The patients clinical presentation and radiographs are consistent with Stage 2 Kienbock's disease in the setting of negative ulnar variance. Radial shortening osteotomy is the most appropriate treatment option listed for Stage 2 disease which is defined as lunate sclerosis without significant collapse. Shortening osteotomy can alter DRUJ contact pressures leading to remodeling, especially in the presence of a Tolat Type II DRUJ, such as that shown in the radiographs. However, this remodeling has been shown to occur without the development of arthritis, and therefore is not a contraindication to this procedure.
This patients radiographs shows some slight sclerosis of the lunate and negative ulnar variance, and the MRI shows diffuse edema and early osteonecrosis of the lunate. The arthroscopic image shows a cartilage flap with a stable base left on the lunate. Based on these images, the patient has Stage 2 disease and should be treated with a joint leveling procedure; or radial shortening osteotomy in this case.
Sltusky et al provide a review article which focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.
Bain et al review the arthroscopic staging of Kienbock's disease, and state that this techinique is a valuable assessment tool which allows for not only classification of Kienbock's disease, but also may guide treatment.
Schuind et al. provide a review of the pathogenesis of Kienbock's. They conclude that the natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. They also state that there is no strong evidence to support any particular form of treatment.
Illustration A shows a table which outlines the Stages of Kienbock's Disease.
Illustration B shows a table which outlines the general treatment options for each stage of Kienbock's Disease.
Answer 1: Immobilization and NSAIDS is indicated in Stage I disease or as a first line of treatment for Stage 2, which this patient has failed.
Answer 3: Proximal row carpectomy is indicated in Stage 3B.
Answer 4: STT Fusion is indicated in Stage 3B.
Answer 5: Wrist fusion is indicated in Stage 4.
Slutsky DJ, Nagle DJ. Wrist arthroscopy: current concepts. J Hand Surg Am.2008 Sep;33(7):1228-44.
PMID:18762125 (Link to Abstract)
Bain GI, Begg M. Arthroscopic assessment and classification of Kienbock's disease. Tech Hand Up Extrem Surg. 2006 Mar;10(1):8-13.
PMID:16628114 (Link to Abstract)
Schuind F, Eslami S, Ledoux P. Kienbock's disease. J Bone Joint Surg Br. 2008 Feb;90(2):133-9.
PMID:18256076 (Link to Abstract)