Poor function after nonoperative treatment of Kienböck's disease

An Algorithmic Approach to the Treatment of Kienböck Disease

The algorithm and rationale described is a reflection of our own surgical experience for this challenging disorder and can be compared with other publications. Our algorithm has evolved from treatment of a large volume of patients with Kienböck disease in a referral practice. However, it is limited to the management that we have found logical, effective, and within our scope of experience. The treatment guidelines for our specialty as a whole will evolve as our understanding of the etiology and our ability to quantify efficacy improves.

Treatment of Advanced Kienbock's Disease (Lichtman Stage IIIB with Carpal Collapse) by a Shortening Osteotomy of the Radius: 21 Cases

Purpose  To review the results of shortening osteotomies of the radius in our stage IIIB Kienbock's disease patients. Materials and Methods  In the past 30 years, we treated 52 cases of Kienbock's disease by a shortening osteotomy of the radius, of which 21 already had carpal collapse. All patient charts and X-rays were reviewed, but only the cases already with carpal collapse (stage IIIB) are presented here. Results  All patients improved after surgery. Pain, on a scale of 0 to 3, generally 2 or 3 before surgery (median: 2.3), was normally 1 or 0 afterward (median: 0.9); median flexion-extension of the wrist improved from 77 to 99 degrees; and grip strength of the other hand improved from 26 to 76%. The last clinical and radiological review was performed 1 to 23 years after surgery (median: 8 years). Conclusion  Advanced Kienbock's disease with carpal collapse is not a contraindication for carpal-sparing surgery radial shortening osteotomy.

Osteotomía de acortamiento del hueso grande en la enfermedad de Kienböck asociada a varianza ulnar positiva o neutra

Objetivos: La enfermedad de Kienböck se asocia generalmente a cubitus minus y la descompresión quirúrgica más común es a nivel radial. El objetivo es conocer los efectos de realizarla en el hueso grande cuando se encuentra asociada a varianza cubital normal o positiva.

Material y métodos: Realizamos un estudio retrospectivo de los resultados de la osteotomía de acortamiento del hueso grande en la enfermedad de Kienböck sin cubitus minus. Hemos revisado a 6 pacientes, intervenidos entre 2006 y 2013 en el Hospital Universitario Ramón y Cajal (Madrid). El seguimiento medio fue 36 meses (12-93). Se registraron: escala de valoración del dolor (EVA), rango de movimiento de la muñeca, fuerza de prensión palmary de la pinza, valoración funcional (DASH, Mayo Score), así como estudio radiológico y con RM.

Resultados: Se obtuvo una mejoría clínica y funcional de los parámetros estudiados, pero no de los radiológicos. En un caso la enfermedad evolucionó y el resto mantuvo los estadios radiológico (Lichtman) iniciales, consiguiendo la consolidación de la osteotomía en todos los casos. No se apreciaron complicaciones destacables.

Conclusión: La osteotomía de acortamiento del hueso grande es una técnica que oferta buenos y duraderos resultados en pacientes con enfermedad de Kienböck sin cubitus minus ni cambios degenerativos carpianos.

Long-Term Natural Outcome (7–26 Years) of Lichtman Stage III Kienböck’s Lunatomalacia

Background and Aims:

The natural history of Kienböck’s disease is controversial. Only three papers report a pure natural history without treatment. We hypothesized that the natural course of Kienböck’s disease may be better than reported.

Material and Methods:

We examined eight patients with Lichtman stage III Kienböck’s disease without any treatment, evaluating clinical and radiological results (9 wrists; 7 men, mean age at onset of symptoms 34 years) over a period of 10–38 years (mean, 27.3 years) after symptom onset.

Results:

Lichtman stage remained the same in five of nine wrists. The inner structure of the lunate improved in three, remained the same in three, and deteriorated in three wrists, and its shape improved in two, remained the same in four, and deteriorated in three wrists. Pain averaged visual analog scale 3.1 at rest, 3.4 during motion, 3.6 with slight, and 5.2 with heavy exertion. The range of motion improved at extension 19% and at flexion 14%, reaching 81% and 72% of that of the contralateral wrist, and grip strength reaching 93%. The Disabilities of the Arm, Shoulder, and Hand averaged 11.3, Optional Disabilities of the Arm, Shoulder, and Hand 18.0, and Mayo Clinic score 70.0. The radiographic course did not correlate with clinical course.

