1. Division of Hand Surgery Groote Schuur Hospital
Kienbock’s Disease
Dr Steve Carter
Division of Hand Surgery
Martin Singer Unit
Groote Schuur Hospital

2. Introduction Robert Kienbock :1910 (Peste:1843 cadaver specimens)
Avascular Necrosis Lunate
Diagnosis can be difficult
Treatment challenging and controversial

3. Etiology Avascularity - Gelberman 8% Lunates single vessel
- 3 vascular patterns
Trauma Repetitive microtrauma
- Fracture
Ulna Variance - Hulten 1928

4. Etiology
Lunate Geometry: Zapico
Load Stresses
Radial slope

5. Etiology
Summary
No single factor can be isolated. It is a combination of
load , either repeated compression or single fracture,
vascular risk, mechanical predisposition and
unavoidable continuous stress on the lunate resulting in
AVN , progressive collapse , carpal derangement and
ultimate arthrosis

6. Staging
Lichtman 1988
Stage 1 Normal XR increased bone scan MRI diagnostic
Stage 2 Increased sclerosis Lunate on XR
Stage 3 Lunate collapse
A. Normal carpal alignment without fixed scaphoid rotation
B. Altered carpal alignment with fixed scaphoid rotation
Stage 4 Lunate collapse with carpal OA

7. Staging

8. Clinical presentation
years of age
Active individual , manual labourer
Dominant hand
May or may not be a history of trauma
Chronic wrist pain
Decreased ROM /dorsal tenderness/ swelling/ synovitis
Youngest 8 yrs , oldest 71 yrs
Most 2-3 yrs of wrist pain that becomes more acute following a trivial injury

9. Natural History
In terms of bony changes there is sclerosis, progressive loss of height of the lunate and fragmentation. This results in dissociation within the proximal row allowing the scaphoid and triquetrum to rotate in opposite directions, scaphoid into palmar flexion and triquetrum into dorsiflexion net effect is loss of carpal height and eventually degenerative changes develop.
So overall although their is relentless progression of XR changes, these changes are only weakly assoc with symptoms
Hence treatment and outcomes are still debated with conflicting opinions

10. Questions The problem is AVN but the result is instability
Is the pain from the avascular lunate, the carpal collapse and instability or a combination of the above?
Does the capitate in fact migrate if the lunate is excised?
Why do we see very few stage 4 SLAC wrists in kienbocks but frequently see in scapholunate dissociation
How SLAC is a SLAC wrist ,or are we dealing with different pathologies
Aetiology unknown therefore Rx not goal directed but rather symptomatic and salvage directed , hence unpredictable results

11. Surgical Options
Depends on age, stage, ulna variance and presence of arthrosis
Conservative splinting intra-articular injection
Denervations
Revascularization / Bone grafting. Used in 1,2,3a Variety of techniques dorsal metacarpal artery /Pronator Quadratus / pisiform
Joint levelling procedures Decrease pressure transmission through Lunate Useful in ulna minus , advantages , disadvantages Up to 40 % reduction in force transmision
Radial closing osteotomy
Ulna procedures

12. Surgical Options Limited carpal Fusions Useful stage 3B
1. STT arthrodesis :most commonly used
Rationale: Designed to stabilize midcarpal joint, prevent carpal collapse and decompress lunate by shifting force transmission thru radioscaphoid joint
Problems: pseudarthrosis rate 40%,Accelerated degeneration mid-carpal and radioscaphoid joint
Scaphocapitate fusion. Similar biomechanical effect, prevents collapse, unloads lunate addresses scaphoid flexion and simple to achieve arthrodesis
Capito-hamate fusion

13. Surgical Options Metaphyseal core decompression JHS 2001
Capitate shortening: Graner procedure
Excision arthroplasty
Proximal row carpectomy
Wrist arthrodesis

14. Literature Review
Conservative treatment vs. STT arthrodesis for Kienbock’s disease (Foucher G; 2006: Chirurgie de la Maine)
- 104 patients over 18 Yrs Conservative 59 STT 25
- STT group increased pain ,stiffness , rehab time
Wrist fusion vs. limited carpal fusion in advanced Kienbock’s disease (I Trail ,J StanleyL; 2005: International Orthopaedics)
- 18 patients 6 total fusions; 12 limited 5 yr follow up
- total fusions better DASH scores , patient satisfaction scores , less
failures
Long term outcome of radial shortening with or without ulna shortening for the treatment of Kienbock’s disease (Zenzai J; Hand Surgery 2005)
- 36 patients stages 1to 3 Average of 19 yr follow up
- Overall good results No significant progression of the disease

15. Literature Review
Arthroscopic assessment and classification of Kienbock’s Disease
Bain; Techniques in Hand and Upper Extremity Surgery 2006

16. Stage 1,2 3a Conservative Ulna -ve Ulna neutral or +
Radial Shortening and PIN denervation
Core Decompression and PIN denervation

17. Stage 3b Conservative Ulna -ve Ulna Neutal or +
Radial shortening and PIN den
Core Decompression and PIN den
Lunate Excision
Wrist Arthrodesis

18. Lunate excision for stage3b
Pros
Gillespie: 88% good to excellent results in 24 cases
Dornan: 16 cases good to excellent results
Kawai JBJS 1988: 70 B 18 cases , 12 year follow up good to excellent , minimal degenerative changes
Cons
Stahl: patients poor results
Therkelsen: 1949 excision worse than leaving in place

19. Lunate
Triquetrum
Scaphoid
Scaphoid
Triquetrum

20. Method
Our series attempt to deal with the avascular lunate and carpal instability with a single procedure
Based on the anatomy of the dorsal radiocarpal ligament and inter-carpal ligament

21. Method Dorsal incision 3rd 4th compartments
Identify dorsal inter-carpal and radio-carpal ligaments
Elevate as a flap (trapdoor) leaving the triquetral attachment intact
Cut the scapho-lunate lig keeping as close to the lunate as possible
Remove the lunate
Suture DIC ligament to SL ligament
Routine closure backslab for 10 days then mobillize
Scaphoid
Dorsal intercarpal lig

22. Demographics Average age: 36 yrs
5 Females and 1 Male ( 1 patient lost to follow up )
1 bilateral Kienbock’s ( 56 yr female )
Average duration symptoms: 6.6 yrs
2 patients with history of trauma , 3 with no history of trauma

23. Results

24. Results X Y
Lunate gap
X/Y = Carpal height ratio

25. Conclusion Viable salvage operation in (failed) grade 3b Kienbock’s
Simple procedure
Reliable pain relief but decreased range of movement
No statistically significant change in carpal height ratio
Lunate gap remains the same ie no capitate migration

26. Conclusion Conservative +++
Treatment symptom directed rather than radiologically directed
No surgical procedure entirely effective
Stepwise approach