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We report a novel sliding plate system (SPS) and its application for radial shortening osteotomy. We conceptualised, designed and introduced the SPS, which helps with precise shortening osteotomy in both radius and ulna. We implanted the SPS in a patient with Kienböck disease following a radius shortening osteotomy. The SPS was safe and efficient, and the surgical technique eliminated extra steps. The SPS affords precise shortening, optimum compression and anatomic alignment after radius shortening osteotomy. Level of Evidence: Level V (Therapeutic).

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BACKGROUND: Radial height is a radiographic parameter used to guide the treatment of distal radius fractures. However, it is often used synonymously with other terms, and there are substantial discrepancies in its measurement/definition. These discrepancies can alter the measurement of radial height and affect treatment decisions. The purpose of this review is to identify the different definitions of radial height in the literature relevant to distal radius fractures. METHODS: A literature review was conducted in the PubMed/MEDLINE database from inception to 2022. Full-length, English-language studies that pertained to distal radius fractures and reported radial height as a recorded measurement were included. The method of radial height measurement (definition) was extracted from included studies. Level of evidence was determined by the Oxford Centre for Evidence-based Medicine Levels of Evidence tool. RESULTS: A total of 385 studies were identified. Of these, 183 (47.5%) did not provide a definition for radial height. Of the studies that defined radial height, 50.9% (103/202) measured radial height from the radial styloid to the distal ulna, 10.9% (22/202) measured from the radial styloid to the distal radius, and 29.2% (59/202) were "other" definitions. CONCLUSIONS: There is substantial discrepancy in the way that radial height is measured and reported. We advocate for a standardized measurement of radial height (synonymous with radial length) from the radial styloid to the distal ulnar articular surface. Radial shortening is a different measurement and requires comparison with a reference value.

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BACKGROUND: Kienböck's disease is the avascular necrosis of the lunate bone. There is no consensus on the treatment strategy to avoid joint deterioration. This trial is conducted to compare the functional and radiological outcomes of radial shortening and capitate shortening techniques, in patients with avascular necrosis of lunate. METHODS: Patients with a confirmed diagnosis of Kienböck's disease who met the inclusion criteria were randomly divided into radial shortening and capitate shortening groups and treated by allocated technique. Physical examination and radiologic evaluations were performed before and 6 and 12 months after the operation. RESULTS: A total of 52 patients (52 wrists) of stage II or III Kienböck's disease were assessed for eligibility, 12 patients in the radial shortening group, and 17 patients remained until the end of the study. Patients in both groups achieved a satisfactory outcome, with no report of postoperative complications. None of the outcome measures, ranges of motion, grip, and pinch strengths were significantly different between the groups. The outcome was not considerably different in patients with positive or negative ulnar variances who were treated by capitate shortening technique. CONCLUSIONS: The capitate shortening technique which is performed through a smaller incision, and takes less time as compared with radial shortening can be advantageous for patients with stage II or III Kienböck's disease regardless of the ulnar variance. This method can be as effective as classical methods such as radial shortening in improving clinical and functional symptoms after surgery while causing fewer complications.

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Various osteotomies, core decompression, and denervation all have demonstrated favorable outcomes in treatment of Kienböck disease. Given the rarity of this disease, there is a dearth of high-level comparative studies to direct treatment. In this article, the authors review the current literature surrounding these techniques, and provide summary recommendations for the procedure choice.

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Objective Kienbock's disease is an unusual disorder caused by osteonecrosis and the collapse of lunate bone which leads to pain and a chronic decrease in wrist function. The treatments in this disease aim to relieve pain and maintain wrist function and movement. Various surgical procedures have been recommended for the subjects with Kienbock's disease; however, the main question posed here is which of the selected procedures are more successful in relief of the pressure applied on lunate. Methods and Materials Computed tomography (CT) scan images of a normal subject were used to create a three-dimensional model of the wrist joint. The effects of several surgical procedures, including radial shortening, capitate shortening, and a combination of both radial and capitate shortening, on the joint contact force of the wrist bones were investigated. Results The pressure applied to the lunate bone in articulation with radius, scaphoid, capitate, hamate, and triquetrum varied between 19.7 and 45.4 MPa. The Von Mises stress, maximum principal stress, and minimum principal stress decreased in the model with a combination of radius and capitate shortening. Conclusion It can be concluded from the results of this study that the combinations of radius and capitate shortening seem to be an effective procedure to decrease joint pressure, if the combined surgery could not be done, shortening of radius or capitate would be recommended. Level of Evidence This is a Level III study.

