KIENBOCH'S DISEASE OF THE SEMILUNAR BONE

Kienböck Disease: Clinical Presentation, Epidemiology, and Historical Perspective

In the now 110 years that have passed since Kienböck first published his seminal description of lunate osteonecrosis, improvements in imaging technology and surgical technique have provided a better understanding of Kienböck disease pathogenesis and treatment. However, the precise etiology, natural history, and optimal treatment remain controversial. Future studies examining the genetics behind the disease and large-scale prospective studies comparing treatment options represent the next step in improving our understanding of this rare and complex phenomenon.

The incidence of asymptomatic Kienböck's disease

The aim of this study was to determine the incidence of asymptomatic Kienböck's disease in patients who attended the Dr George Mukhari Hospital (formerly Ga-Rankuwa Hospital), as well as the relevance of ulnar variance on the disease. This was a retrospective study. In a 12 month period we reviewed postero-anterior radiographs of 1287 patients seen at our radiology department, with complaints unrelated to the upper limb including the wrist and hand. We identified 23 cases (1.9%) of asymptomatic Lichtman stage II-IV Kienböck's disease in our African population. The majority (63%) were male with an average age of 49 years, and 37% were female with an average age of 46.5 years. All cases were unilateral and all were in the dominant hand. Thirteen cases (57%) had an ulnar neutral wrist and the remaining ten (43%) had an ulnar negative variance. The vast majority (83%) were unemployed. Analysis of the data shed no further light on the aetiology. The relevance of ulnar variance as an aetiological factor is questioned.

Vascularized bone grafting for the treatment of carpal pathology

Vascularized bone graft procedures have been applied to several maladies of the carpus including proximal pole fractures of the scaphoid, Preiser's disease, and Kienböck's disease. Vascularized bone grafts are capable of primary bony healing without creeping substitution and can thus accelerate fracture healing, replace deficient bone, and revascularize ischemic bone. Long-term data are now available to evaluate the benefits and deficiencies of vascularized grafts in the treatment of many carpal maladies. This article reviews the pertinent literature and provides some treatment algorithms for the use of vascularized bone grafting in cases of carpal pathology.

A historical report on Robert Kienböck (1871-1953) and Kienböck's Disease

Robert Kienböck was the first to identify and describe Kienböck's disease. Considered one of the early fathers of radiology, he was a prolific researcher who made an immense contribution to the early development of radiology. In addition to groundbreaking work in therapeutic radiology Kienböck had a special interest in diseases of the bones and joints, especially those that involved the hand. Kienböck's contribution to medicine, particularly the diagnosis of hand disorders, continues to resonate today.

Arthroscopic debridement for the treatment of Kienbock's disease

The treatment results of seven patients (age range, 37 to 74 years, male:female ratio, 1:6) with Kienbock's disease (Lichtman stage IIIA-IIIB) who underwent arthroscopic debridement of the necrotic lunate bone and degenerative intrinsic ligaments were studied retrospectively. Osteoarthritic changes of the articular cartilage were documented in all cases. Partial (n = 2) and complete (n = 5) ruptures of the lunotriquetral and scapholunate ligaments, local synovitis (n = 5), and loose fragments (n = 6) occurred most commonly in the radiocarpal joint. All patients were available for an average of 19 months of follow-up (range, 6 to 42 months), physical examination, and radiographic evaluation. All patients reported significant improvement in pain relief and complete relief of mechanical symptoms. Radiographs showed progression of the disease in three cases; two of these were followed-up for more than 2 years. Arthroscopy in Kienbock's disease allows direct visualization and assessment of the exact pathology of the radiocarpal and midcarpal joint and the lunate cartilage. Arthroscopic debridement of the necrotic lunate increased wrist functional range of motion, provided excellent pain relief, and improved health-related quality of life in all patients.

An Unusual Source of Wrist Pain

In brief After weight lifting, a 15-year-old boy pain in his right wrist, had tenderness over the dorsum of the lunate, and had limited wrist motion. Radiographs revealed avascular necrosis of the lunate, or Kienböck's disease, and negative ulnar variance. The patient was successfully treated with an ulnar lengthening procedure and immobilization. This patient's symptoms are typical of Kienböck's disease, which should be considered in the differential diagnosis of any active patient who has wrist pain and limited wrist motion. Treatment of this rare disorder can include immobilization for early-stage disease, or surgery, which is most likely to provide an optimal outcome.

Radial shortening osteotomy for treatment of Kienböck's disease

Sixteen patients who had radial shortening osteotomy for treatment of Kienböck's disease were reviewed. Ulnar minus variance averaged 3.3 mm. All patients had conservative management that failed. Six were stage II, six were stage III, and four were stage IV. Average follow-up was 4.5 years. In all patients osteotomies united within 3 months. Thirteen patients were totally relieved of pain, and three had mild pain. Motion in the dorsal palmar plane improved, on average, 15 degrees. Grip strength increased 20% to 30% after the operation. Follow-up radiographs did not show continued collapse of carpal height or disease progression except in one patient. No radiographic evidence of degenerative changes at the distal radioulnar joint materialized. As a safe, reliable, and consistently successful method of managing Kienböck's disease, we strongly recommend radial shortening. Excluding the rare extended stage IV disease in which midcarpal arthritis with or without intercarpal instability is present, we have successfully applied this technique to all stages of Kienböck's disease. We recognize that further collapse and progression of disease may occur in stage III and IV disease, as was evident in one patient 5 years after osteotomy.

LUNATE OSTEOMALACIA OR KIENBOCH'S DISEASE

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A CASE OF KIENBOCH'S DISEASE

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