Conclusions:

The long-term natural history of Lichtman stage III Kienböck’s disease is insufficiently good to suggest thoughtful observation alone as an option to treat it.

Long-term outcomes for Kienböck's disease

BACKGROUND

The precise etiology of Kienböck's disease is unclear. Controversy exists regarding the appropriate treatment modality. The present study sought to investigate and compare surgical and nonsurgical treatment outcomes of patients suffering from Kienböck's disease in the province of Newfoundland and Labrador (NL), Canada.

METHODS

The present study was a retrospective analysis of 66 patients. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Student's t test was used to assess differences in outcomes between treatment groups. One-way ANOVA was used to assess differences in primary outcome in time since first assessed in an effort to examine progression over time. Pearson correlation was used to assess for correlation between primary outcome and age at diagnosis.

RESULTS

The average age was 38.6 ± 11.4 (18-70) years; Four patients were excluded due to inaccessible imaging. Of the remaining patients, 44 were treated conservatively, while 18 were treated surgically. The DASH scores for the surgical group were 23.7 ± 24.5 (0.9-82.8) and nonsurgical group were 20.0 ± 20.1 (1.7-81). As expected, the surgical group was mainly comprised of late-stage Kienböck's. When both groups were compared, there was no significant difference in the DASH scores. There were no difference in DASH scores within groups according to time since first diagnosed (<5 years; between 5 and 10 years; and >10 years). A positive correlation was found between age at diagnosis and DASH score (r = 0.42, p = 0.007), despite treatment modality. This finding remained significant after accounting for confounding factors (p = 0.029).

CONCLUSION

The DASH score for the surgical group was 23.7 ± 24.5 (0.9-82.8) and nonsurgical group was 20.0 ± 20.1 (1.7-81). No significant difference in DASH scores was found between surgically and nonsurgically treated patients. A positive association was found between the age at diagnosis of Kienböck's and DASH score, which suggests that patients diagnosed and treated later in life tend not to do as well.

Distraction histiogenesis for treatment of Kienbock's disease: A 2- to 8-year follow-up

BACKGROUND

Distraction histiogenesis is known to enhance vascularity and stimulate new tissue formation. Its use in Kienbock's disease is not reported in the literature, so we proposed to study the outcome after distraction histiogenesis in treating this condition.

MATERIALS AND METHODS

This prospective study comprised of six patients (two male and four female) with mean age 18.16 years (range 21-35 years) with clinicoradiologically diagnosed Lichtman stage II (n = 3) and stage III (n = 3) Kienbock's disease with a mean duration of symptoms 6.67 months. The ulnar variance was neutral in two and was negative in four patients treated with the application of Joshi external stabilization system (JESS) across the wrist. The gradual distraction was done at a rate of 0.5 mm/day. After the distraction of 5-7 mm, the distractors were kept static for 3 weeks. The wrist was mobilized by using hinged distractors for next 3 weeks. Later short cockup splint was used for further 4 weeks. At the end of minimum 2 years, an assessment was done on the basis of relief of symptoms, ability to perform activities of daily living, range of movement at wrist, grip strength, and on radiology (change in the density of bone and C:MC ratio i.e ratio of carpal height to third metacarpal height).

RESULTS

The mean follow-up was of 4.5 years (range 2-8 years). The average duration of treatment was 5.3 months (range 4.5-6 months), and the duration of distraction (both static and hinged) was 8 weeks. Clinically all the patients were relieved of the symptoms with an increase in the range of wrist movement (ulnar deviation increased from 20.8 degrees to 29.5 degrees , radial deviation from 17.5 degrees to 21 degrees , dorsiflexion from 37.5 degrees to 52.5 degrees , and palmer flexion from 38.3 degrees to 47.5 degrees ). At the last follow-up, activities of daily living were not affected, and all the patients were on their previous jobs without any fresh complaints. The average grip strength increased to 73-86% of normal. Radiologically the C:MC ratio (ratio of carpal height to third metacarpal height) did not show any significant improvement, but the density of lunate decreased.

