Vascularized Integral Capitate Transposition Based On Dorsal Intercarpal Arch For Advanced Kienbdck’s Disease

Objective:Kienb ck’s disease is a condition of uncertain aetiology that inducesaseptic necrosis of the lunate and pain of the wrist. Although there are manysolutions for the advanced Kienb ck’s disease, the effect of its treatments havebeen disputed.The purpose of this study is to study the number and position ofnutrient foramen in the capitate bone and to introduce a surgical procedure ofintegral capitate transposition based on dorsal intercarpal arch and toinvestigate the outcomes.Methods:The palmar and dorsal part of each capitate bone was divided into threeequal parts, and the number and position of nutrient foramen was analyzed inthe100capitate bones through magnifying glass (5times).According to thedistribution of the capitate bone and the capitate anatomical basis of the bloodsupply, a1.5-cm-wide fascia was performed including the dorsal intercarpalarch, the third dorsal metacarpal artery and its accompanying vein，then thevascularized integral capitate was got. Shift the capitate proximally into thelunate fossa of the distal radius and contact the capitate intimately with thelunate fossa under neutral position. Fix the transposed capitate to the scaphoidand triquetrum using a Kirschner wire and the trapezo-capitate andscaphocapitate bones were fixed by two Kirschner wires through osseous graftharvested from the ipsilateral iliac crest. The average age of6patients at thetime of the procedure was40years (range,36-45years). All of them were men,and4dominant hands and2nondominant hands were involved. The extremitywas immobilized postoperatively in the below-the-elbow thumb spica cast. Theobservations included symptoms, wrist range of motion, grip strength and radiography, which were compared with the preoperative.Results:The number of nutrient foremen on dorsal and palmar part of the capitatebone was5.9±2.8,4.7±2.4, respectively. The distribution on the proximal andcentral and remote part of the capitate bone was19.5%,49.7%and30.8%.6patients were followed up for14months~56months，the meanfollow-up was32months. The patients subjectively scored the procedure asgood or excellent. Pain disappeared after surgery in patients at rest, and had amild level pain during wrist motion．The average flexion and extension rangesof the operated wrist were41°,36°， respectively． X-ray showed thatradiocapitate joint had well connected, and compact bone substance density ofcapitate is normal, and bone implant knit together well. Visual analog scalescores（VAS）for pain, and Disabilities of the Hand and Wrist (DASH) scoreswere significantly improved. The mean percentage of grip strength to normalwas more than85%.Conclusions:Our study suggested the nutrient foremen of the capitate bone mostly liedon the dorsal part, and the vascular network consisting of the palmar arteriesand the dorsal vessels through the nutrient arteries provided the rich bloodsupply for the capitate bone, which provides the anatomical basis for the lunatebone shift after lunate necrosis.Vascularized integral capitate transposition based on dorsal intercarpalarch for Advanced Kienb ck’s Disease was simple to manipulate, and ensuredadequate blood supply of capitate to reduce the probability of necrosis of thetransposed capitate. Pain disappeared after surgery and the average flexion andextension ranges of the operated wrist improved. The integral capitate transferpedicled by dorsal intercarpal arch is an effective procedure to treat advancedKienb ck’s Disease, with favorable preliminary results.