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The purpose of this study was to compare the methods of distal radial shortening osteotomy (RSO), lateral closing distal radial wedge osteotomy (RWO), and scaphotrapeziotrapezoid (STT) fusion in the treatment of stage 3A Kienböck's disease (KD). The research was planned as a single-center and retrospective study for the period 2008-2018. Patients were allocated to three groups according to surgical method: group 1, patients with negative ulnar variance, undergoing RSO; group 2, patients with non-negative (neutral or positive) ulnar variance, undergoing RWO; and group 3, patients with non-negative ulnar variance, undergoing STT fusion. Radiological measurements were compared: pre- and postoperative Stahl index, radioscaphoid angle, and carpal height ratio. Clinical comparison used QuickDASH and modified Mayo wrist scores. Fifty-one patients, with a mean age of 34 ± 12 years (range; 16-69 years), were included. Mean follow-up was 4.47 ± 1.8 (range 2-9) years. No statistically significant difference was observed between the groups in terms of change in carpal height ratio or Stahl index (respectively; P = 0.08, P = 0.065). A significant difference was observed in change in radioscaphoid angle between patients undergoing STT fusion versus RWO (P < 0.05). There was no statistically significant difference in postoperative functional scores between groups, and similar postoperative functional scores were achieved with STT fusion and with RWO in the surgical treatment of stage 3A KD with positive or neutral ulnar variance. Good medium-term radiological and clinical results were obtained with RSO in patients with stage 3A KD with negative ulnar variance.

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Objective To determine the rate of salvage procedures and any other unplanned reoperations in patients with symptomatic Kienböck's disease who were treated with radial shortening osteotomy. In addition, we studied patient-reported outcome in the long term using Patient-Reported Outcome Measure Information System (PROMIS) instruments. Patients and Methods We performed a retrospective review of all patients who underwent radial shortening osteotomy for stage 2 and 3A Kienböck's disease. Patients who had concomitant revascularization were grouped separately. We collected demographic data, data regarding type of surgery and reoperations, and radiographic data. Patient-reported outcome measures were the PROMIS Upper Extremity Computer Adaptive Testing (CAT) and Pain Interference instruments, the abbreviated Disabilities of Arm, Shoulder, and Hand (QuickDASH), and the 0 to 10 numeric rating scale for pain and satisfaction. Results We included 48 patients who had radial shortening osteotomy alone, and 17 patients who had a combined procedure of radial shortening and direct revascularization. The rate of unplanned reoperations was 33% (16 of 48) in those who had radial shortening osteotomy and 24% (4 of 17) in those who had a combined procedure. Six (13%) of 48 patients underwent proximal row carpectomy due to failed radial shortening osteotomy. No salvage procedures were performed after combined radial shortening/revascularization. Median PROMIS Physical Function CAT scores were 56 (interquartile range [IQR]: 44-56) and 56 (IQR: 41-56), respectively. Median PROMIS Pain Interference scores were 39 (IQR: 39-52) and 39 (IQR: 39-49), respectively. Median QuickDASH scores were 2.3 (IQR: 0-23) and 4.5 (IQR: 2.3-14), respectively. Conclusion Radial shortening osteotomy for symptomatic Kienböck's disease yields reasonable long-term function. We observed that approximately one in eight patients underwent salvage surgery after radial shortening, and this should be taken into account when making the initial decision to treat Kienböck's disease surgically. There appeared to be no benefit of direct revascularization in addition to radial shortening in terms of patient-reported outcome in the long term. Level of Evidence This is a Level IV, therapeutic study.

