Kienbock's disease of the lunate: What we have not learned in 100 years?

Kienböck’s disease(what we haven’t learned in the first

100 years…)

Nickolaos A. Darlis, MD, PhD

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“Traumatic Malacia”

Robert Kienböck

Courtesy Dr Stephanie Low

Contributing Factors:• Trauma/stress May simply aggravate a pre-

existing condition (catalyst)

– Acute Fracture– Occupational– Anatomic variations

• Vasculopathies– Septic emboli– Vasculitis– Raynaud’s– Scleroderma– SLE

• Viral disorders– Reactive arthritis (Hepatitis,

HIV)

• Coagulopathies– Sickle cell anemia– Secondary factor

• Miscellaneous stuff– Steroid exposure– Caisson’s disease– Fat storage

• Role of Genetics• Role of Osteoclasts

Pathophysiology

Early – Vascular• Ischemia• Necrosis• Revascularization

Intermediate – Osseous• Sclerosis• Subchondral collapse• Coronal fracture• Remodeling

Late – Chondral• Subchondral bone collapse• Articular surface non-functional• Opposing surface non-

functional

Vascularity• Palmar vs Dorsal

• Intraosseous pattern Gelberman, JHS, 1980

Morphology

Trabecular pattern weakest

Zapico 1966

Ulnar variance- Radial inclination

Negative ulnar variance and flattened radial inclination may predispose certain patients to develop Kienböck's disease, but neither is likely the sole cause

(Allan, JAAOS, 2001)

MRI

Not all MRI abnormalities = Kienbock’s

Pronated grip view

Highlight ulnacarpal impaction

Pronated Grip View Radiographs

Stage INormal radiographs or linear fracture, MRI changes in vascularity

Stage IILunate sclerosis, one or more fracture lines with possible early collapse of lunate on radial border

Stage IIIALunate collapse normal carpal alignment and height

Stage IIIBLunate collapse, carpal collapse, scaphoid rotation, carpal height decreased, capitate migration proximally•SL angle > 600

Stage IVSevere lunate collapse with intra-

articular degenerative changes at the midcarpal joint, radiocarpal joint, or

both

Is Stage I really “The Beginning”?

• There may be (probably is) an earlier stage when…wrist pain is present only with stress, and…the standard MRI is still normal.

“Angina of the wrist”

Lunate Stress Test(Similar in concept to coronary stress

test)

• Repetitive axial wrist loads followed by:

• Gd. enhanced fat suppressed T-1 sequences– Normal signal at rest– Schmitt-Lanz pattern A (bone edema) with

stress

• Gd. perfusion scan – compare bilateral flow rates pre and post

exercise

Stage “III-C” Kienböck’s

• Coronal plane fracture:– Poor prognosis (even if it otherwise resembles stage II

or III-A)

Stage “III-C” Kienböck’s

More aggressive treatment

• Lunate excision w. fusion (STT/SC)

• PRC

Different pathway in children?

Irisarri:

Infantile Kienböck’s (5-10 yrs) Excellent prognosis with non operativemanagement Juvenile Kienböck’s10 -15 yrs – similar to infantile >15 yrs – more likely to need surgical Rx, butbetter prognosis than adult as seen on MRI“Teenböck’s” disease?

16 y.o. female gymnast

• 5 months wrist pain @ diagnosis

16 y.o. female gymnast

• @ diagnosis

16 y.o. female gymnast• 2 month post diagnosis (7 mo post presentation)

16 y.o. female gymnast

• 9 month post diagnosis (14 mo post presentation)

15 yo male stage IIIA

Kienböck’s in the “Elderly”Taniguchi et al…Studied 14 pts with onset >60

• Etiology different?– Ulnar minus less frequent– Women more frequent

• Related to osteoporosis?• Natural history different?

– Collapse progressed in all

Conservative treatment

Treatment by Stage/Variance

CurrentStage Variance TreatmentI (+/-) Immobilization (3-6 mos)II/III-A (-) Radial shorteningII/III-A (+) VBG /Capitate shorteningIII-B (+/-) PRC or STT/SC fusionIV (+/-) Wrist Arthrodesis/PRC

Non-operativeTreatment(I/II/IIIA)

• Conservative vs operative (various) in 43 pts at 5 years found no superiority of surgery over non-surgical outcomes

(Delaere, JHS Br, 1998)

• Non-operative trial and careful selection of operative candidates

• However… the natural history is PROGRESSION

REVASCULARIZATION

UNLOADING

SALVAGE

Stage II Stage II, IIIA

Stage IIIB, IV

DRILLINGVBG

FREE PEDICLELT ARTHRODESIS

RADIAL SHORTENING

WEDGE OSTEOTOMIES

CAPITATE SHORTENING

STT/SC ARTHRODESIS

EX-FIXPRCWRIST FUSION

LUNATE EXCISIONWRIST

DENERVATION

Metaphyseal Core Decompression(II/IIIA negative ulnar variance)

• 22 patients, 10 year follow up– 16 patients pain free– Slightly improved ROM– 20 patients returned to

occupation– No patients underwent additional

surgical procedure (Illarramendi,

JHS, 2001)

• No Biomechanical analysis

Treat or Salvage?

