1. Kienbock’s Disease
D. Bunker

2. Origin Peste, 1843  lunate collapse
Dr. R. Kienbock, 1910: ‘lunatomalacia’
Traumatic rupture of the ligaments and vessels around the lunate produced lunate fracture, necrosis and subsequent collapse

3. Clinical Picture
Unilateral, persistent dorsal wrist pain, weakness, restricted ROM
20-45 years
M : F = 7 : 1
Hx minor/repetitive trauma
Rare: < 1,2000
History of manual work: ~97% of cases

4. Lunate (semilunar bone)
Middle of proximal carpal row
Ligaments: SLL, LT + extrinsics

5. Lunate morphology Antuna-Zapico, 1966
Type 1 more proximal apex (ulnar –ve)
Type 2 & 3 more rectangular
Type 1 seen with negative ulnar variance and higher rate of Kienbocks
(not supported by Tsunge, 1992)

6. Blood supply Gelberman, JHS, 1980: Gelberman & Gross, CO, 1986
Dorsal branches: dorsal radiocarpal arch and dorsal intercarpral arch
Volar branches: radial/ulnar/anterior interosseous
Extraosseous vessels through 2 – 3 dorsal and 3-4 volar vessels feeding capsular plexuses

7. 8% have a single palmar vessel
Blood supply
1 – 2 nutrient vessels entered the lunate from both plexuses, forming patterns
8% have a single palmar vessel X I Y

8. Geometrical considerations
Unequal load distribution through radiocarpal joint
Negative ulnar variance 23% vs 74% (Hulten, 1928; Bonzar, 1998)
Lower radial inclination (Mirabello, 1987; Jafari, 2012)
Both associated with higher RLJ loading (Goeminne, 1976; Jafari, 2012)
May predispose certain patients to the disease, but is not a reason in itself
(Allan, JAAOS, 2001)

9. Putting it all together
Intrinsic factors:
Blood supply: poor intraosseous anastomosis/single vessel/disruption of venous outflow
Morphology
Extrinsic:
Luno-capitate radius of curvature
Repetitive trauma
Ulnar variance
Radial inclination
Etiologic factors include vascular and skeletal variations combined with trauma or repetitive loading - Allan, JAAOS, 2001
The ‘Lunate at Risk’

10. Pathological stages
Early vascular: ischaemia/necrosis/revascularizatio n
Intermediate osseous: sclerosis, coronal #, subchondral collapse, remodeling
Late chondral: subchondral bone collapse, articular surface collapse, degeneration of opposing articular cartilage
Proximal portion of lunate is a terminal perfusion zone dependent on intraosseous retrograde blood supply. In Kienbock disease, the pathoanatomical changes show zone of necrosis in the proximal portion, zone of reparation in the middle layer with fibrovascular reparative tissue and zone of viability in the distal portion.

11. Gd T1 MRI Schmitt and Lanz
Pattern A: marrow edema with intact trabeculae (increased homogenous)
Pattern B: marrow necrosis with fibrovascular response (inhomogenous signal)
Pattern C: necrotic bone marrow with collapse (decreased homogenous)

12. Schmitt and Lanz

13. Investigations
X-ray: sclerosis/collapse of lunate, scaphoid rotation, pan- carpal arthritis (assess ulnar variance on 90-90)
(CT)
Bone scan
MRI (vascularity/edema, UCA, fracture)
Arthroscopy – staging

14. Modified Lichtman Classification
Decoulox et al. 1957; Lichtman et al., 1977/1993/1994, Stahl
Stage
Findings
Stage 1
Normal X-ray (+ve bone scan, Diffuse T1/2 changes on MRI)
Stage 2
Sclerosis
Stage 3A
Collapse (normal scaphoid alignment)
Stage 3B
Collapse with fixed scaphoid rotation (ring sign)
‘Stage 3C’
Coronal fracture (II/IIIA)
Stage 4
Radiocarpal/intercarpal arthritis

15. Treatment reflects disease stage
Pain relief, preserve ROM, maintain strength and function, preserve/restore carpal kinematics
Revascularise (II)
Unload (II/IIIA)
Salvage (IIIB/IV)
Non-operative
Revascularisation
Joint leveling/osteotomies
PRC
Fusion

16. Rx: Conservative ~3/12 casting/NSAIDS (Role of hand therapy)
Stage I
Non-specific wrist pain/synotivitis (sprain)
Plain films may be normal (or show compression #)
Rx: Conservative ~3/12 casting/NSAIDS (Role of hand therapy)

17. Stage II/IIIA Swelling, varying stiffness, progressive pain
Sclerosis on X-ray  height maintained
Sclerosis/collapse
No scaphoid rotation
Lunate appears widened

