Should we save the lunate? A comparison of lunate fixation versus salvage for coronal plane fractures in Kienbockâ€™s disease.
Lauren E Dittman, MD1, Nicholas F Munaretto, MD1 and Sanjeev Kakar, MD, FAOA2, (1)Mayo Clinic, Rochester, MN, (2)Orthopaedics, Mayo Clinic, Rochester, MN
Introduction: The treatment of coronal plane fractures in Kienbockâ€™s disease is controversial. These fractures were previously thought to make the lunate unsalvageable, leading to treatment with partial arthrodesis or proximal row carpectomy (PRC). More recently, there has been evidence to suggest that these fractures can heal after being treated with screw fixation. However, there are no studies to date examining the outcomes between these two groups.
Methods: A retrospective chart review of all patients at a single institution with coronal plane fractures of the lunate in Kienbockâ€™s disease was undertaken. Patients were classified into a lunate fixation cohort (open reduction internal fixation or VBG) (n=14) or lunate salvage (scaphocapitate arthrodesis or PRC) (n=23). Clinical outcomes examined included VAS pain, range of motion, grip strength and Mayo Wrist Score (MWS). For those who underwent lunate fixation, union rate was examined. Reoperation rates between cohorts were compared.
Results: There was improvement in VAS pain and grip strength in both cohorts postoperatively, however there was no significant difference based on treatment type (p=0.624 and 0.305, respectively). Total arc of motion decreased by an average of 5 degrees in the fixation cohort and 14 degrees in the salvage cohort, however this difference was not significant (p=0.285). There was a greater improvement in MWS in the salvage group (32 points) compared to the fixation group (10 point), which approached but did not reach statistical significance (p=0.062). The overall union rate in the fixation cohort was 33% (4 out of 12 patients with postoperative CT scan). Patients with volar fractures had a higher rate of union compared to central or dorsal 1/3 fractures (p=0.083 and 0.035, respectively). Overall, six patients (16%) underwent reoperation at latest follow-up, including 4 patients (29%) in the fixation cohort and 2 patients (9%) in the salvage cohort (p=0.151). Four of the 8 patients (50%) who did not achieve union after lunate fixation went on to require reoperation. The Kaplan-Meier survivorship free from reoperation is shown in Figure 1.
Discussion: The overall union rate of coronal plane fractures is 33%, with a higher rate in volar fractures. Given this, there is a higher rate of revision surgery in these patients compared to those who went onto an initial salvage procedure. This information is important for surgeons when counseling patients.
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