1
|
Salva-Coll G, Esplugas M, Carreño A, Lluch-Bergada A. Kienböck's disease: preventing disease progression in early-stage disease. J Hand Surg Eur Vol 2023; 48:246-256. [PMID: 36799262 DOI: 10.1177/17531934221146851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Currently Kienböck's disease remains an 'unsolved' problem in hand surgery. Different factors have been associated with the avascular necrosis of the lunate. Mechanical, vascular and biological factors, alone or in combination, may have an influence in the aetiopathogenesis and determine the progress of the disease and even the results of the treatment. This is especially relevant in the early stages, in which conservative or surgical treatment may modify the natural history of the disease, maintaining the lunate structure and thus preserving the joint surfaces. There are multiple surgical treatments for Kienböck's disease in the early stages, before lunate collapse; each one is based on one of the possible factors that can cause avascular necrosis of the lunate. The objective is not only to treat symptoms but to prevent progression. This article is a review of the most frequent treatments used in the early stages and a personal view of the authors.Level of evidence: V.
Collapse
Affiliation(s)
- Guillem Salva-Coll
- Hand and Upper Extremity Surgery, Kaplan Institute, Barcelona, Spain
- Department of Hand Surgery and Microsurgery, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
- Ibacma Institute, Balearic Institute for Hand Surgery, Palma de Mallorca, Illes Balears, Spain
| | - Mireia Esplugas
- Hand and Upper Extremity Surgery, Kaplan Institute, Barcelona, Spain
| | - Ana Carreño
- Hand and Upper Extremity Surgery, Kaplan Institute, Barcelona, Spain
- Hand and Elbow Surgery, Hospital Clinic, Barcelona, Spain
| | - Alex Lluch-Bergada
- Hand and Upper Extremity Surgery, Kaplan Institute, Barcelona, Spain
- Department of Hand and Upper Extremity Surgery, Hospital Vall d'Hebron, Barcelona
| |
Collapse
|
2
|
Arthroscopic Management of Kienböck Disease. Hand Clin 2022; 38:461-468. [PMID: 36244713 DOI: 10.1016/j.hcl.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Wrist arthroscopy represents the most recent development in the diagnosis and treatment of Kienböck disease. Through direct visualization of lunate and adjacent carpal articulations, a more accurate diagnosis can be obtained and, ultimately, a more precise treatment decision. Treatments that are based on bypassing, fusing, or excising "nonfunctional" articulations can be done with less morbidity than traditional open techniques by using arthroscopy. Given the minimal capsular and soft tissue scarring, this potentially improves early pain and functional recovery. Although technically demanding, long-term outcomes studies have shown that the benefits of an arthroscopic approach may be worth the learning curve.
Collapse
|
3
|
Lichtman DM, Pientka WF, MacLean S, Bain G. Precision Medicine for Kienböck Disease in the 21st Century. J Hand Surg Am 2022; 47:677-684. [PMID: 35809999 DOI: 10.1016/j.jhsa.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/13/2022] [Accepted: 03/13/2022] [Indexed: 02/02/2023]
Abstract
One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.
Collapse
Affiliation(s)
- David M Lichtman
- Department of Surgery, Uniformed Services University, School of Medicine, Bethesda, Maryland.
| | - William F Pientka
- JPS Health Network, Department of Orthopaedic Surgery, Fort Worth, Texas
| | | | - Gregory Bain
- Department of Orthopaedic Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| |
Collapse
|
4
|
Rimokh J, Najjari H, Rotari V, Maes C, Lebeau N, Moughabghab M. Arthroscopy-assisted treatment of scaphoid and lunate cysts: Clinical evaluation of 7 cases. HAND SURGERY & REHABILITATION 2018; 37:358-362. [PMID: 30224229 DOI: 10.1016/j.hansur.2018.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 08/01/2018] [Accepted: 08/11/2018] [Indexed: 10/28/2022]
Abstract
Intraosseous cysts of the carpus are relatively common benign tumors. They are often discovered by chance and can cause wrist pain thereby requiring appropriate management. While conventional open surgical treatment leads to good results, it has certain disadvantages, the main one being postoperative stiffness. Arthroscopic treatment has been proposed as an alternative for lunate cysts. The present study consisted in evaluating the feasibility and outcomes of arthroscopic treatment for lunate and scaphoid cysts. The main objective was to evaluate the postoperative clinical outcomes at 3 and 18 months. The secondary objective was to evaluate the integration of a cancellous bone graft. We conducted a retrospective study of eight patients who underwent surgery between April 2010 and October 2016. Of these, four had a lunate cyst and four had a scaphoid cyst; all cysts had a dorsal operculum. Patients had disabling wrist pain that did not respond to conservative treatment. The diagnosis was confirmed by radiography and either a CT scan or an MRI. Curettage and cancellous grafts were performed under arthroscopic control. The technique was carried out successfully in all cases. One patient was lost to follow-up. At 18 months, postoperative pain was rated at 1.28 on a visual analog scale. The grip strength (measured with a Jamar dynanometer) was 77% when compared to the contralateral side. There was an improvement in joint range of motion, with an average wrist flexion of 67.5° compared to 48.3° preoperatively and an average wrist extension of 71.5° compared to 47.6° preoperatively. The Patient-Rated Wrist Evaluation (PRWE) score decreased from 69.7 to 12.7, which was a significant decrease. A good integration of the cancellous graft was confirmed at 6 months in all cases by CT scan or MRI. Curettage with a cancellous graft of lunate and scaphoid cysts under arthroscopic control is a technique that allows surgeons to obtain satisfactory clinical results with good integration of the graft.