CONCLUSION

Distraction histiogenesis when used in Lichtman stage II and III with negative or neutral ulnar variance gives good symptomatic relief, allowing return to normal activities. This study has also shown that reparative process is possible in avascular bone by distraction. The authors recommend further research in this modality of treatment.

[Kienböck's disease. Diagnosis and therapy]

Kienböck's disease (carpal lunate necrosis or lunatomalacia) is the most common aseptic osteonecrosis of the upper extremity. Other bone necroses in the hand occur less frequently. The name indicates a disease with unclear etiology which eventually always leads to necrosis of the lunate bone. It usually affects the dominant hands of males between 20 and 40 years of age. Treatment methods extend from immobilization to revascularization surgery on the affected bone. There is still no gold standard for the treatment of Kienböck's disease.

Vascularized bone grafts and their applications in the treatment of carpal pathology

Vascularized bone grafts (VBGs) are techniques in the management of certain types of carpal pathology. VBGs have traditionally been advocated for conditions including delayed and nonunion of fractures and avascular necrosis. The most common indications for VBG have been for scaphoid nonunion, lunatomalacia (Kienböck's disease), and osteonecrosis of the scaphoid (Preiser's disease). Advantages over NVBG have been established. VBGs provide improved blood flow, osteocyte preservation, and accelerated healing rates. Local pedicled VBGs are the most commonly used methods. They are technically less demanding than are free VBGs and are associated with less morbidity. Commonly used donor grafts arise from the dorsal vasculature of the wrist and include the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), the 2,3 ICSRA, the fourth extensor compartment artery (fourth ECA), and the fifth ECA. A 4 + 5 ECA combination graft has been described to provide a longer pedicle. In managing osteonecrosis, most surgeons would agree that VBG should be reserved for carpal bones with an intact cartilaginous shell and no collapse. In treating scaphoid pathology, indications for VBG include fractures/nonunions with proximal pole avascular necrosis and/or small proximal pole fragments.

Kienböck's disease in elderly patients

PURPOSE

Kienböck's disease occurs most commonly in the dominant hands of young or middle-aged male manual workers. The aim of this study was to investigate the characteristics of Kienböck's disease in patients older than 60 years of age.

METHODS

Gender, age at onset, affected side, dominant hand, occupation, and clinical results in 15 wrists of 14 elderly patients with Kienböck's disease were investigated. Age at onset of the disease was defined as the age at first onset of wrist pain. Clinical results were evaluated using the criteria of Dornan. Based on radiographic findings the stage of disease according to Lichtman's classification, ulnar variance, and carpal height ratio were determined.

RESULTS

Kienböck's disease in elderly patients occurred in 10 women and 4 men. Fourteen wrists of 13 patients developed the disease when the patients were in their 60s and 1 patient developed the disease in her 70s. It commonly was observed in the dominant hand of manual workers. Negative ulnar variance was present in only 2 wrists. Although radiographic examination revealed development of carpal collapse in all patients, clinical results including surgical and conservative treatment were good or excellent.

CONCLUSIONS

In elderly patients Kienböck's disease commonly occurred in the dominant hand of manual workers, similar to the conventional characterization of Kienböck's disease. It different, however, from concepts that had been reported previously that Kienböck's disease in elderly patients was found more often in women than in men, and frequency of negative ulnar variance was low. Therefore etiologic factors different from conventional ones might have played a role in our aged patients with Kienböck's disease.

Pediatric Kienböck's disease: case report and review of the literature

A 13-year-old boy with symptomatic Stage III Kienböck's disease was treated successfully with a radial shortening procedure. A comparison of the preoperative and postoperative radiographs and magnetic resonance imaging studies showed evidence of lunate revascularization and remodeling after a radial shortening osteotomy.

Open treatment of stage III Kienböck's disease with lunate revascularization compared with arthroscopic treatment without revascularization

PURPOSE

The goal of this study was to compare the results of open scaphocapitate fusion and revascularization with the results of arthroscopic scaphocapitate fusion and capitate pole excision.

TYPE OF STUDY

Prospective randomized study.