Gadolinium Infused MRI (fat suppressed T-1)Patterns (Schmitt and Lanz) :

Pattern A - Marrow edema with intact (viable) bone trabeculae

- Increased (homogenous) signal

Pattern B - Early marrow necrosis with fibro-vascular reparative tissue

- Mixed (inhomogenous) signal zones

Pattern C - Necrotic bone marrow with collapse

- Decreased (homogenous) signal

A

B

C

Stage II-b: Poor prognosis>> PRC

Arthroscopic assessment

Courtesy, Gregory Bain, MD

Arthroscopic assessment

• Differentiate between Lichtman IIIA-B and IV disease

• Exact location of arthrosis in stage IV– is PRC indicated?

• Diagnose stage IIIC– Poor prognosis

Radial Shortening Osteotomy (II/IIIA negative ulnar variance)

• Only 2-4 mm of shortening – consider saw kerf

size (1-2mm)– beware of ulnocarpal

impaction

• Diaphyseal straight plate

• Distal metaphyseal w fixed angle plate

UNLOAD

Radial Shortening Osteotomy (II/IIIA negative ulnar variance)

UNLOAD

Radial Wedge Osteotomy (closed)

(II/IIIA positive/neutral ulnar variance)

Giannikas 1968

Biomechanics

• 2-D Mathematical model– Lunate offloaded by 23% (Wantanabe, JHS, 1993)

• Cadaveric– 24% increased lunate strain in extension (Kam, JHS, 2002)

• Pressure sensitive film– Increased lunate fossa pressure on

radius (Werner, Hand Clinics, 1993)

UNLOAD

Courtesy Prof A. Beris

Radial Wedge Osteotomy (opening)

(II/IIIA negative ulnar variance)

• Increased forces across ulna and nearly eliminated forces across radiolunate joint

(Viegas, JHS, 1989)

• 26% decrease on lunate cortical strain

(Kam, JHS, 2002)

• Decreased pressure across lunate fossa measured on pressure sensitive film

(Werner, Hand Clin, 1993)

UNLOAD

2D Radial Wedge Osteotomy (II/IIIA negative ulnar variance)

UNLOAD

Capitate Shortening (II/IIIA positive/neutral ulnar variance)

• Must ensure hamate does not abut on the lunate after shortening

• If present, removal of proximal tip of hamate

• Usually requires capitohamate fusion– ? Impact on ROM

UNLOAD

Capitate Shortening (II/IIIA positive/neutral ulnar variance)

UNLOAD

STT Fusion(Stage IIIB)

• Decreases lunate loading– Significant decrease in wrist

ROM (Trumble, JHS,

1986)

• Increased force transmission through radioscaphoid and midcarpal joints may lead to early degenerative changes

(Iwasaki, JOR, 1998)

SALVAGE

UNLOAD

Arthroscopic directed forage (drilling) of the lunate in a patient with an arthroscopic grade O Kienbock’s disease. (from Bain and Durrant, THUES 2011.)

DrillingREVASC

Reverse Flow Pedicle/Bone Graft from Distal Radius

REVASC

15 yo male stage IIIA

Courtesy D.G. Sotereanos, MD

Capsular Based Bone Graft from Distal Radius

REVASC

Sotereanos, Darlis et al. , JHS(A), 2006

Capsular Based Bone Graft from Distal Radius

REVASC

Capsular Based Bone Graft from Distal Radius

REVASC

Vascular Pedicle with Cancellous Bone Graft

(

Moneim, Iowa Ortho J, 1998Hori, Tami

REVASC

Vascularized Bone Graft from Metacarpals

Bengoechea-Beeby, JHS, 2001

REVASC

Vascular Grafts

• Cartilage shell of lunate must not be compromised

• Post op immobilize & unload lunate– Ex-fix– Temporary STT fusion

• Does not preclude other treatment options (revasularize + unload)

REVASC

Lunotriquetral Arthrodesis Unpublished data

rationale based on bone grafting a scaphoid nonunion with AVN of the proximal fragment where healing is achieved by “creeping substitution”

Courtesy: Martin Posner, Steve Green

REVASC

1 year Post-Op

Proximal Row Carpectomy(Stage IIIB)

• Relative Contraindication if capitate head or radiolunate fossa demonstrate degenerative changes – Can be technically overcome

• Beware of palmar ligaments (RSC), avoid ulnar tanslocation of the wrist

• Not universally accepted– Better pain relief, ROM, and strength

with limited wrist arthrodesis (Nakamura,

JHS, 1998)

SALVAGE

Lunate Excision(Stage IIIB)

• Tendon Ball Implant (palmaris longus, plantaris)

• Silicone Replacement Arthroplasty, Titanium Implant

– No longer widely used

SALVAGE

Stage IV

• Proximal row carpectomy • Wrist fusion• Wrist denervation• Wrist arthroplasty?

SALVAGE

Take home messages

• Simple surgery –patient tailored

– Etiology? Ulnar plus? Inclination?

• Get as much info as you can – Gd MRI, Arthroscopy

• VBGs do not restore cartilage• Radial Shortening and PRC time

tested operations

THANK YOU

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