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American Association for Hand Surgery

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Outcomes of Lunate Fixation versus Proximal Row Carpectomy for Lichtman Stage IIIC Lunate in Kienböck's Disease
Lauren E Dittman, MD1, Nicholas Munaretto, MD1, Karina Lenartowicz, BS1 and Sanjeev Kakar, MD, FAOA2, (1)Mayo Clinic, Rochester, MN, (2)Orthopaedics, Mayo Clinic, Rochester, MN

Introduction
The treatment of a Lichtman Stage IIIC lunate (coronally oriented fracture) Kienböck's patients is controversial. Traditional teaching was to proceed with a salvage procedure such as a proximal row carpectomy (PRC) but more recently, there has been evidence to suggest that these fractures may be treated with screw fixation or vascularized bone graft (VBG). To our knowledge, no comparative studies exist. The purpose of this study was to examine the reoperation rates and functional outcomes between these two groups.

Materials & Methods
A retrospective chart review was performed for all patients with coronal plane fractures of the lunate in Kienböck's disease at a single institution (2003-2020). Patients who initially underwent a lunate fixation procedure (i.e. open reduction internal fixation, VBG) (n=21) or PRC (n=14) were included in this study. The primary outcome examined was reoperation rate, and secondary outcomes included pain, grip strength, and Mayo Wrist Score (MWS).

Results
There was a higher rate of reoperation in patients who underwent a lunate fixation procedure compared to those who underwent PRC (p=0.028). The procedure type and union rate of the 21 patients who underwent lunate fixation are listed in Table 1. Of the 21 patients who underwent a lunate fixation procedure, 6 required reoperations. Average time to reoperation was 9 months. There were no patients in the PRC group who required reoperation. There were no significant differences in the postoperative VAS pain scores, gain in grip strength, or change in MWS between the lunate fixation and PRC cohorts (Table 2). The patients who required reoperation were excluded from outcome analysis.

Conclusions
This study showed that there is a significantly higher reoperation in patients who initially undergo a lunate fixation procedure compared to PRC. Overall, functional outcomes are similar between patients who undergo primary PRC and lunate fixation for coronal plane fractures in Kienböck's disease.



Vascularized graft


n=10



Union (9 pts with CT)


2 (22%)



Reoperation


3 (30%)




Offloading


n=8



Union (3 pts with CT)


0



Reoperation


2 (25%)




ORIF alone


n=3



Union (3 pts with CT)


2 (67%)



Reoperation


1 (33%)





Table 1. Lunate union rate and complications by fixation method. Offloading includes scaphocapitate pinning/arthrodesis, core decompression of radius, etc.



Fixation


PRC


p-value


VAS


2.3


1.3


0.303


Grip Strength


5.9


6.5


0.923


MWS


27.4


34.4


0.487


Table 2. Outcome measures.
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