Collapse
Affiliation(s)
- J Rimokh
- University Hospital Center of Amiens, avenue Rene-Laennec, 80480 Salouel, France.
| | - H Najjari
- University Hospital Center of Amiens, avenue Rene-Laennec, 80480 Salouel, France
| | - V Rotari
- University Hospital Center of Amiens, avenue Rene-Laennec, 80480 Salouel, France
| | - C Maes
- University Hospital Center of Amiens, avenue Rene-Laennec, 80480 Salouel, France
| | - N Lebeau
- Saint-Quentin Hospital Center, 1, avenue Michel de l'hospital, 02321 Saint-Quentin, France
| | - M Moughabghab
- University Hospital Center of Amiens, avenue Rene-Laennec, 80480 Salouel, France
| |
Collapse
|
5
|
Abstract
Kienbock disease (KD) is a disease of uncertain etiology, leading to chondral and osseous change in the lunate and wrist. Traditionally, Lichtman's classification of KD, based on radiographic appearances, has been used to direct treatment. Diagnostic wrist arthroscopy allows direct assessment of the lunate and surrounding articulations. Wrist arthroscopy can also serve as a therapeutic tool for performing debridement, resection, or arthrodesis procedures. The new Lichtman-Bain algorithm takes into consideration the status of the lunate, the effect on the wrist, and surgical and patient factors to guide management.
Collapse
Affiliation(s)
- Simon B M MacLean
- Department of Orthopaedic Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Karim Kantar
- Department of Orthopaedic Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.
| | - Gregory I Bain
- Department of Orthopaedic Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David M Lichtman
- Uniformed Services University, Bethesda, MD, USA; Department of Orthopaedic Surgery, University of North Texas, Health Science Center, Fort Worth, TX, USA
| |
Collapse
|
6
|
Lichtman DM, Pientka WF, Bain GI. Kienböck Disease: A New Algorithm for the 21st Century. J Wrist Surg 2017; 6:2-10. [PMID: 28119790 PMCID: PMC5258126 DOI: 10.1055/s-0036-1593734] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 09/06/2016] [Indexed: 10/20/2022]
Abstract
Background It has been over 100 years since the initial description of avascular necrosis of the lunate. Over the last two decades, there has been the introduction of advanced information regarding the etiology, natural history, classification, and treatment options for lunate osteonecrosis. There have been new classifications developed based on advanced imaging, perfusion studies of lunate viability, and arthroscopic assessment of the articular cartilage. Purpose This article brings together a new treatment algorithm, incorporating the traditional osseous classification system (Lichtman) with the perfusion/viability classification (Schmitt) and the articular cartilage classification (Bain). Methods We have developed a new algorithm to manage Kienböck avascular necrosis of the lunate. This new algorithm incorporates the current concepts of the diseased lunate and its effects on the remainder of the wrist. Conclusion For patients with a good prognosis and in the earliest stages, the "intact lunate" is initially protected utilizing nonoperative measures. If this fails, then appropriate lunate unloading procedures should be considered. If the lunate is "compromised" then it can be reconstructed with a medial femoral condyle graft or proximal row carpectomy (PRC). With the further collapse of the lunate, the wrist is then also compromised, with the development of secondary degeneration of the central column articulation. The "compromised wrist" will have functional articulations, which allows motion-preserving procedures to be utilized to maintain a functional wrist. With advanced disease (Kienböck disease advanced collapse), the wrist is not reconstructable, so only a salvage procedure can be performed. Other than these objective pathoanatomical factors, the final decision must accommodate the various patient factors (e.g., age, general health, lifestyle, financial constraints, and future demands on the wrist) and surgeon factors (skill set, equipment, and work environment).
