Kienböck’s Disease, Early Stage 3––Height Reconstruction and Core Revascularization of the Lunate

Abstract

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.

What Is the Radiographic Prevalence of Incidental Kienböck Disease?

“…The natural history of Kienböck is incompletely understood [3]. Progression of lunate osteonecrosis can ultimately lead to collapse and fragmentation of the diseased bone with or without secondary distortion of the carpal alignment [2]. What remains uncertain is how frequently the process arrests before complete collapse, the time course of active changes in the lunate, and how often the process arrests at each radiographic stage.…”

“…We attempted to answer the following questions: (1) What is the prevalence of incidental and symptomatic Kienböck disease? (2) What are the factors associated with incidental and symptomatic Kienböck disease? (3) Are there differences in Lichtman stage distribution between incidental and symptomatic Kienböck disease?…”

Vascularized Bone Grafting in a Canine Carpal Avascular Necrosis Model

“…It is possible that it is the gradual revascularization process occurring over a period of several months to several years that leads to the observed collapse in Kienböck's disease and not in our canine radiocarpal bones. For example, Bochud and Büchler reported 42% of lunates to be at least partly viable and only 15% of lunates necrotic based on MRI data for 26 patients obtained at an average of 6.7 years (range, 2.5-9.3 years) after core revascularization of the lunate in Stage IIIA Kienböck's disease [9]. Sowa et al reported MRI evidence for revascularization was observed at 12 months in three of five lunates with Kienböck's disease treated with radial shortening osteotomy [33].…”

Radial recession osteotomy for early Kienböck's disease

“…The surgical options are numerous and include wrist immobilisation [6,21], temporary distraction [2,39], open reduction internal fixation with or without bone graft, revascularisation procedures [7,35], joint levelling procedures [1,3,4,5,8,14,22,25,26,27,28,30] various intercarpal arthrodeses [scaphoidtrapezium-trapezoid arthrodesis (STT), scapho-capitate (SC), capito-hamate (CH)] [8,11,14,24,31,36,37], lunate excision with or without replacement [13,17,20,33] wrist denervation [10,29], and end-stage salvage procedures such as proximal row carpectomy and total wrist fusion [16]. There is support in the literature for all these procedures.…”

“…In the absence of a complete understanding of the aetiology of this disease, however, the possible options in its management are numerous, and the literature lends support to all. In advanced disease, operative extirpation with or without replacement [13,17,20,33] and numerous procedures attempting to promote revascularisation [7,35,39] have been advocated while in the early disease stages joint levelling procedures [4,30] or intercarpal arthrodeses are favoured [24,36].…”