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Purpose: This study aimed to report the outcomes of patients with stage III Kienböck disease after treatment with a vascularized bone graft (VBG) to the lunate combined with capitate shortening osteotomy (CS) after a more than 10-year follow-up. Methods: A VBG to the lunate was combined with CS in 10 patients with stage III Kienböck disease (6 patients with stage IIIA and 4 with stage IIIB). We performed VBG, CS, and radial shortening osteotomy (RS) on 7 patients. Among them, 4 had undergone RS previously. The passive wrist extension angle and wrist flexion angle, grip strength (GS), carpal height ratio, Stahl index, visual analog scale of wrist pain, and Mayo modified wrist score were assessed before surgery and at the final follow-up. Results: The flexion angle decreased markedly after surgery, when GS increased in all 10 patients. Radiographic examinations revealed that the carpal height ratio decreased in 9 of 10 patients, whereas the Stahl index increased in 8 patients and remained unchanged in 2. The oldest 3 of 7 patients who underwent VBG, CS, and RS exhibited fusion of the proximal carpals except the pisiform. The mean visual analog scale decreased from 27.6 before surgery to 5.7 afterward. The Mayo modified wrist score improved in 9 patients after surgery and remained unchanged in one. Conclusions: In stage III Kienböck disease, VBG to the lunate combined with CS relieved wrist pain and increased GS and lunate height but was followed by severely restricted wrist motion. Fusion of the proximal carpals developed in 3 of 7 patients who received VBG with CS and RS. Type of study/level of evidence: Therapeutic Ⅳ.

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BACKGROUND: Several methods have been reported to correct deformity and shortening of the distal radius. However, the results are not entirely satisfactory. The results of bifocal osteosynthesis were retrospectively analyzed in this study. METHODS: Eight patients treated with bifocal osteosynthesis were evaluated retrospectively. Pre-operative and post-operative clinical and radiographic examinations were performed. Subjective symptoms and objective joint function were assessed. Radiographic data of the extent of radial lengthening and distal radial articular angle were collected. RESULTS: The mean follow-up period was 46 months (37-68 months). Satisfactory wrist appearance and radial lengthening was achieved in all patients. All patients were satisfied with the wrist appearance and willing to undergo the same treatment again. The range of motion (ROM) of the forearm and wrist was significantly improved. Pin-track infections occurred in two patients, for which they received wound care and oral antibiotics. Complications such as fixation device failure, tendon rupture, fracture of regenerated bone or nerve impairment did not occur. The duration of lengthening depended on the shortening of the radius. Delayed union in the docking site was observed in two patients and union was achieved after bone grafting. CONCLUSIONS: Bifocal osteosynthesis using the Ilizarov method provides a useful method for correction of radial shortening deformity with dislocation of the inferior radioulnar joint. Despite the fact that we did not validate pre-and post-operation functional outcome scores, all patients were satisfied with the wrist appearance and function.

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PURPOSE: To evaluate the effect of radial length change on distal forearm loading during simulated dynamic wrist motion. METHODS: A custom-built adjustable radial implant was used to simulate up to 4 mm of distal radius shortening (-4 mm) and 3 mm of lengthening (+3 mm). Load cells were placed in the distal radius and ulna in cadavers to measure their respective axial loads. The specimens were mounted on a wrist motion simulator that produced active wrist motion via tendon actuation. To simulate radial lengthening osteotomy following radial shortening from malunion, the radius was sequentially lengthened by 1-mm intervals from -4 mm to +3 mm. Radial and ulnar loads were measured during simulated wrist flexion, ulnar deviation (UD), and flexion dart throw (DT) at each interval of radial lengthening up to +3 mm. RESULTS: During wrist flexion and UD, for each millimeter of radial lengthening from -4 mm to the native length, there was a significant increase in distal radial loads. No significant change in radial load was observed beyond the native length during flexion and UD. There was no change in distal radial loads during DT for each interval of radial lengthening from -4 mm to +3 mm. A sequential decrease in ulnar loads was observed as the radius was lengthened from -4 mm to +3 mm for all wrist motions evaluated. CONCLUSIONS: Radial lengthening beyond the native length was not detrimental to radial loading and further reduced distal ulnar loading; achieving at least native ulnar variance seems to be appropriate to restore normal biomechanical loading based on this in vitro study. CLINICAL RELEVANCE: Lengthening of the radius beyond native variance in the setting of ulnar impaction syndrome, distal radius malunion, or distal radioulnar instability may not result in excessive loading of the distal radius and further reduces loading on the distal ulna. Surgeons should obtain contralateral wrist x-rays to serve as a template when performing distal radius osteotomies.

