Kienbock's Disease

Author: Mark Karadsheh

Topic updated on 04/24/13 9:07am

Introduction

Avascular necrosis of the luntate leading to abnormal carpal motion
Epidemiology
- incidence
  - most common in males between 20-40 years old
- risk factors
  - history of trauma
Pathophysiology
- thought to be caused by multiple factors
  - biomechanical factors
    - ulnar negative variance
      - leads to increased radial-lunate contact stress
    - repetitive trauma
  - anatomic factors
    - geometry of lunate
    - vascular supply to lunate
      - patterns of arterial blood supply have differential incidences of AVN
      - disruption of venous outflow
Prognosis
- potentially debilitating condition if unrecognized and untreated

Anatomy

Blood supply to lunate
- 3 variations
  - Y-pattern
  - X-pattern
  - I-pattern
    - 31% of patients
    - postulated to be at the highest risk for avascular necrosis

Classification

Lichtman Classification
Stage	Description	Treatment	Image
Stage I	No visible changes on xray, changes seen on MRI	Immobilization and NSAIDS
Stage II	Sclerosis of lunate	Joint leveling procedure (ulnar negative patients) Radial wedge osteotomy or STT fusion (ulnar neutral patients) Distal radius core decompression Revascularization procedures
Stage IIIA	Lunate collapse, no scaphoid rotation	Same as Stage II above
Stage IIIB	Lunate collapse, fixed scaphoid rotation	Proximal row carpectomy or STT fusion
Stage IV	Degenerated adjacent intercarpal joints	Wrist fusion, proximal row carpectomy, or limited intercarpal fusion

Presentation

Symptoms
- dorsal wrist pain
  - usually activity related
  - more often in dominant hand
Physical exam
- inspection and palpation
  - +/- wrist swelling
  - often tender over radiocarpal joint
- range of motion
  - decreased flexion/extension arc
  - decreased grip strength

Imaging

Radiographs
- recommended views
  - AP, lateral, oblique views of wrist
- findings (see table above)
CT
- most useful once lunate collapse has already occurred
- best for showing
  - extent of necrosis
  - trabecular destruction
  - lunate geometry
MRI
- best for diagnosing early disease
- findings
  - decreased T1 signal intensity
  - reduced vascularity of lunate

Treatment

Nonoperative
- immobilization, NSAIDS
  - indications
    - initial management for Stage 1 disease
  - outcomes
    - a majority of these patients will undergo further degeneration and require operative management
Operative
- temporary scaphotrapeziotrapezoidal pinning
  - indications
    - adolescent with radiographic evidence of Kienbock's and progressive wrist pain
- joint leveling procedure
  - indications
    - Stage I, II, IIIA disease with ulnar negative variance
  - technique
    - can be radial shortening osteotomy or ulnar lengthening
- radial wedge osteotomy
  - indications
    - Stage I, II, IIIA disease with ulnar positive or neutral variance
- vascularized bone grafts
  - indications
    - Stage I, II, IIIA disease
  - outcomes
    - early results promising, but long-term data lacking
    - greatest success in Stage II patients
- distal radius core decompression
  - indications
    - Stage I, II, IIIA disease
  - technique
    - creates a local vascular healing response
- STT fusion
  - indications
    - Stage II disease with ulnar neutral or positive variance
    - Stage IIIA or IIIB disease
  - must address internal collapse pattern (DISI)
- proximal row carpectomy (PRC)
  - indications
    - stage IIIB disease
    - stage IV disease
  - outcomes
    - some studies have shown superior results of STT fusion over PRC for stage IIIB disease
- wrist fusion
  - indications
    - stage IV disease
  - technique
    - must remove arthritic part of joint
- total wrist arthroplasty
  - indications
    - Stage IV disease
  - outcomes
    - long-term results not available

Surgical Techniques

Vascularized bone grafts
- technique
  - many options have been described including
    - transfer of pisiform
    - transfer of distal radius on a vascularized pedicle of pronator quadratus
    - transfers of braches of the first, second, or third dorsal metacarpal arteries
  - temporary pinning of the STT joint, SC joint or external fixation may be used to unload lunate after revascularization
Impact of surgical procedure on radiolunate contact stress

Operative Procedure	% decrease on radiolunate contact stress
STT fusion	3%
Scaphocapitate fusion	12%
Capitohamate fusion	0%
Ulnar lengthening of 4mm	45%
Radial shortening of 4mm	45%
Capitate shortening and capitohamate fusion	66%, but 26% increase in radioscaphoid load

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Qbank (5 Questions)

TAG

(OBQ11.112) Figures A through E depict various conditions affecting the pediatric hand and wrist. For which of the depicted conditions is temporary scaphotrapeziotrapezoidal pinning most indicated? Topic

Review Topic

FIGURES: A

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶

DISCUSSION: Temporary scaphotrapeziotrapezoidal (STT) pinning is indicated for treatment of Kienbocks disease in adolescents as shown in Figure D. The radiograph shows increased density and slight lunate collapse. The result is a decrease in radiolunate contact stress while increasing the load on the radioscaphoid articulation. STT pinning is not indicated in any of the conditions explained below.