METHODS

Between April 1997 and January 2000, 16 consecutive patients (5 men and 11 women with a mean age of 31 years [range, 18 to 61]) presenting with Kienböck's disease stage IIIA and stage IIIB were randomized to either open scaphocapitate fusion and lunate revascularization (group I) or fully arthroscopic scaphocapitate fusion and capitate pole excision (group II) groups. Cannulated 3.5-mm ASIF screws were used for the purpose of scaphocapitate fixation in both groups. Operation time, hospital stay, time to fusion, range of wrist motion at final follow-up, grip strength, and return to unrestricted activities of daily living were evaluated at 33 months' follow-up.

RESULTS

The mean operating time (153 v 99 minutes), hospital stay (3.6 v 2.3 days), and return to unrestricted daily activities (15 v 5.8 weeks) were shorter in group II. Average time to radiographically evident fusion was shorter in group I (7.25 weeks v 9 weeks). There was a significant increase in grip strength and in range of motion at final follow-up in both groups, and the final grip strength and range of motion was not different between the groups. There were no major complications in either group.

CONCLUSIONS

Although the number of patients was small and the follow-up period was short, arthroscopic scaphocapitate fusion and capitate pole excision in stage IIIA and IIIB Kienböck's disease resulted in shorter operating time, shorter hospital stay, earlier return to unrestricted daily activities, and equal range of motion and grip strength as compared with open scaphocapitate fusion and lunate revascularization. Determination of specific surgical indications for the benefits of arthroscopic treatment of Kienböck's disease must be analyzed in larger studies.

Treatment of Kienbock's disease with capitohamate arthrodesis: pain relief with minimal morbidity

Despite the large number of procedures available for treatment of Kienbock's disease, no single method has emerged as being clearly superior. Ultimately, the goal of treatment must be the relief of pain and maintaining wrist range of motion. The authors' experience with 45 consecutive wrists that had undergone capitohamate fusion for treatment of Lichtman's stage 1, 2, or 3 Kienbock's disease is presented. Average follow-up was 32 months (range, 4 to 107 months). All arthrodeses healed with an average time to fusion of 1.9 months. Postoperatively, 93 percent of patients had either no pain or less pain than they had preoperatively, with preservation of wrist range of motion and improved grip strength (52 percent of normal preoperatively to 72 percent of normal postoperatively). The authors conclude that capitohamate arthrodesis relieves pain in 93 percent of patients with stage 1, 2, or 3 Kienbock's disease and is an effective treatment for this disease.

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.

Bilateral Kienböck's disease

Bilateral Kienböck's disease is very rare. We report here five cases of bilateral Kienböck's disease in the wrist. Of the five patients, two were manual workers and one was a housewife. The two other patients were retired and had received steroids for long periods to control autoimmune disease. The mean ulnar variance was 1. 8 (0-5) mm, and none of the patients had negative variance, indicating that negative ulnar variance was not a major risk factor for the development of bilateral Kienböck's disease.

External fixation and cancellous bone grafting for Kienböck's disease: a preliminary report

Between 1985 and 1990, 17 patients with histologically proven Kienböck's disease (Lichtman stages I, II, and III) underwent a combination of cancellous bone grafting to the lunate and external fixation across the wrist. All 17 patients were available for review with a minimum follow-up of 2 years (average, 47 years). Based on pain, functional status, range of motion, and grip strength (Mayo wrist score), there were 6 excellent, 6 good, 2 fair, and 3 poor results (2 of whom required further surgery). An overall success rate of 71% (12 of 17) was achieved. Ten patients underwent postoperative magnetic resonance scanning, and in 5, some improvement in signal intensity was demonstrated. The combination of cancellous bone grafting and external fixation is an alternative treatment for Kienböck's disease.

Ulnar lengthening and radial recession procedures for Kienböck's disease. Long-term clinical and radiographic follow-up

Twenty patients with Kienböck's disease who had undergone a joint levelling procedure, were reviewed at a mean of 11 years following surgery. Clinical and radiological evaluation revealed good long-term results with all patients complaining of less pain than before surgery and with statistically significant increases in range of motion and grip strength. Radiologically a significant number of patients were found still to have lunate fractures and fragmentation. In addition, 13 patients have developed new bone formation in the lunate fossa, and 12 show osteoarthritic changes, particularly at the radioscaphoid interface. Radial shortening was felt to be superior to ulnar lengthening in that there were fewer problems with bone union.