Collapse
Affiliation(s)
- David M. Lichtman
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
- Department of Orthopaedic Surgery, University of North Texas Health Science Center, Fort Worth, Texas
| | - William F. Pientka
- Department of Orthopaedic Surgery, John Peter Smith Hospital, Fort Worth, Texas
| | - Gregory Ian Bain
- Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| |
Collapse
|
7
|
Bain GI, MacLean SBM, Tse WL, Ho PC, Lichtman DM. Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment. J Wrist Surg 2016; 5:255-260. [PMID: 27777814 PMCID: PMC5074828 DOI: 10.1055/s-0036-1584546] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
The assessment and management of Kienböck Disease (KD) has always been a conundrum. The Lichtman classification has traditionally been used to guide treatment based on imaging. Arthroscopy provides a direct visualization of the articular surface, allows probing of the surfaces, and enables minimally invasive techniques to be performed. The Lichtman-Bain classification is a new classification that takes into account the osseous, vascular, and cartilage aspects of the lunate and the secondary effects on the wrist. It identifies the important prognostic factors including age, the status of the lunate, and the status of the wrist. With arthroscopy, the articular surfaces of the lunate can be assessed to better understand the status of the lunate. The lunate can be defined as intact, compromised, or not reconstructable. If the lunate is intact then lunate decompression (forage) and arthroscopic assisted bone grafting can be performed. If the lunate facet and capitate are functional, then a proximal carpectomy can be performed. This can be performed as an arthroscopic procedure. Assessment of the wrist includes assessment of the adjacent articular surfaces of the central column articulations (radiocarpal and midcarpal articulations). Instability of the proximal carpal row can also be assessed. The radioscaphoid articulation is often preserved except in late KD, which allows the scaphocapitate fusion to be a good surgical option. This can now be performed as an arthroscopic procedure. Once the radioscaphoid articulation is degenerate, a salvage procedure is required.
Collapse
Affiliation(s)
- Gregory I. Bain
- Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Simon B. M. MacLean
- Flinders Medical Centre, Adelaide, South Australia, Australia
- Department of Orthopaedics, Flinders University, Adelaide, South Australia, Australia
| | - Wing-Lim Tse
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Pak-Cheong Ho
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - David M. Lichtman
- Uniformed Services University, Bethesda, Maryland
- Department of Orthopaedic Surgery, University of North Texas, Health Science Center, Fort Worth, Texas
| |
Collapse
|
8
|
Bain GI, Yeo CJ, Morse LP. Kienböck Disease: Recent Advances in the Basic Science, Assessment and Treatment. ACTA ACUST UNITED AC 2016; 20:352-65. [PMID: 26387994 DOI: 10.1142/s0218810415400079] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Kienböck disease is a disorder of impaired lunate vascularity which ultimately has the potential to lead to marked degeneration of the wrist and impaired wrist function. The aetiology of the avascular necrosis is uncertain, but theories relate to ulnar variance, variability in lunate vascularity and intraosseous pressures. Clinical symptoms can be subtle and variable, requiring a high index of suspicion for the diagnosis. The Lichtmann classification has historically been used to guide management. We present a review of Kienböck disease, with a focus on the recent advances in assessment and treatment. Based on our understanding thus far of the pathoanatomy of Kienböck's disease, we are proposing a pathological staging system founded on the vascularity, osseous and chondral health of the lunate. We also propose an articular-based approach to treatment, with an arthroscopic grading system to guide management.
Collapse
Affiliation(s)
- Gregory Ian Bain
- * Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.,† Department of Orthopaedics and Trauma, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Chong Jin Yeo
- ‡ Hand&Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Levi Philip Morse
- * Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.,† Department of Orthopaedics and Trauma, Flinders Medical Centre, Adelaide, South Australia, Australia
| |
Collapse
|
9
|
Lichtman DM, Pientka WF, Bain GI. Kienböck Disease: Moving Forward. J Hand Surg Am 2016; 41:630-8. [PMID: 27055625 DOI: 10.1016/j.jhsa.2016.02.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/06/2016] [Accepted: 02/21/2016] [Indexed: 02/02/2023]
Abstract
Over the past decade, a plethora of new information has been reported regarding etiology, natural history, classification, and treatment options for lunate osteonecrosis. New disease classifications have been described based on advanced imaging determination of lunate viability as well as a cartilage-based arthroscopic classification. Here we review the newest literature regarding Kienböck disease and present a new treatment algorithm that incorporates the traditional osseous classification system with a perfusion/viability classification and an articular cartilage-based classification.
Collapse
Affiliation(s)
- David M Lichtman
- Department of Orthopaedic Surgery, University of North Texas Health Science Center, Fort Worth, TX.
| | - William F Pientka
- Department of Orthopaedic Surgery, John Peter Smith Hospital, Fort Worth, TX
| | - Gregory I Bain
- Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia
| |
Collapse
|
10
|
Abstract
Kienböck's disease is a rare disorder involving the lunate, one of the carpal bones, and is, therefore, not commonly included in the differential diagnosis of patients presenting to the emergency department with wrist pain. Delay in diagnosis inevitably leads to disease progression, thereby reducing surgical options. This article presents a patient's case including patient history, differential diagnosis, radiographic findings, and management. The challenges in the diagnosis of this disease are discussed in relation to significance to clinical practice for nurse practitioners and emergency department physicians.
Collapse
|
11
|
Liverneaux PA. Reply to Letter to the Editor on: Augmented Reality-Based Navigation System for Wrist Arthroscopy: Feasability (J Wrist Surg 2013;2(4):294-298). J Wrist Surg 2014; 3:154. [PMID: 25077051 PMCID: PMC4078156 DOI: 10.1055/s-0034-1374545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|