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Updated: Aug 6 2023

Kienbock's Disease

Images variance.jpg 1.jpg 2.jpg 3a.jpg
  • Summary
    • Kienbock's Disease is the avascular necrosis of the lunate which can lead to progressive wrist pain and abnormal carpal motion.
    • Diagnosis can be made with wrist radiographs in advanced cases but may require MRI for detection of early disease.
    • Treatment is NSAIDs and observation in minimally symptomatic patients. A variety of operative procedures are available depending on severity of disease and patient's symptoms. 
  • Epidemiology
    • Incidence
      • most common in males between 20-40 years old
    • Risk factors
      • history of trauma
  • Etiology
    • Pathophysiology
      • thought to be caused by multiple factors
        • biomechanical factors
          • ulnar negative variance
            • leads to increased radial-lunate contact stress
          • decreased radial inclination
          • 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 leading to increased intraosseous pressure
            • Blood supply to capitate is also poor and may lead to AVN.
  • 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
      • 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, STT fusion, or SC 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
      • rule out ulnar impaction
      • findings
        • decreased T1 signal intensity
        • reduced vascularity of lunate
  • Treatment
    • Nonoperative
      • observation, immobilization, NSAIDS
        • indications
          • initial management for Stage I 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
          • initial operative managment
        • technique
          • can be radial shortening osteotomy or ulnar lengthening
          • more evidence on radial shortening
      • radial wedge osteotomy
        • indications
          • Stage I, II, IIIA disease with ulnar positive or neutral variance
      • vascularized bone grafts
        • indications
          • Stage I, II, IIIA, IIIB disease
        • outcomes
          • early results promising, but long-term data lacking
          • best results in Stage III patients
      • distal radius core decompression
        • indications
          • Stage I, II, IIIA disease
        • technique
          • creates a local vascular healing response
      • partial wrist fusions
        • STT
        • capitate shortening osteotomy +/- capitohamate fusion
        • scaphocapitate
        • 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
  • 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 branches of the first, second, or third dorsal metacarpal arteries
            • 4 + 5 extensor compartment artery (ECA)
              • greatest arc of motion of the most commonly used arterial pedicles
        • 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
        • 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
  • Prognosis
    • Progressive and potentially debilitating condition if unrecognized and untreated
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