.Methods:This study included two groups. The imaging information of the patients who had taken standard posteroanterior wrist X-ray was acquied from the PACS system in the radiology department of our hospital. The first group included 100 cases wrist X-ray diagnosed with Kienb?ck disease(The diagnosis is mainly based on X-ray). Accoarding to the Lichtman classification of Kienb?ck disease, all the cases in the first group were stageⅡ to Ⅳ. The first group including 45(45.0%) male and 55(55.0%) female,and the average age was 45.0. There were 57(57.0%) cases of right side and43(43.0%) cases of left side. The second group included 200 cases wrist X-ray of normal adult population, including 113(56.5%) male and 87 female and the average age was 39.3. There were 101(50.5%) cases of right side and99(49.5%) cases of left side. The method of perpendiculars was used to measure the ulnar variance. After identifying the longitudinal axis of the radius, a line is drawn through the distal ulnar aspect of the radius that is perpenducular to its longitudinal axis. The distance between this line and the distal cortical rim of the ulna is measured to determine ulnar variance. Ulnar variance was classified by Hulten’s classification: positive variance, the ulna was longer than the radius; negative variance, the ulna was shorter than the radius; neutral or zero, the ulnar length was equal to the radial length. The imaging measurement was takened by two senior radiologist and hand surgeon.Statistical analyses were performed using SPSS 19.0 statistical software.Differences were regraded as statistically significant when P values were<0.05.Results:Thet group A(Kienb?ck disease group) contained 100 patients.There were 49(49%) with ulnar positive, 32(32.0%) with neutral and19(19.0%) with ulnar negative variance. The male were 45(45.0%), included20(44.4%) with ulnar positive, 17(37.8%) neutral and 17(37.8%) ulnar negative variance. The female were 55(55.0%), included 29(52.7%) with ulnar positive, 15(27.3%) neutral and 11(20.0%) ulnar negative variance. The left side were 43(43.0%), included 14(32.6%) with ulnar positive, 19(44.2%)neutral and 10(23.3%) ulnar negative variance. The right side were 57(57.0%),included 35(61.4%) with ulnar positive, 13(22.8%) neutral and 9(15.8%) ulnar negative variance.The group B(normal group) contained 200 patients. There were 94(47.0%) with ulnar positive, 79(39.5%) with neutral and 27(13.5%) with ulnar negative variance. The male were 113(56.5%), included 55(48.7%) with ulnar positive, 42(37.2%) neutral and 16(14.2%) ulnar negative variance. The female were 87(43.5%), included 39(44.8%) with ulnar positive, 37(42.5%)neutral and 11(12.6%) ulnar negative variance. The left side were 101(50.5%),included 40(39.6%) with ulnar positive, 46(45.5%) neutral and 15(14.9%)ulnar negative variance. The right side were 99(49.5%), included 54(54.5%)with ulnar positive, 33(33.3%) neutral and 12(12.1%) ulnar negative variance.The results showed that there was no statistical difference of the ulnar negative variance in the two groups(P<0.05).Conclusions: The results show that there was not an association between ulnar negative variance and Kienb?ck disease in the people of south-central province of Hebei.Part Ⅱ Clinical research of treat Kienb?ck disease by using balloon kyphoplasty system and bone cement injectionObjective: The option of treatment methods of Kienb?ck disease is still a challenge problem for the clinical surgeons. The purpose of this study was to demonstrate the feasibility and effect of percutaneous balloon kyphoplasty for treatment of stage Ⅱ to Ⅲ Kienb?ck disease.Methods: The study group comprised 9 patients including 6 male and 3female and the average age was 38.6 years(range 27-50 years). There were 2left hands and 7 right hands in this group and all of them were dominant side hands. In the group 7 patients had the history of heavy manual labour and the other 2 patients had no obvious reason. Patients with obvious history of trauma, infection, gout, rheumatoid arthritis and other neuromuscular diseases were excluded. The average preoperative pain time of the 9 patients was 24.8months(range 12-42 months). 