Mr. Kiran Kumar Naikoti

Introduction

• Described by Robert Kienbock, Austrian radiologist in 1910

• Idiopathic osteonecrosis of Lunate

• Common in Men between 20 – 40 years of age

• Progressive

• Bone necrosis leads to trabecular fractures, sclerosis, fragmentation and collapse

• In turn leading to decrease in the carpal height, proximal migration of the Capitate, carpal instability and degenerative changes in the radiocarpal and midcarpal joint

Etiology

• Multifactorial

• Trauma

• Anatomical factors • Vascular causes

• Arterial

• Venous stasis

• Lunate morphology

• Biomechanical factors • Negative ulnar variance

• Decreased Radial inclination

• Systemic causes – SLE, septic emboli, Raynaud’s, vasculitis, scleroderma

Vascular supply

• Lunate is supplied by volar and dorsal branches (Lamas, 2007)

• Dorsal - Dorsal radiocarpal arch and Dorsal intercarpal arch

• Volar – Braches from Radial, Ulnar and Anterior interosseous artery

• 7 -26% of Lunate bones were supplied by a single volar vessel (Gelberman, 1983)

Vascular supply

• Intra-osseous branching patters

• 31% show single path through the lunate bone

• Lunate with a single vessel and minimal branching is at increased risk of AVN

• Venous stasis (shiltenwold, 1996)

Lunate Morphology (Antuna-Zapico, 1966)

• Type 1 with weakest trabecular pattern

Ulnar Variance

• Negative ulnar variance increases load transmission through radiolunate joint (Goeminne et al, 1976)

Clinical Features

• Dorsal wrist pain

• Wrist swelling

• Weakness

• Reduced wrist movements

Investigations • X ray

• MRI (Differential diagnosis – Ulnocarpal abutment, fracture, Benign cyst)

• CT scan

Lichtman classification

• Stage 1: Normal radiographs, diffuse changes in the signal intensity on T1 and T2 on MRI

• Stage 2: Lunate sclerosis

• Stage 3: Lunate collapse • 3A: Normal scaphoid alignment

• 3B: Fixed scaphoid rotation (Ring sign)

• Stage 4: severe lunate collapse with Radio-carpal and Mid-carpal joint degenerative changes

• Goldfarb et al, 2003 – Use of radioscaphoid angle increases the interobserver reliability

Stage 1

Stage 2

Stage 3

Stage 4

Conservative Rx

• Limited success

• Immobilisation for 3 months in cast/ splint

• Improvement in outcomes – conservative vs operative – 63% vs 72-90% (innes, 2010)

We recommend a radial shortening procedure for

patients with severe pain and radiological signs of

progressive carpal collapse.

In this study collapse of the carpal bones developed

in elderly patients who had received nonsurgical

treatment. Their clinical results were good or

excellent, however, and there were no problems in

occupation or quality of life, regardless of deterioration

in radiographic findings. Therefore we consider

that nonsurgical treatment can be chosen first for

treatment of Kienbo¨ck’s disease in elderly patients

• Below 12 years • Conservative

• 13 – 15 years • Conservative, may need immobilisation for more longer period

• Above 15 years • In advanced cases, conservative Rx frequently fails

• Surgical Rx has good prognosis

References Gelberman RH, Bauman TD, Menon J, Akeson WH. The vascularity of the lunate bone and Kienbock’s disease. J Hand Surg. 1980;5:272e278

Schiltenwold M, Martini AK, Eversheim S, Mau H. Significance of intraosseous pressure for pathogenesis of Kienböck’s disease. Handchir Mikrochir Plast Chir 1996;28:215-19 (in German).

Innes L, Strauch RJ. Systematic review of the treatment of Kienbock’s disease in its early and late stages. J Hand Surg 2010;35A: 713–717, e711–e714.

Antuña-Zapico JM. Malacia del semilunar. Doctoral thesis. University of Valladolid, 1966.

Tsuge S, Nakamura R. Anatomical risk factors for Kienböck’s disease. J Hand Surg 1993;18:70–5.

Goeminne S, Degreef I, De Smet L. Negative ulnar variance has prognostic value in progression of Kienbock’s disease. Acta Orthop Belg 76:38–41.

Salmon J, Stanley JK, Trail IA. Kienbock’s disease: conservative management versus radial shortening. J Bone Joint Surg 2000;82B: 820–823.