Kienbock's disease

Kienbock's disease

1. Kienbock's Disease Birimong, MS ortho.CMC vellore (14/03/18) Hand surgery Department Ref; Green's Operative Hand Surgery, 6 th edition

2. Kienbock's Disease Avascular necrosis of the lunate  leading to abnormal carpal motion

3. history AVN of the lunate was first described in 1843 by Peste , who noted a collapsed lunate in certain cadaver dissections. Robert Kienbock , a radiologist from Austria in 1910, described the x-ray changes associated with lunatomalacia that is now associated with his name

4. anatomy Carpal key stone Carpal keystone

5. vascularity three major vascular patterns have been identifed . Y , X, and I patterns. I pattern is the only one with a single vessel to the lunate and is considered to be most at risk for development of avascular necrosis.

6. vascularity Both a palmar and a dorsal blood supply are present in 74% to 100% of bones. single vascular blood supply in approximately 7% of lunates . dual blood supply; 33% have a single palmar and dorsal vessel for anastomosis , 66% have a three-vessel anastomosis , and 10% have a four-vessel anastomosis On the palmar aspect, the radial, ulnar, and palmar branches of the anterior interosseous artery combine to form three transverse arches to supply the lunate . Dorsally, the radial, ulnar, and dorsal branches of the anterior interosseous artery combine to form three arches.

7. Etiology of Kienbock’s Not clear Multifactorial ; Pirmary ; circulatory problems, traumatic interference, poor circulation, ligament injury with collapse, and single or multiple fractures resulting in secondary vascular impairment. Secondary; scleroderma, sickle cell anemia, systemic lupus erythematosus , corticosteroid

8. Ulnar variance; Positive Neutral Negative

9. Ulnar variance In 1928, Hulten published his classic study comparing ulnar variance in normal subjects and patients with Kienbock’s disease. in normal subjects the distal articular surface of the radius and ulna was neutral in 51% ulnar negative in 23%. In contrast to the normal control group, in patients with Kienbock’s disease the majority showed an ulnar-negative variant

10. Morphologic types* Antuña Zapico classification 3 types of lunate based on the angle between the lateral scaphoid and proximal radial sides • Type I: the angle is more than 130° • Type II: the angle is less than 130° • Type III: here are two distinct facets on the proximal surface. One articulates with the radius, the other with the triangular fibrocartilage

11. Morphologic types* Antuña Zapico classification described the relationship between the shape of the lunate and ulnar length. He noted that a Type I lunate coexists with ulnar-negative variance . Type II and type III lunates coexist with zero and ulnar-positive variance. felt the pattern in type I was the weakest configuration with the greatest potential for both fatigue and stress fracture under loads. Antuna Zapico JM: Malacia del Semilunar1966

12. Interosseous pressure; Schiltenwolf and colleagues studied the interosseous pressure of the lunate with wrist motion. interosseous pressure of the lunate is greater in wrist extension than in neutral, Capitate as a control. This rise in intraosseous pressure may explain the lunate’s predisposition to osteonecrosis

13. Slope of radius Tsuge and Nakamura found that the radial inclination was lower in patients with Kienbock’s disease .

14. radiology Increased bone density of the lunate is the early sign of avascularity on plain radiographs. MRI is the most sensitive important not to confuse Kienbock’s disease with findings limited to the ulnar side of the lunate consistent with ulnar impaction. Frequently, radiologists will diagnose ulnar impaction changes as Kienbock’s disease, even though the entire lunate must show signal loss on MRI

15. MRI

16. classification

17. Lichtman Classification; 1 X rays; normal, but a linear fracture through the lunate may be noted. MRI; demonstrates diffuse T1 signal decrease in lunate . Bone scan is positive. *Images; ortjhobullets

18. Lichtman Classification; II Sclerosis of the lunate is seen on plain radiographs. Multiple fracture lines may be seen, though collapse of the lunate has not occurred. *Images; ortjhobullets

19. Lichtman Classification; IIIA Lunate collapse has occurred, but the carpal height alignments have been maintained . *Images; ortjhobullets

20. Lichtman Classification; IIIB Lunate collapse has occurred, and the capitate has migrated proximally. The scaphoid assumes a hyperflexed position. *Images; ortjhobullets

21. Lichtman Classification; IV This is a continuation of stage IIIB disease, with the addition of carpal ( radiocarpal and/or midcarpal ) arthritis. *Images; ortjhobullets

22. treatment There are many treatment options, but they basically fall into three main groups: procedures to unload the lunate , procedures to promote revascularization of the necrotic lunate , and s alvage procedures used when arthritic conditions exist

23. Stage I, II, or IIIA with Ulnar-Negative Variance   immobilization of the wrist for three weeks and taking NSAID’s Stahl F: On lunatomalacia ( Kienbock’s disease): a clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment, Acta Chir Scand 95 Suppl (126):3, 1947

24. However, a recent study by Keith and colleagues reviewed 33 patients treated nonoperatively for Kienbock’s disease They found a predictable pattern of deterioration of motion, grip strength, and Disabilities of Arm, Shoulder, and Hand (DASH) scores Keith PP, Nuttall D, Trail I: Long-term outcome of non surgically managed Kienbock’s disease, J Hand Surg [Am] 29:63-67, 2004.

25. Stage I, II, or IIIA with Ulnar-Negative Variance In these stages salvage of the lunate is possible to maintain normal carpal kinematics . In a symptomatic patient a joint-leveling procedure should be considered Most common procedure for unloading the lunate in patients with ulnar-negative variance is radial-shortening osteotomy The goal is to leave the patient with ulnar-neutral or slightly ulnar-positive variance

26. Stage I, II, or IIIA with Ulnar-Negative Variance radial-shortening osteotomy

27. Stage I, II, or IIIA with Ulnar-Negative Variance Vascularized Bone Grafting. BASED ON THE FOURTH AND FIFTH EXTENSOR COMPARTMENT ARTERIES; The most useful vessels TECHNIQUE BASED ON THE SECOND OR THIRD METACARPAL TECHNIQUE FOR VASCULARIZED BONE GRAFT FROM THE RADIUS

28. Stage I, II, or IIIA with Ulnar-Positive or Ulnar-Neutral Variance In this situation, the radius is as short as the ulna, and further shortening is not likely to decrease load on the lunate . lunate has not collapsed, so salvage procedures are not warranted. Technique: Capitate Shortening with Capitate-Hamate Fusion Technique: Radial Osteotomy . Radial-closing radial osteotomy with reduction in the angle of radial inclination has been described

29. Stage I, II, or IIIA Illarramendi and colleagues described their technique of coring out the metaphyseal region of the distal radius and ulna idea was from Illarramendi’s observation that complete resolution of Kienbock’s disease occurred in patients who sustained a distal radius fracture it is used mainly to increase venous outflow , which is similar to cord decompression, and to decrease interosseous congestion.

30. Stage IIIB various salvage procedures should be considered . Various intercarpal fusions have been described, including STT and scaphocapitate arthrodesis . proximal row carpectomy has also been reported Recently, pyrocarbon arthroplasty has become an option in patients with late-stage Kienbock’s disease

31. Stage IIIB pyrocarbon arthroplasty ,

32. Stage IV Proximal row carpectomy may be a possibility In most instances with end-stage Kienbock’s disease, wrist radiocarpal fusion is recommended. Patients frequently achieve pain relief,

33. Stage IV Proximal row carpectomy

34. Thank you