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Avascular Necrosis: a Short-Term Outcome Analysis

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Avascular Necrosis: a Short-Term Outcome Analysis SCIENTIFIC ARTICLE Arthroscopic Partial Capitate Resection for Type Ia Avascular Necrosis: A Short-Term Outcome Analysis Takamasa Shimizu, MD,* Shohei Omokawa, MD,*† Francisco del Piñal, MD,‡ Koji Shigematsu, MD,§ Hisao Moritomo, MD,k Yasuhito Tanaka, MD* Purpose To examine short-term clinical results of arthroscopic partial resection for type Ia avascular necrosis of the capitate. Methods Patients who underwent arthroscopic treatment for type 1a avascular necrosis of the capitate with at least 1-year follow-up were identified through a retrospective chart review. The necrotic capitate head was arthroscopically resected with removal of the lunate facet and preservation of the scaphoid and hamate facets. Wrist range of motion, grip strength, and radiographic parameters—carpal height ratio, radioscaphoid angle, and radiolunate angle— were determined before surgery and at the latest follow-up. Patients completed a visual analog scale for pain; Disabilities of the Arm, Shoulder, and Hand measure; and the Patient-Rated Wrist Evaluation score before surgery and at the latest follow-up. Results Five patients (1 male, 4 females) with a mean age of 34 years (range, 16e49 years) and a mean follow-up duration of 20 months (range, 12e36 months) were identified during the chart review. All were type Ia (Milliez classification). Arthroscopy revealed fibrillation or softening with cartilage detachment at the lunate facet of the capitate head and an intact articular surface at the scaphoid and hamate facet. At the latest follow-up, the mean wrist flexion-extension was 123 (vs 81 before surgery) and grip strength was 74% (vs 37% before surgery). The visual analog scale score for pain; the Disabilities of the Arm, Shoulder, and Hand score; and the Patient-Rated Wrist Evaluation score before surgery showed a significant improvement following treatment. Radiographic parameters did not significantly change at the final follow-up, although the proximal carpal row trended toward flexion. Conclusions Arthroscopic partial resection of the capitate head was an acceptable treatment for type Ia avascular necrosis of the capitate. It provided adequate pain relief and improved the range of wrist motion and grip strength during short-term follow-up. (J Hand Surg Am. 2015;40(12):2393e2400. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Capitate, necrosis, carpal bone, arthroscopy, partial resection. From the *Department of Orthopedic Surgery, the †Department of Hand Surgery, Nara Corresponding author: Shohei Omokawa, MD, Department of Orthopaedic Surgery, Medical University, Nara, Japan; the ‡Instituto de Cirugía Plástica y de la Mano, Private Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan; e-mail: Practice and Hospital Mutua Montañesa, Santander, Spain; the §Department of Orthopaedic [email protected]. k Surgery, Higashiosaka City General Hospital; and the Department of Orthopedic Surgery, 0363-5023/15/4012-0011$36.00/0 Yukioka Hospital Hand Center, Osaka Yukioka College of Health Science, Osaka, Japan. http://dx.doi.org/10.1016/j.jhsa.2015.09.010 Received for publication March 17, 2015; accepted in revised form September 15, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Ó 2015 ASSH r Published by Elsevier, Inc. All rights reserved. r 2393 2394 RESECTION ARTHROPLASTY FOR NECROTIC CAPITATE VASCULAR NECROSIS OF THE CAPITATE is rare and TABLE 1. Milliez Classification of unknown etiology. Retrograde blood flow and poor intraosseous vascular anastomosis Type Radiographic Appearance A fl make the proximal pole prone to impaired blood ow, I Sclerotic change and fragmentation are apparent 1 leading to avascular necrosis. Several predisposing in the proximal part of the capitate. 2e8 factors have been reported, including trauma, Ia Lunocapitate joint is involved. 9 10,11 hypermobility of the wrist, steroid use, systemic Ib Both lunocapitate and scaphocapitate joints are 12 13 lupus erythematosus, and gout. Repetitive minor involved. trauma may also be a cause in cases in which no other Ic Scaphocapitate joint is involved. fi 14e20 de nitive etiological factor can be detected. II Sclerotic change and fragmentation are apparent The choice of surgical procedure depends on the in the distal part of the capitate. pathological condition of the necrotic capitate, but III Sclerotic change and fragmentation are apparent therapeutic guidelines have not been established. Thirty- in the entire capitate. eight cases have been reported in the English literature, with treatment using surgical techniques, including 4,5,8,9,10,16,21e29 intercarpal arthrodesis (22 cases), lesion (Table 1). All patients had cystic changes and proximal pole resection (4 cases) with or without collapse at the proximal pole of the capitate and were 19,20,30 drilling of the capitate, prosthetic arthroplasty categorized as type Ia. The indication for surgery was 4,17,24,31 (4 cases), vascularized or conventional bone collapse or subchondral bone fracture of the capitate on 2,15,32e34 grafting (5 cases), posterior interosseous nerve plain radiographs, no revascularization on MRI, and 35,36 37 resection (2 cases), and arthroplasty (1 case). failure to respond to conservative measures (Table 2). Wrist arthroscopy has evolved from being a pre- dominantly diagnostic tool to a valuable adjunctive Pre- and postoperative evaluations procedure for treatment of various wrist disorders.38 At the initial evaluation and latest follow-up, the Several authors have reported arthroscopic manage- operating surgeons determined functional outcomes ment for avascular necrosis of other carpal bones.39,40 based on the range of wrist extension and flexion and Here we investigated short-term clinical outcomes of grip strength (compared with those of the unaffected 5 patients who underwent arthroscopic partial resec- side) and the results of the Disabilities of the Arm, tion for type Ia avascular necrosis of the capitate. Shoulder, and Hand (DASH) score and Patient-Rated Wrist Evaluation (PRWE) score. Subjective pain was MATERIALS AND METHODS rated on a visual analog scale (VAS). Radiographs were obtained in a standard manner with 90 shoulder Patient demographics abduction, neutral forearm rotation, and neutral wrist From 2011 to 2014, we treated 5 patients (1 male, 4 position. Changes in the carpal height ratio (CHR), females) with idiopathic avascular necrosis of the capi- radioscaphoid angle (RSA), and radiolunate angle tate using arthroscopic partial resection. Their ages at the (RLA) were evaluated. MRI scans were examined timeofsurgeryrangedfrom16to49years(mean,34 before surgery and at the final follow-up for all pa- years). In 4 of 5 patients, the dominant hand was affected; tients. Informed consent was obtained from each pa- in 1 posttraumatic case, the nondominant hand was tient, and the appropriate institutional review board affected. None of the patients had a history of major approval was obtained prior to case review. trauma or inflammatory disease. All patients had un- dergone conservative treatment including nonsteroidal Statistical analysis anti-inflammatory drugs, orthosis fabrication, and corti- Pre- and postoperative differences in functional and costeroid injection at other hospitals, and all had pain in radiographic evaluations were compared by the Mann- the dorsal aspect of the wrist during rest and activities of Whitney U test. Significance was set at P < .05. daily living. The mean interval from the initial onset to diagnosis was 18 months (range, 12e36 months). Surgical technique Avascular necrosis was diagnosed using magnetic Three surgeons (S.O., F.D., and H.M.) performed the resonance imaging (MRI) in all patients. Capitate ne- operations under general anesthesia with tourniquet crosis was radiologically evaluated using the Milliez control. A 1.9-mm 30 arthroscope was placed in the 3-4 classification.24 As per the classification, necrosis is portal, and surgical instruments were passed through the defined as types Ia, Ib, Ic, II, or III based on the sclerotic 4-5 portal. A radiocarpal portal was first used to assess or fragmentation pattern and extent of the necrotic the articular surfaces of the radiocarpal joint, volar J Hand Surg Am. r Vol. 40, December 2015 RESECTION ARTHROPLASTY FOR NECROTIC CAPITATE 2395 TABLE 2. Patients’ Demographics Affected Side/ Case Age (y) Sex Dominant Side Etiology Complaints (mo)* Follow-up (mo) 1 45 F L/R Trauma 12 24 2 49 M R/R Idiopathic 36 18 3 25 F R/R Corticosteroids and chemotherapy 19 30 4 37 F R/R Idiopathic 12 12 5 16 M R/R Idiopathic 12 14 *The interval from the initial onset to diagnosis. carpal ligaments, scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament, and triangular fibrocartilaginous complex. Next, the mid- carpal portal was used to assess the integrity of SLIL and LTIL and to inspect for cartilage detachment or loose bodies in the midcarpal joint (Fig. 1). The radial mid- carpal portal was used as a viewing portal, and the ulnar midcarpal portal was used as a working portal. The capitate head was excised by forming a “reversed U- shaped” plane with preservation of the scaphoid and hamate facets (Fig. 2). The radial edge of the resection matched the SLIL, which divides the capitate head into the scaphoid and lunate facets. The ulnar edge of the resection fit the hamate facet. The distal resection was in a convex and concave shape, with the distal edge located approximately 5 mm from the articular surface of the capitate head. A 3.0-mm bur was applied in a back-and- forth motion to resect 5 mm of the capitate head via the ulnar midcarpal portal. The bur diameter was used to gauge the amount of bony resection. The depth was also checked using a portable fluoroscopy unit. The wrist was extended and flexed during the resection to confirm that there was no mechanical impingement (Fig. 1). After the tourniquet was removed, bleeding from the resected capitate edge was observed.
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