Kienböck's disease, characterized by avascular and aseptic necrosis of the lunate bone, is difficult to manage in its late stages1. It most commonly occurs in adults between the ages of 20 and 50 years, an age group in whom a high level of functional recovery is a priority. Wrist immobilization, unloading procedures, decompression surgery, and vascularized bone grafts are among the therapeutic approaches in patients with early-stage (stages 0–II) disease, whereas in those with advanced disease (stages III–IV), the various treatment options, including pedicled pisiform bone transplantation, ligament reconstruction tendon interposition (LRTI), arthroplasty, and arthrodesis, still suffer from several limitations1–3. For instance, proximal row osteotomy and wrist fusion decrease mobility; instability is an issue in arthroplasty; and LRTI lacks sufficient mechanical support.
Costal cartilage transplantation is a common technique in maxillofacial reconstruction, and in recent years, it has been applied in orthopaedics, especially in hand surgery4–6. Obert et al. reported lunate bone replacement with free costochondral autografts in 4 patients, with significant symptom resolution and functional recovery at a mean of 27 months follow-up5. However, the precise shaping and proper fixation of the implanted cartilage needed to restore the anatomical structure and activity of the lunate are of continuing concern.
Three-dimensional (3D) printing has been used both directly, to design complex implants and prostheses, and indirectly, in preoperative planning and intraoperative surgical guidance7. If the contralateral wrist is intact, it can be used to create a symmetric template of the lunate bone, similar to the intraoperative sculpture of cartilage grafts. We provide the first report of 3D printing-assisted costochondral transplantation to reconstruct the lunate bone. The inserted cartilage spacer was fixed using the autologous palmar longus (PL) tendon. This customized treatment provides an option for optimizing current costochondral transplantation procedures in wrist surgery.
The patient was informed that data concerning the case would be submitted for publication, and he provided consent.
Case Report
A 46-year-old man presented to our clinic with concerns of right wrist pain and limited use of his right hand, even in moderate tasks, for >7 years. Physical examination revealed limited wrist movement in each direction, especially in dorsal extension. There was no obvious asymmetry or deformity based on a comparison with his left wrist. The visual analog scale (VAS); Disabilities of the Arm, Shoulder, and Hand (DASH); and the Mayo Modified Wrist (MMW) scores were 7, 88, and 30, respectively. Sclerosis and collapse of the lunate as well as extensive traumatic arthritis in the wrist were seen on the plain radiographs (Fig. 1-A). Magnetic resonance imaging (MRI) revealed a hypointense lesion of the lunate on the T1WI images and hyperintensity on the T2WI images; the scaphoid bone was also involved (Fig. 1-B).
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Fig. 1: Preoperative plain radiographs (Fig. 1-A) and MRI images (Fig. 1-B).
Computed tomography (CT) scans of the chest and 2 sides of the wrist were obtained for preoperative planning. The sixth rib was chosen for transplantation after matching the length of the narrowest side of the intact lunate with each costal cartilage. The 3D data of the left lunate were then flipped vertically, and a prosthesis was created on a 3D printing machine (Form3; Formlabs) using SG resin (Formlabs) (Fig. 2).
Fig. 2: Preoperative measurements and evaluation based on CT images of the wrist (Fig. 2-A) and chest (Fig. 2-B); illustration of surgical planning (Fig. 2-C).
The surgical procedure was performed with the patient in the supine position and under general anesthesia. The affected hand was positioned in pronation on an arm table, and a tourniquet was applied. A transverse incision was made over the sixth right rib, after which a 2.5-cm rib osteochondral graft was harvested (Figs. 3-A and 3-B). Wrist surgery was started by exposing the lunate using a standard dorsal approach. The necrotic lunate bone was resected, and the involved cartilage surfaces of the scaphoid and triquetral bones as well as the distal radius were debrided (Fig. 3-C). After the surgical site had been thoroughly irrigated, the sterile 3D-printed SG prosthesis was inserted, and its suitability was tested (Fig. 3-D). A scalpel was used to sculpt the collected costochondral graft according to the shape of the prosthesis, and the graft was then drilled on its coronal aspect (Fig. 3-E). Half of the autologous PL tendon (∼6.5 cm) was harvested (Fig. 3-F) and positioned such that it crossed the drilled tunnel (Fig. 3-G) of the graft, scaphoid bone, and triquetral bone (Figs. 3-G and 3-J). The graft was then placed in the cavity, with the PL tendon crossed over the back. Dorsal stability was strengthened by suturing the PL tendon to the cut ends of the scapholunate (SL) and lunotriquetral (LT) ligaments, and the intersection was fixed (Figs. 3-I and 3-K). Finally, the incision was rinsed with saline and closed. On the same day, the patient was instructed to perform active functional exercises of flexion and dorsiflexion to improve range of wrist motion.
