Kienbock’s Disease

Dr Steve CarterDivision of Hand Surgery

Martin Singer UnitGroote Schuur Hospital

Introduction

• Robert Kienbock :1910 (Peste:1843 cadaver specimens)

• Avascular Necrosis Lunate

• Diagnosis can be difficult • Treatment challenging and controversial

Etiology

• Avascularity - Gelberman 8% Lunates single vessel

- 3 vascular patterns

• Trauma - Repetitive microtrauma

- Fracture

• Ulna Variance - Hulten 1928

Etiology

• Lunate Geometry: Zapico

• Load Stresses

• Radial slope

EtiologySummary

No single factor can be isolated. It is a combination of

load , either repeated compression or single fracture,

vascular risk, mechanical predisposition and

unavoidable continuous stress on the lunate resulting in

AVN , progressive collapse , carpal derangement and

ultimate arthrosis

Staging

Lichtman 1988

Stage 1 Normal XR increased bone scan MRI diagnostic

Stage 2 Increased sclerosis Lunate on XR

Stage 3 Lunate collapse

A. Normal carpal alignment without fixed scaphoid rotation

B. Altered carpal alignment with fixed scaphoid rotation

Stage 4 Lunate collapse with carpal OA

Staging

Clinical presentation

• 20- 40 years of age• Active individual , manual

labourer• Dominant hand • May or may not be a history of

trauma• Chronic wrist pain • Decreased ROM /dorsal

tenderness/ swelling/ synovitis• Youngest 8 yrs , oldest 71 yrs • Most 2-3 yrs of wrist pain that

becomes more acute following a trivial injury

Natural History

• In terms of bony changes there is sclerosis, progressive loss of height of the lunate and fragmentation. This results in dissociation within the proximal row allowing the scaphoid and triquetrum to rotate in opposite directions, scaphoid into palmar flexion and triquetrum into dorsiflexion net effect is loss of carpal height and eventually degenerative changes develop.

• So overall although their is relentless progression of XR

changes, these changes are only weakly assoc with symptoms

• Hence treatment and outcomes are still debated with conflicting opinions

Questions• The problem is AVN but the result is instability• Is the pain from the avascular lunate, the carpal collapse and

instability or a combination of the above? • Does the capitate in fact migrate if the lunate is excised?• Why do we see very few stage 4 SLAC wrists in kienbocks but

frequently see in scapholunate dissociation• How SLAC is a SLAC wrist ,or are we dealing with different

pathologies • Aetiology unknown therefore Rx not goal directed but rather

symptomatic and salvage directed , hence unpredictable results

Surgical OptionsDepends on age, stage, ulna variance and presence of arthrosis

1. Conservative splinting intra-articular injection

2. Denervations

3. Revascularization / Bone grafting. Used in 1,2,3a Variety of techniques dorsal metacarpal artery /Pronator Quadratus / pisiform

4. Joint levelling procedures Decrease pressure transmission through Lunate Useful in ulna minus , advantages , disadvantages Up to 40 % reduction in force transmision

5. Radial closing osteotomy

6. Ulna procedures

Surgical OptionsLimited carpal Fusions Useful stage 3B

1. STT arthrodesis :most commonly used Rationale: Designed to stabilize midcarpal joint, prevent carpal

collapse and decompress lunate by shifting force transmission thru radioscaphoid joint

Problems: pseudarthrosis rate 40%,Accelerated degeneration mid-carpal and radioscaphoid joint

2. Scaphocapitate fusion. Similar biomechanical effect, prevents collapse, unloads lunate addresses scaphoid flexion and simple to achieve arthrodesis

3. Capito-hamate fusion

Surgical Options

1. Metaphyseal core decompression JHS 2001

2. Capitate shortening: Graner procedure

3. Excision arthroplasty

4. Proximal row carpectomy

5. Wrist arthrodesis

Literature Review• Conservative treatment vs. STT arthrodesis for Kienbock’s disease

(Foucher G; 2006: Chirurgie de la Maine) - 104 patients over 18 Yrs Conservative 59 STT 25 - STT group increased pain ,stiffness , rehab time • Wrist fusion vs. limited carpal fusion in advanced Kienbock’s disease

(I Trail ,J StanleyL; 2005: International Orthopaedics) - 18 patients 6 total fusions; 12 limited 5 yr follow up - total fusions better DASH scores , patient satisfaction scores , less failures

• Long term outcome of radial shortening with or without ulna shortening for the treatment of Kienbock’s disease (Zenzai J; Hand Surgery 2005)

- 36 patients stages 1to 3 Average of 19 yr follow up - Overall good results No significant progression of the disease

Literature Review

• Arthroscopic assessment and classification of Kienbock’s Disease

Bain; Techniques in Hand and Upper Extremity Surgery 2006

Stage 1,2 3a

Conservative

Ulna -ve

Radial Shortening and PIN denervation

Ulna neutral or +

Core Decompression and PIN denervation

Stage 3b

Conservative

Ulna -ve

Radial shortening and PIN den

Ulna Neutal or +

Core Decompression and PIN den

Lunate Excision

Wrist Arthrodesis

Lunate excision for stage3b

Pros • Gillespie: 88% good to

excellent results in 24 cases• Dornan: 16 cases good to

excellent results• Kawai JBJS 1988: 70 B 18

cases , 12 year follow up good to excellent , minimal degenerative changes

Cons• Stahl: 1947 14 patients poor

results• Therkelsen: 1949 excision

worse than leaving in place

LunateScaphoid Triquetrum

Scaphoid Triquetrum

Method• Our series attempt to deal with the avascular lunate and carpal

instability with a single procedure• Based on the anatomy of the dorsal radiocarpal ligament and inter-

carpal ligament

Method• Dorsal incision 3rd 4th compartments• Identify dorsal inter-carpal and radio-carpal ligaments• Elevate as a flap (trapdoor) leaving the triquetral attachment intact• Cut the scapho-lunate lig keeping as close to the lunate as possible• Remove the lunate • Suture DIC ligament to SL ligament

• Routine closure backslab for 10 days then mobillize

Scaphoid

Dorsal intercarpal lig

Demographics

• Average age: 36 yrs• 5 Females and 1 Male ( 1 patient lost to follow up )• 1 bilateral Kienbock’s ( 56 yr female )• Average duration symptoms: 6.6 yrs• 2 patients with history of trauma , 3 with no history of trauma

Results

Results

Lunate gap

X

Y

X/Y = 0.5 Carpal height ratio

Conclusion

• Viable salvage operation in (failed) grade 3b Kienbock’s

• Simple procedure

• Reliable pain relief but decreased range of movement

• No statistically significant change in carpal height ratio

• Lunate gap remains the same ie no capitate migration

Conclusion• Conservative +++

• Treatment symptom directed rather than radiologically directed

• No surgical procedure entirely effective

• Stepwise approach