Ando et al retrospectively reviewed the results of six adolescents treated with temporary scaphotrapezoidal (ST) pinning. All patients had an increase in wrist flexion/extension arc, strength, and lunate intensity on MRI from their preoperative baseline.

Shigematsu et al published a case study on a single 11-year-old patient with wrist pain at rest and with use who was treated with temporary scaphotrapeziotrapedoidal (STT) pinning and cast immobilization for 8 weeks. Both wrist ROM and grip strength improved. Lunate revascularization was also seen on subsequent MRI.

Incorrect Answers:
Answer 1,2,3: Radial clubhand, scaphoid fracture, and hypoplastic thumb are not treated with temporary scaphotrapeziotrapezoidal pinning.
Answer 5: Gymnast’s wrist is a distal radius physeal injury due to repetitive axial loading. Plain films will show physeal widening and hazy irregularity. The condition is not treated with temporary scaphotrapeziotrapezoidal pinning.

REFERENCES:

1. Ando Y, Yasuda M, Kazuki K, Hidaka N, Yoshinaka Y. Temporary scaphotrapezoidal joint fixation for adolescent Kienböck's disease. J Hand Surg Am. 2009 Jan;34(1):14-9. PMID:19121725 (Link to Abstract)

2. Shigematsu K, Yajima H, Kobata Y, Kawamura K, Nakanishi Y, Takakura Y. Treatment of Kienböck disease in an 11-year-old girl with temporary fixation of the scaphotrapeziotrapezoidal joint. Scand J Plast Reconstr Surg Hand Surg. 2005;39(1):60-3. PMID:15848968 (Link to Abstract)

Question Authors:

Terrill Julien MD, Michael Hughes MD, John Badylak MD,

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TAG

(OBQ11.144) A 39-year-old male presents with longstanding right wrist pain. He has failed conservative measures including prolonged immobilization. His radiographs and MRI are seen in figures A and B. Which of the following options is an accepted treatment option? Topic

Review Topic

FIGURES: A

1. Ulnar shortening osteotomy
2. TFCC repair
3. Radius core decompression
4. Arthroscopic lunate chondroplasty and debridement
5. Scapholunate ligament reconstruction

PREFERRED RESPONSE ▶

DISCUSSION: The patient in the clinical scenario has Kienbock's disease. Treatment options include a joint leveling procedure, or radius core decompression, which is thought to incite a local vascular healing response in the lunate.

Sherman et al did a biomechanical study reviewing distal radius core decompression for Kienbock's disease. Although the procedure has good clinical outcomes for this disease process, their findings did not show any biomechanical explanation for these good outcomes.

Illarramendi et al reviewed results of curettage of the distal radius and ulna metaphyseal bone through small cortical windows for the treatment of Kienbock's disease. They concluded that the decompression procedure had good results without any complications. Most patients had improvement in pain and were able to return to work.

Incorrect Answers:
Answer 1: Kienbock's disease is commonly associated with ulnar negative variance which is thought to lead to increased forces on the lunate leading to this disease. Therefore a ulnar shortening osteotomy would not be appropriate.
Answer 2,4,5: Are not treatment options for this disease process.

REFERENCES:

1. Sherman GM, Spath C, Harley BJ, Weiner MM, Werner FW, Palmer AK. Core decompression of the distal radius for the treatment of Kienböck's disease: a biomechanical study. J Hand Surg Am. 2008 Nov;33(9):1478-81. PMID:18984326 (Link to Abstract)

2. Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck's disease by radius and ulna metaphyseal core decompression. J Hand Surg Am. 2001 Mar;26(2):252-60. PMID:11279571 (Link to Abstract)

Question Authors:

David Abbasi MD, Derek Moore, John Badylak MD, Bobby Chhabra M.D.,

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TAG

(OBQ10.61) A 32-year-old carpenter complains of progressively worsening wrist pain for 2 months duration. He denies any recent history of trauma to the wrist or hand. A MRI is provided in figure A. Which of the following surgical interventions is thought to be effective for this condition by inciting a local vascular healing response. Topic

Review Topic

FIGURES: A

1. Wrist fusion
2. Ulnar shortening osteotomy
3. Distal radius core decompression
4. Proximal row carpectomy
5. Scapholunate ligament reconstruction

PREFERRED RESPONSE ▶

DISCUSSION: This clinical scenario and imaging studies are consistent with Kienbock's disease, avascular necrosis of the lunate, in the pre-collapse stage. Core decompression of the distal radius is an accepted treatment for Kienbock's disease. The procedure creates a local vascular healing response facilitating vascular recovery prior to collapse and degeneration of the lunate. Other acceptable interventions include revascularization with a pedicled graft and joint leveling procedures such as a radial shortening osteotomy. The radial shortening osteotomy is ideal for patients with negative ulnar variance who experience greater loads through the radiolunate fossa. Proximal row carpectomy and wrist fusion would be options for the collapsed and degenerative lunate. Ulnar shortening osteotomy and schapholunate ligament reconstruction are incorrect as they do not address the pathology of Kienbock's.