Fig. 3: Surgical procedure: The costal cartilage was exposed (Fig. 3-A) and harvested (Fig. 3-B); the necrotic lunate bone was exposed and resected(Fig. 3-C); the printed SG prosthesis was inserted to test the matching (Fig. 3-D); sculpture of the costochondral graft (Fig. 3-E); harvested PL tendon (Fig. 3-F); a tunnel through the trimmed graft was made (Fig. 3-G); PL goes through the costochondral graft, scaphoid bone, and triquetral bone (Figs. 3-H and 3-J); the PL tendon was crossed over the back and sutured with ST and LT ligaments (Figs. 3-I and 3-K).
After 14 months of follow-up, the patient had neither pain nor numbness during daily activities. The strength and movement of the wrist had improved significantly (Figs. 4-A and 4-B). Moreover, 8 months after surgery, the patient could perform weight-bearing exercises, including push-ups (Video 1) and parallel bars (Video 2). The degenerative arthritis had regressed, as seen on a plain radiograph (Fig. 4-C). MRI revealed that the inserted rib graft was well-positioned and was not absorbed or calcified (Fig. 4-D). The VAS, DASH, and MMW scores had improved to 0, 26, and 90, respectively.
Fig. 4: Range of wrist extension and flexion (Fig. 4-A); weight-bearing exercise on parallel bars and push-ups (Fig. 4-B); and plain radiographs (Fig. 4-C) and MRI images (Fig. 4-D) at 8 months of follow-up.
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Discussion
This case presents a novel surgical strategy, which combines 3D printing and costochondral transplantation, offering a therapeutic option for patients with advanced Kienböck's disease. The use of 3D printing ensured that the complex shape and structure of the carpal bone could be recreated, thus allowing anatomical reconstruction and a rapid functional recovery.
Precise 3D sculpting of the costal cartilage to replace lunate is the key process in the surgical treatment of Kienböck's disease because it determines the reconstructed anatomic position and function. Previously, shaping was usually performed subjectively, based on the preoperative CT images, and overtrimming could not be corrected. However, 3D printing based on mirror symmetry with the heathy wrist yields a reliable template allowing trimming of the cartilage. The inserted cartilage achieved a tight 3D match with the surrounding carpal bones while the costochondral graft was used to maintain slight motion of the carpal joints. Moreover, the use of a graft with an intact cartilaginous surface enabled filling of the cavity to obtain considerable support and, as demonstrated by the follow-up results, prevented the development of osteoarthritis. This strategy should, therefore, also be applicable to other carpal bone replacement surgeries.
Another innovation of our technique is the fixation method. A lack of congruity and inherent instability are 2 major limitations of conventional lunate arthroplasty. Repair of the SL and LT ligaments after prosthesis implantation is difficult. Xie et al. used a 3D-printed metal prosthesis for lunate replacement, but its stability entirely relied on the surrounding bony structures, whose poor postoperative stability risked dislocation and prolapse8. In our patient, immobilization of the graft using the PL tendon ensured a high dorsal strength. In addition, the drilled holes facilitated the flow of synovial fluid and, therefore, an adequate nutrient supply to prevent graft degeneration.
However, the current technique still has some limitations. First, the size of costal cartilage presents individual anatomic differences so that whether it could match each patient’s lunate remains uncertain. Second, as a case report, the level of evidence is relatively low, and further parallel, controlled studies comparing with traditional surgical techniques are needed to be performed. In addition, a longer follow-up is necessary in the future to assess the grafted costochondral morphology and determine whether it would be absorbed or calcified. To sum up, although this study is of novelty, more rigorous study with longer follow-up is of significance in the future.
Note: This work was supported by the National Natural Science Funding of China (grant no.82172400, 81820108020) and Shanghai Shen Kang Hospital Development Center (no. SHDC2020CR1025B).
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