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The QUAL® (Memometal, Stryker) device is a shape memory staple used for bone fixation during distal radius shortening osteotomy in the context of Kienböck's disease. The present study is a retrospective, single-center and multisurgeon study of 30 patients with a mean follow-up of 8 years. Clinical criteria (range of motion (ROM), strength, pain and functional score) and radiographic data (ulnar variance, distal radius articular surface inclination, Lichtman stage, carpal height and bone healing) were evaluated pre- and post-operatively. We found satisfactory results with the mean grip strength of 22 kg/F before surgery and 24 kg/F after surgery. The mean ROM was 88° preoperatively and 82° postoperatively and the mean ulnar deviation was 23° preoperatively and 21° post-operatively. There was no change in radial deviation and pronation-supination after surgery. The average ulnar variance was 1 mm before surgery and 0.2 mm after surgery. The inclination of the distal radius articular surface on lateral and anteroposterior views and the mean carpal height were similar to the pre-operative ones. There was no delay in bone healing. The mean pain score was 2 at rest on a visual analogue scale after surgery. Seven patients experienced an increase in their Lichtman stage at the follow-up, and two patients were waiting for conversion to a non-conservative surgical treatment. Seven staples were removed postoperatively. Seventy-eight percent of patients returned to work after 3 months on average. Seventy-five percent of patients were at least satisfied with the outcome of their surgery. The QUAL® staple is a reliable option for fixation during shortening osteotomy of the radius in Kienböck's disease.

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Distal radius fractures are a common upper extremity fracture and a considerable number of patients have a stable fracture. In the treatment of distal radius fractures, there is considerable disagreement regarding the need for a strict anatomical restoration with operation in elderly patients. Therefore, nonsurgical treatment is a still important treatment option in distal radius fractures. The radiological parameters of before or after manual reduction are important for deciding whether to perform operation or not. The radiological parameters include dorsal angulation of the articular surface, radial shortening, extent of dorsal comminution, intra-articular displacement, concomitant ulnar metaphyseal fracture, shear fracture, and fracture-dislocation of the distal radio-ulnar joint. In addition, clinical situations of patients, including age, activity level, underline disease, and recovery level, which the patients wish should be considered, comprehensively. For the duration of a splint or cast, three to four weeks are recommended in impacted or minimally displaced fractures and five to six weeks in displaced fractures. After reduction of the displaced fractures, patients should undergo a radiologicical examination every week to check the redisplacement or deformity of the fracture site until two or three weeks post trauma. Arm elevation is important for controlling fracture site swelling and finger exercises, including metacarpophalangeal joint motion, are needed to prevent hand stiffness. Active range of motion exercise of the wrist should be initiated immediately after removing the splint or cast.

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We carried out a retrospective study to analyse the long-term outcome of 36 patients after radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease at a mean follow-up of 12.1 years (range 5.4-17.5). At review, seven wrists had progressed to Stage IIIB, eight wrists to Stage IV and 21 remained in Stage IIIA. Motion and grip strength were significantly improved. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score at review was 12 points (range 0-52), and patient satisfaction was high. Apart from plate removals in 14 patients and one wrist denervation, no subsequent surgical procedures were done. Radial shortening yields good long-term clinical results, but does not prevent radiographic progression of disease in some patients. LEVEL OF EVIDENCE: Therapeutic IV.

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PURPOSE: The natural course of the pathophysiology of Kienböck disease is uncertain. Shortening of the radius is believed to modify the pathophysiology by addressing mechanical influences on the lunate. The aim of this study was to compare the radiographic progression of Kienböck disease among patients who had radial shortening osteotomy and patients who had no surgical treatment, with a minimum 1-year interval between radiographs. METHODS: Among 207 patients with Kienböck disease, we included all 48 eligible patients who had either radial shortening osteotomy or nonsurgical treatment and 2 sets of wrist radiographs available a minimum of 1 year apart. We compared changes in carpal height ratio, Stahl index, and carpal angles between the 2 sets of radiographs and between radial shortening osteotomy and nonsurgical treatment. RESULTS: We found, on average, a small decrease in the carpal height ratio and the Stahl index in patients who did and did not have surgery, with no differences between the 2 groups. Nearly half of the patients had no decrease in the carpal height ratio and/or the Stahl index. CONCLUSIONS: Radiographic progression of Kienböck over 1 year or more seems slight on average regardless of treatment. Future research might address the probability of and factors associated with radiographic progression of Kienböck disease. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

