Staging of Kienböck’s disease - Swisshandsurgery...(Microsoft PowerPoint - Staging of...

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SGH/SSCM Post-graduate course, CH8-Geneva, 20.09.2012

Staging

of Kienböck’s disease

F. Hahn


Introduction

Why staging?

• Standardisation

• Communication

• Prognosis

• Treatment options


X-rays

1910 First description by Kienböck

1947 Ståhl (Rx)

1957 Decoulx (modif. Ståhl, Rx)

1977 Lichtman (Rx)

1982 Lichtman Stage IIIA/IIIB

2010 Lichtman Stage 0 and IIIC


Ståhl 1947

1. normal shape of lunate, compression fx

2. resorbtion around lunate fx

3. sclerosis and flattening of lunate

4. fragmentation and cystic degenerations of lunate

5. arthritis radiocarpal/midcarpal

Ståhl F. Acta Chir Scand 1947, 95(126):120


Decoulx (modif. Ståhl) 1957

1. normal form of lunate, increased density

2. cystic changes within lunate

3. fragmentation and collapse

4. arthritis radio- and/or midkarpal

Decoulx P, Lille Chir 1957; 12:65


Lichtman

Based on Decoulx but:

• suspicion of an occult initial stage with normal plain Rx (1977)

• differentiation of stage IIIA/IIIB (1982)

• proposition of stage 0 and IIIC (2010)

Lichtman. J Bone Joint Surg Am 1977;59:899

Lichtman. J Hand Surg Am 1982, 7:343

Lesly, N.. , Lichtman, D. HaMiPla 2012, 42:171


Lichtman classification

Stage 0: prenecrotic

Stage I: osteonecrosis without changes in x-rays

Stage II: osteonecrosis with changes in x-rays, no collapse of

lunate

Stage IIIA: osteonecrosis with lunate collapse, no carpal collapse

Stage IIIB: as IIIA + scaphoid rotation (RS-angle > 60°)

Stage IIIC: coronal lunate fracture

Stage IV: arthritis radiocarpal or midcarpal

Lesly, N.. , Lichtman, D. HaMiPla 2012, 42:171


Lichtman 0 (not yet validated)

• stress-test with gadolinium i.v. in an extended and

axial loaded position.

• to detect very early stages of Kienböck with

normal MRI

prenecrotic


Lichtman I (MRI)

Normal radiographic findings, uniformly decreased MRI signals on T1 and T2

osteonecrosis without changes in x-rays


Lichtman II

Diffuse osteosclerosis, sometimes flattening of proximal pole, no lunate collapse


Differentiation Lichtman IIIA / IIIB

Key point: carpal collapse!

Lunate collapse by Ståhl Index:

In sagittal Rx : high/length of lunate

Carpal collapse/instability:

• Gilula lines

• Ring sign

• Youm index: carpal high/ length of MC III,

• Radio-scaphoid angle >60°

Youm-index

Ståhl index


Lichtman IIIA

Lunate collapse (prox. Pole) but no carpal collapse !


Lichtman IIIB

Lunate collapse with carpal instability by radioscaphoid angle > 60°


Lichtman IIIC (not yet validated)

Based on the poor healing potential of coronal

fractures in the vascular compromised lunate.

Based on the arthroscopic and clinical evaluation

according to Bain and Begg (Stage 2b)

Bain, GI. Tech Hand Up Extrem Surg 2006; 10:8

Coronal lunate fracture


Lichtman IV

Lunate collapse with radiocarpal or midcarpal degenerative arthritis

(KDAC= kienböck disease advanced collapse)


MRI Stages (Schmitt 1997)

For osteonecrosis of carpal bones, T1 always with low signal

stage enhancement pathology

I homogenous edema

II patchy-inhomogenous partial necrosis

III absent complete necrosis

Schmitt, R. Eur J Rad 1997 25:92


Arthroscopic Staging (Bain 2006)

Bain, GI. Tech Hand Up Extrem Surg 2006; 10:8

number of non-functional articular surfaces


SUMMARY

• Classifications based on X-rays/CT/MRI/arthroscopy

• Lichtman most widely used and evaluated

• Schmitt classification supplementary to Lichtman

• Bain/Begg still needs to be evaluated


OUTLOOK

Based on

vascular

osseous

cartilage

Integrated Classification System

+

+


OUTLOOK

Osseous Vascular Cartilaginous

(RX/CT) (MRI) (Arthroscopy)

0 A 0

I A, B or C 0 or 1

II A, B or C 0,1 or 2

III-A,B or C A, B or C 3 or 4

IV C 4

Proposed by Bain/Lichtman/Garcia-Elias/Schmitt/Amadio

Instructional Course 20, ASSH Annual Meeting 2012

IIIA - B - 3

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