Stage III Kienböck’s disease treated with hyperbaric oxygen: the role of an unusual approach to a rare condition

Abstract

Kienböck’s disease is a rare condition characterised by avascular necrosis of the lunate bone. Its natural history and aetiopathogenesis have not yet been clarified, nor are its triggering factors identified. We present a case of a 17-year-old male gymnast, without relevant medical/family history, with stage IIIA Kienböck’s disease diagnosed in 2016. Initially, submitted to conservative treatment that proved to be insufficient. Consequently, surgical treatment was proposed, but refused. The patient instead underwent experimental treatment with hyperbaric oxygen (120 sessions, 100% oxygen at 2.5 atm, for 70 min periods, once daily, five times per week). In April 2018, a favourable clinical and radiological evolution was observed, with an improvement in the patterns of pain, motion and strength and an almost complete involution of the process of aseptic necrosis of the semilunar. To the best of our knowledge, this is the first report of Kienböck’s disease treated with hyperbaric oxygen.

Repetitive Microtrauma and Negative Ulnar Variance as Possible Culprits of Avascular Necrosis of the Lunate

“…Kienböck’s disease is a rare condition characterized by avascular necrosis of the lunate, which results in the death of the bone. This condition commonly presents among individuals between the ages of 20 and 40 years [1]. This case presentation strengthens the idea that a complex interplay of repetitive microtrauma and anatomical variances may contribute to the pathogenesis of Kienböck’s disease [2].…”

“…The advantage of radial shortening osteotomy can partly be explained by decreasing the mechanical stress on the lunate exerted by a relatively long radius [3,4]. Despite many treatment options available, current interventions have had limited success in reversing the progression of Kienböck’s disease until recently, where a case report demonstrated that hyperbaric oxygen therapy (HBOT), an off-label approach reversed stage IIIA in a 17-year-old male patient [1]. Originally, this conservative therapy is recommended for osteonecrosis of the femoral head with a type II indication defined by the 10th European Consensus Conference on Hyperbaric Medicine as the presence of sufficient evidence supporting its therapeutic action [20].…”

“…Kienböck’s disease is a rare condition characterized by avascular necrosis of the lunate bone in the wrist, which results in the death of the bone. The condition commonly presents among individuals between the ages of 20 and 40 years [1]. While limited knowledge into the pathogenesis of Kienböck’s disease exists, multiple factors including repetitive microtrauma, anatomical variances, and/or vascular abnormalities have been suspected to contribute to the disease onset and progression.…”

Hyperbaric oxygen therapy in stage III C Kienböck disease: Time is bone

“…The few experiences reported in the literature related to the treatment with HBOT of aseptic necrosis of the semilunate have extended the duration of treatment up to 120 sessions. 16 Consequently, we cannot exclude that a further extension of the HBOT treatment could improve the radiological‐anatomical picture.…”

“…Based on the beneficial effects that HBOT is able to produce on the mobilization of mesenchymal cells, 13 wound healing, 14 and neo angiogenesis, 15 many published works have proposed the use of HBOT as an experimental therapeutic option also for osteonecrosis in other bone districts such as the wrist. 16 …”