7 patients had seen a doctor because of the wrist pain. They were taken plaster fixation for 4 weeks. The other 2 patients had never been taken plaster fixation. In this group 8 patients had taken non-steroidal drugs and 1 patient had not taken any drugs. Accoarding to the Lichtman classification of Kienb?ck disease, there were 2 patients in stage Ⅱ,4 patients in stage ⅢA and 3 patients in stage ⅢB in the group. All of the patients were treated by using balloon kyphoplasty system and bone cement injection. Radiographic evaluations of the lunate were performed at 1, 3, 6, 12,18, and 24 months postoperatively to observe the lunate and the changes of the carpal bones. The evaluation index included pain, grip power, wrist flexion/extension range of motion, the Mayo Wrist Score and the DASH(Disabilities of the Arm, Shoulder and Hand) score preoperatively and postoperatively. The data was analyzed statistically.Results: The average operation time was 22.8 min(range 18-45 min).The average amount of bone cement injected into the lunate was 0.32 m L(range 0.25-0.40 m L). The pressure demonstrated on the screen of the digital gauge was 0.45 Mpa(range 0.35-0.55 Mpa). The next day after the operation,5 patients relieved pain symptoms. One week after the operation, the pain was almostly gone in 3 patients, reduced significantly in 4 patients, and the other 2patients had no obvious change. At the 24-month follow-up, the mean VAS pain score had improved significantly from 6.0±1.2 preoperatively to 0.6±1.0 postoperatively and it was statistical difference(P﹤0.001). One patient still complained of mild pain but the pain symptom had relieved obviously(the VAS pain score was 3). The grip strength increased from 43.4 ± 6.7%preoperatively to 82.7±8.2% postoperatively and it was statistical difference(P﹤0.001). The wrist flexion/extension range of motion was average 42.7±4.1%(referencing the healthy side) preoperatively to 77.1 ± 7.9%postoperatively and it was statistical difference(P﹤0.001). The mean Mayo Wrist Score was increased from 42.2(range 35-50) preoperatively to 78.9(range 35-50) postoperatively(P﹤0.001). Based on the Mayo Wrist Score, 1patient was excellent, 4 patients were good and 4 patients were better outcomes. In the subjective evaluation, four patients were enthusiastic and four were satisfied.Conclusions: Balloon kyphoplasty could prevent lunate collapse, reduce pain, and improve wrist function of patients with stage Ⅱ to ⅢKienb?ck disease.Part Ⅲ Primary results of the therapeutic effect of bone cement injection in the treatment of intraosseous ganglion of the lunate bonesObjective: The aim of this study is to treat intraosseous ganglion of the carpal bones with injectable bone cement grafting.Methods: From 2012, 4 patients diagnosed as intraosseous ganglion of lunate bone by radiography were treated with percutaneous minimal invasive curettage and bone cement injection operation. The group included 3 men and 1 woman. The average age of the 4 patients was 44.5(range 33-60). 3 patients’ lesion was in the right side, 1 case in the left side, and no patients has bilateral lesion. All of the patients came to the diagnosis of X-ray examination due to the affect of wrist joint pain. Conservative treatments including the plaster fixation and nossteroidal drugs didn’t relieve the symptoms. Trauma history,local infection, or neurovascular leisions were excluded from this study. The time of the pain lasted from 8 to 18 months. All patients were followed up at least for 12 months.Results: The average operation time of the 4 patients was 20 min(range15-30 min), with an average amount of 5.5m L(range 3-10 m L) of bleeding during the operation. The average follow-up time was 16.8 months(range12-22 months). Wrist pain symptoms disappeared after operation. Bone cement absorption was not observed by X-ray examination during the follow up. No tumor recurrence and other complications. No rejection reaction.At 12-month postoperative follow-up, the score of pain on VAS reduced from 7.8(7-8) at to be 0.3(0-1) and it was statistical difference(P﹤0.001).The grip strength increased from 39.3%(32-46%) preoperatively to 87.3%(82-91%) postoperatively and it was statistical difference(P ﹤ 0.001). The wrist flexion/extension range of motion was average 43.3%(38-50%)(referencing the healthy side) preoperatively to 72.8%(66-80%)postoperatively and it was statistical difference(P﹤0.001). The mean Mayo Wrist Score was increased from 42.2(range 35-50) preoperatively to 78.9(range 35-50) postoperatively and it was statistical difference(P﹤0.001). The DASH score reached 12.0(range 11.0-15.0). In the subjective evaluation,three patients were enthusiastic and one was satisfied. These results suggested a good recovery.Conclusions: The bone cement injection was an effective and safe therapeutic strategy to the treatment of intraosseous ganglion of the lunate.This method could relieve the pain effectively and avoid the side hurting of the autologous bone graft. |
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