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BACKGROUND: There is no consensus on the best surgical treatment in Kienböck disease. We compared the short-term outcomes of radial shortening osteotomy and capitate shortening osteotomy in patients affected with this disease. METHODS: In a retrospective study of 21 patients with Lichtman stage IIIA of Kienböck disease, 12 patients with an average follow up of 3.2 ± 0.6 years had radial shortening osteotomy (group I) and 9 patients with an average follow up of 3.1 ± 0.7 years had capitate shortening osteotomy (group II). The two groups were comparable in age, sex, operated side, initial Lichtman stage, and follow-up duration. At the last follow-up the patients were evaluated for pain, wrist range of motion, grip strength, wrist functional status and change in their Lichtman stage. The overall results were evaluated by the Cooney wrist function score and DASH score. RESULTS: All the patients in the two groups had improvement of their wrist pains. According to the Cooney wrist function score group I had 1 excellent, 9 good, and 2 fair scores and group II had 1 excellent, 6 good, and 2 fair scores. Comparisons between the means of pain VAS scores, wrist range of movement, grip strength, DASH score, and Cooney wrist function score in the two groups were not significant. Also, the changes of the Lichtman stage in the two groups were not significant. CONCLUSIONS: Both groups had reasonable short-term outcomes. We were unable to recognize a substantial clinical difference between the two surgical treatments in short-term outcomes.

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BACKGROUND: To evaluate the intermediate-term outcomes of radius shortening as a treatment for Kienbock's disease. MATERIALS AND METHODS: In a historical cohort, 16 skeletally mature patients (9 men and 7 women) with Kienbock disease, who were treated with radial shortening osteotomy between 2002 and 2012, were reviewed in our study. The mean age of our patients was 30 (range 18-43) years old. According to Litchman staging, there were 7 wrists at stage II and 9 wrists at stage III (6 at stage IIIA and 3 at stage IIIB). The data of grip strength, pain (visual analog scale (VAS) score), wrist range of motion (ROM), ulnar variance (according to Palmer method), and the Lichtman stage were gathered before and after surgery. We evaluated overall wrist function using the Mayo Wrist score and disabilities of the arm shoulder and hand (DASH) score before surgery and at the last follow-up. RESULTS: The average of follow-up was 7 years (range from 5 to 9 years). Preoperative ulnar variance was -1.3 mm (range from 2.5 to 1) preoperatively. The mean postoperative ulnar variance was 1 mm positive (range from 0.5 to 1.5). The VAS pain score, the mean arc of wrist flexion and extension, and grip strength improved significantly preoperatively compared to after recovery from surgery. The Lichtman stage was unchanged in nine patients, one grade worse in six patients, and one grade better in one patient. The mean DASH and Mayo scores improved significantly postoperatively compare with preoperation. Comparing preoperative positive, neuter, and negative ulnar variance, there was no significant difference in terms of VAS, DASH, and Mayo scores as well as ROM and grip strength. CONCLUSION: Our study shows that radius shortening surgery improves pain and disability regardless of ulnar variance.