Sherman et al performed a cadaveric study demonstrating minimal change in the distribution of force between the radiocarpal fossa and ulnocarpal fossa following core decompression of the distal radius.

Illarramendi et al reviewed 22 cases of Kienbock's treated with radial and ulnar metaphyseal core decompression. No surgical complications occurred, and 20 of 22 reported satisfactory clinical outcomes while one patient developed intercarpal arthritis.

REFERENCES:

1. Sherman GM, Spath C, Harley BJ, Weiner MM, Werner FW, Palmer AK. Coredecompression of the distal radius for the treatment of Kienböck's disease: a biomechanical study. J Hand Surg Am. 2008 Nov;33(9):1478-81. PMID:18984326 (Link to Abstract)

2. Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck'sdisease by radius and ulna metaphyseal core decompression. J Hand Surg Am. 2001Mar;26(2):252-60. PMID:11279571 (Link to Abstract)

Question Authors:

John Badylak MD, Michael Hughes MD,

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TAG

(OBQ10.74) A 30-year-old female undergoes arthroscopy for a chronically painful right wrist that failed to improve with 4 months of immobilization and NSAIDS. Her clinical examination revealed point tenderness dorsally over the lunate but no tenderness elsewhere in the wrist. A picture from the procedure is shown in Figure A where 'R' identifies the distal radius, 'L' the lunate, and '*' represents a chondral flap. The articular surface of the lunate is stable to probing. A radiograph and MRI image of the patients wrist are shown in Figures B and C respectively. What is the most appropriate next step in treatment? Topic

Review Topic

FIGURES: A

1. Continue Immobilization and NSAIDS
2. Radial shortening osteotomy
3. Proximal row carpectomy
4. Scaphotrapeziotrapezoid fusion
5. Wrist fusion

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Incorrect Answers:
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.

Illustrations: A

REFERENCES:

1. Slutsky DJ, Nagle DJ. Wrist arthroscopy: current concepts. J Hand Surg Am.2008 Sep;33(7):1228-44. PMID:18762125 (Link to Abstract)

2. 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)

3. 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)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Michael Hughes MD,

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Cases

http://upload.orthobullets.com/cases/1272/2.jpg

http://upload.orthobullets.com/cases/1272/3.jpg

Kienbock's disease (stage 3A vs 3B) (C1272)

Hand - Surgical Techniques - Kienbock's Disease

HPI - Patient is a 22 year old healthy LHD male college student with more than 6 month...

How would you treat this patient's Keinbock's disease?

9/14/2012

183 responses

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Videos

Proximal Row Carpectomy for Kienbock's Disease

Hand - Surgical Techniques - Kienbock's Disease

Proximal Row Carpectomy for Keinbock's Disease

2/19/2013

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Posts

Temporary scaphotrapezoidal joint fixation for adolescent Kienbock's disease. Includes Poll

Ando Y, Yasuda M, Kazuki K, Hidaka N, Yoshinaka Y
J Hand Surg Am. 2009 Jan;34(1):14-9. PMID: 19121725 (Link to Pubmed)

Hand - Journal Club - Kienbock's Disease

2 weeks ago

17 responses

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Groups

ABOS II: Kienbock's Disease

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Ando Y, Yasuda M, Kazuki K, Hidaka N, Yoshinaka Y. Temporary scaphotrapezoidal joint fixation for adolescent Kienböck's disease. J Hand Surg Am. 2009 Jan;34(1):14-9. PMID:19121725 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Shigematsu K, Yajima H, Kobata Y, Kawamura K, Nakanishi Y, Takakura Y. Treatment of Kienböck disease in an 11-year-old girl with temporary fixation of the scaphotrapeziotrapezoidal joint. Scand J Plast Reconstr Surg Hand Surg. 2005;39(1):60-3. PMID:15848968 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Sherman GM, Spath C, Harley BJ, Weiner MM, Werner FW, Palmer AK. Core decompression of the distal radius for the treatment of Kienböck's disease: a biomechanical study. J Hand Surg Am. 2008 Nov;33(9):1478-81. PMID:18984326 (Link to Abstract)
Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck's disease by radius and ulna metaphyseal core decompression. J Hand Surg Am. 2001 Mar;26(2):252-60. PMID:11279571 (Link to Abstract)
Sherman GM, Spath C, Harley BJ, Weiner MM, Werner FW, Palmer AK. Coredecompression of the distal radius for the treatment of Kienböck's disease: a biomechanical study. J Hand Surg Am. 2008 Nov;33(9):1478-81. PMID:18984326 (Link to Abstract)
Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck'sdisease by radius and ulna metaphyseal core decompression. J Hand Surg Am. 2001Mar;26(2):252-60. PMID:11279571 (Link to Abstract)
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)
Imaeda T. et al, J of Hand Surg 1992
Allan CH. Et al, JAAOS 2001

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Kienbock's Disease

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