Treatment of Kienböck's disease with scaphotrapezio-trapezoid arthrodesis

The long-term results of 28 cases of Kienböck's disease treated with scaphotrapezio-trapezoid arthrodesis between 1980 and 1990 are presented. The average follow-up period was 51 months. Of these wrists, nine required late lunate excision for pain and limited motion; however, only three patients in the entire series required further wrist salvage procedures (wrist arthrodesis, proximal row carpectomy). At late follow-up examination, range of motion averaged 48 degrees in extension, 52 degrees in flexion, 11 degrees in radial deviation, and 27 degrees in ulnar deviation. Using a subjective pain relief rating scale, patients reported excellent results in 12 cases, good results in 9, fair results in 4, and poor results in 2 (1 case was omitted because of a coexisting different disease).

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.

Proximal row carpectomy in advanced Kienböck's disease

Sixteen patients with advanced Kienböck's disease (Lichtman stage IIIa and IIIb) were treated with proximal row carpectomy. Two patients were lost to follow-up study. The remaining 14 patients were followed for 3 years (range, 1 to 8 years) and all experienced less pain. Wrist motion was improved or unchanged in 12. Grip strength averaged 72% of the unaffected side. All patients returned to their previous jobs. Proximal row carpectomy in this group of patients provided satisfactory results.

Kienböck's disease, early stage 3--height reconstruction and core revascularization of the lunate

Early stage 3 Kienböck's disease has been treated by inner débridement, recontouring, height reconstruction, bone grafting and core revascularization of the lunate; additional procedures included temporary external fixation of the wrist and/or shortening osteotomy of the radius in selected cases. 26 patients, representing an uninterrupted series of 28 procedures, were followed-up for an average of 6.7 years (range 2.5-9.3 years) with periodic clinical and radiographic evaluations until they reached the final comprehensive assessment that included trispiral tomography and MRI. Every patient was subjectively improved, pleased with the result and able to resume his previous job. Pain intensity, rated on a zero to five scale, improved from 2.5 points pre-operatively to a final score of 0.8 points. Wrist motion gained slightly. Grip strength improved significantly. Lunate reconstruction proved successful in 37% of the cases; in an additional 23%, the disease process was stabilized. Carpal height decreased 4.7%; ulnar translation was not substantially altered. Arthrosis increased postoperatively in 55%, remained unchanged in 36% and progressed in 9%. Overall, 43% good and excellent, 43% fair and 14% poor results were observed.

Sports-related Kienböck's disease

Ten patients with Kienböck's disease who were actively engaged in sports activities involving repeated minimal trauma to the wrist are presented. Comparative studies between the 10 patients with sports-related Kienböck's disease and 82 manual laborers with Kienböck's disease showed no difference in clinical presentation or radiographic findings. The history of repeated minimal trauma appeared to be similar in the two groups. Therefore, sports activities in which the wrist suffers repeated impact can lead to the development of Kienböck's disease identical to that occurring in manual laborers, although the sports group was younger and had smaller ulnar variance. Radial osteotomy improved clinical symptoms even in sports-related Kienböck's disease.

Aged-onset Kienböck's disease

Kienböck's disease with onset after 50 years of age was studied. Of 127 patients with Kineböck's disease seen over the past 30 years, the cases of 15 (12 female, 3 male) were analyzed. The average age of onset was 58.3 years. Five specimens were obtained operatively in which necrosis of the lunate bone mixed with empty lacunae was identified, as was bony remodelling. Ulnar variance in the aged diseased group (group A) was smaller than that of the aged control group (group C). Moreover, it was noteworthy that the variance among aged controls (group C) was higher than among the young controls (group D). The metacarpal index of the patients with aged-onset Kienböck's disease was markedly lower than that of the young. Considering the increase of ulnar variance with age, the persistence of minus variance and the presence of osteoporosis might make the lunate bone susceptible to injury.

Wrist Pain in a Rugby Player

A group of experts from the University of California, San Diego, School of Medicine, met to discuss a case. This case conference is part of a series featuring a variety of sports medicine topics.