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PURPOSE: To clarify long-term clinical and radiological results more than 10 years after radial shortening osteotomy for Kienböck disease. METHODS: Eleven wrists of 10 patients that had been classified as Lichtman stages 3A (2 wrists), 3B (8 wrists), and 4 (1 wrist) underwent radial shortening for Kienböck disease. The mean follow-up period was 14.3 years (range, 10-21 y). Clinical outcomes were quantified using the Japanese version of the Disabilities of the Arm, Shoulder, and Hand questionnaire and the modified Mayo wrist score. Radiographic and magnetic resonance imaging studies were performed for 9 of the 10 patients preoperatively and all 10 patients at follow-up. RESULTS: At follow-up, 6 wrists were asymptomatic and the remaining 5 had mild occasional pain. The mean range of extension and grip strength significantly improved. The mean modified Mayo wrist score and Disabilities of the Arm, Shoulder, and Hand scores were 92 (range, 80-100) and 5 (range, 0-18), respectively. At follow-up, no progression of the Lichtman stage was found in any patient. There was no significant progressive lunate collapse in any patient. The magnetic resonance imaging in 7 wrists showed increased signal intensity of the lunate; the remaining 3 wrists had no alteration in signal intensity of the bone. CONCLUSIONS: Our study demonstrated satisfactory clinical results after 10 or more years in patients who underwent radial shortening for Kienböck disease. Although we found no improvement in signal intensity of the lunate in 3 wrists, unloading of the diseased lunate after radial shortening gives long-lasting symptom relief and may prevent lunate collapse. TYPE OF STUDY/LEVEL OF DISEASE: Therapeutic IV.

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Radial shortening osteotomy (RSO) as treatment for Kienböck's disease usually improves patient symptoms for several years. Four small series have also shown that the effect may last for decades, but only two studies have used a patient-based assessment. We examined 16 patients, with a mean age at operation of 32 years, evaluating clinical and radiological results at a mean 25 (range 20 to 33) years after surgery. Three patients had progressive lunate collapse, of whom one patient needed a silicone implant arthroplasty 2 years after RSO and one patient a wrist fusion 16 years after RSO. The time between onset of symptoms and osteotomy in the remaining 14 patients averaged 20 months. The mean VAS for pain was 0.9 at rest, 0.9 with unloaded motion, 1.7 with slight, and 3.0 with heavy exertion. Two patients had marked wrist pain. Compared with the contralateral wrist the mean range of motion was 88%, grip strength was 95%, and key pinch 107%. The Disabilities of the Arm, Shoulder, and Hand score averaged 6.1, and the Mayo wrist score, 79.3. The Lichtman stage remained unchanged in 56% of patients. The inner structure of the lunate improved in all patients, and its shape remained unchanged in half of the cases. Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck's disease.

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PURPOSE: Radial shortening osteotomy and ulnar lengthening osteotomy for decreasing axial loading have been known to treatment for avascular necrosis of lunate bone. The purpose of this study was to evaluate the clinical outcomes of radial shortening osteotomy for Lichtman stage III Kienbock disease. MATERIALS AND METHODS: Between December 2001 and October 2008, thirteen patients with Kienbock disease underwent a radial shortening osteotomy at our institution. On the basis of Lichtman classification, six had stage IIIA and seven had stage IIIB. Radiographic measurement of the ulnar variance and the carpal height ratio were assessed preoperatively and at the follow-up. Patients were examined for wrist pain, range of motion at flexion and extension and grip strength both preoperatively and postoperatively. The clinical outcomes was evaluated through the modification of Evans scoring system. RESULTS: All thirteen had maintained the preoperative stage at the follow-up. In ulnar variance, negative variance was seven. The carpal height ratio was increased mean 0.018 at the follw-up. Pain in VAS was improved mean 3.6 at the follow-up. In range of motion of wrist flexion-extension, in the eleven which had limitation of motion preoperatively, all eleven showed improvement. In grip strength, among the ten which had decreased preoperatively, eight showed improvement and two showed no change at the follw-up. The clinical outcomes were good in eight, fair in three and poor in two. Among the five, negative ulnar variance of stage IIIB, three had good, two had fair clinical outcomes. CONCLUSIONS: We found that radial shortening osteotomy can prevent disease progression, also show good clinical results for stage IIIB Kienbock disease as well as stage IIIA.

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Between 1995 and 1999, ten patients with Lichtman stage II and III Kienböck's disease with negative ulnar variance underwent a joint-levelling radial recession osteotomy in our unit. The procedure was performed by the senior author in all cases. Eight patients were available for follow-up (average 31 months). Based on the Mayo Clinic modification of the Green wrist score, there were three excellent, three good and two fair results. Radiologically, there was improvement in lunate density in five of eight patients and evidence of healing in two of five patients with lunate fractures. We found that simple radial recession osteotomy for Lichtman stage II and III Kienböck's disease offers excellent early results.