18. Rx: Stage II/IIIA Ulnar –ve (Unload)
joint leveling (radial shortening, ulnar lengthening), capitate shortening, opening wedge osteotomy, STT arthrodesos
core decompression (induces local vascular response)
Ulnar +ve/neutral: (Revascularise)
distal radius/pisiform/arterial grafts, capitate shortening, radial closing wedge
Forage/VBG/core decompression

19. Core Decompression
The surgical treatment of Kienbock’s disease by radial and ulna mataphyseal core decompression, Illarramendi et al, JHS, 2001
22 patients
10 years
16 pain free, 20 return to work
Grip 75%, arc 77%
Radius decompression for Kienbock’s disease, Illarramendi et al., THUEMS, 2003
N = 48 (stage I – IIIA), years  equivalent

20. Stage IIIB
Collapse, proximal capitate migration, diminished carpal height, DISI pattern
Goals: Stabilise/prevent progressive collapse/decrease load
PRC  transfer load to capitate
SC/STT arthrodesis correct scaphoid malalignment, stabilise midcarpus, prevent further collapse
?Arthroplasy / Lunate excision & interposition

21. Lunate excision / arthroplasty
Long-term outcome (22-36 years) of silicone lunate athroplasty for Kienbock’s disease, Viljakka et al., JHS 2014
Silicone cyst formation ~80%
N = 53, 12 removed, 6 fused
Ongoing significant pain
Strength 72%, ROM 65%
STT arthrodesis and lunate excision for advance Kienbock’s disease, Lee et al., JHS, 2001
n = 16, Stage IIIB, follow-up 67 months
Sig improvement in grip strength and pain scores,
Scaphoid shift (n = 14), development of radioscaphoid arthritis

22. Stage IV Stiffness, constant pain and swelling:
Radiocarpal and midcarpal degeneration
PRC if mild
Wrist arthrodesis/arthroplasty/denervation

23. Treatments II/IIIA II/IIA IV IIIB PRC Fusion
Wrist arthrodesis/denervation
SC/STT arthrodesis
Arthroplasy / Lunate excision & interposition
Radial shortening/ulnar lengthening
Capitate shortening
STT/SC arthrodesis
Forage
VBG
Radial wedge osteotomy
Core decompression
II/IIIA
II/IIA IV
IIIB

24. Role of Athroscopy
Diagnosis and management (IIIB/IV), IIIC, stage IV ?PRC)
Athroscopic decompression
(ulnar n/+ve, grade 0, no collapse)
n = 7, 37 – 74 yrs, IIIA/B, debridement of necrotic bone and ligament tears, f/u 6-42 months  improved pain/ROM/QOL

25. New Techniques

26. Temporary STJ fixation
Temporary scaphotrapezoidal joint fixations for adolescent Kienbock’s disease, Ando et al., JHS, 2009
n = 6, 14 years, 23 month follow-up
2 – 3 K-wires from dosal trapezdoid to scaphoid, kept in for 3 – 6 months
SS: wrist ROM, (460/480 : 680/770), no pain, grip (52%/86%), no sclerosis/fragmentation, improved MRI

27. Temporary STJ fixation (Yasuda, 1998)

28. Advanced disease  PRC/arthrodesis (loss of alignment and revascularisation potential)
GOAL: Address pain while preserving mid-carpal mobility and preventing progression

29. Lunate excision/replacement with pedicled vascularised scaphoid graft and partial radioscaphoid arthrodesis
, n = 13, 41 years, Stage IIIB (4) or IV (10)
Excised lunate
Filled gap with rotated scaphoid as a pedicled vascularised osteochondral autograft
Radioscaphoid arthrodesis

30. Raising the flap Distal 3rd raised, radially based between C2 – 5
Capsular flap raised preserving vessels from dorsal intercarpal arch

31. Enucleation Dorsal ligament sparing capsulotomy
SL and LT sectioned, lunate excised
Dorsal scaphoid enucleation

32. Insetting
Rotation of scaphoid through it’s flap with medial translation
Radiolunate facet denuded
Lunate facet dorsal and trapezoidal facet volar

33. Radioscaphoid arthrodesis

34. Outcomes

35. Outcomes Outcomes (4 years): ‘Better’ or ‘excellent’, n = 10
No rest pain, n = 6 non-restricted activity
n = 12 able to work
ROM: 700 (44% that of contralateral, 16% less than pre-op)
Grip: 30% improvement
At 4 years, 12 of 13 had no evidence of OA or collapse at the scaphocapitate joint

36. Summary
AVN of lunate  progressive and predictable pattern of degeneration
Gather all the information you can (MRI/arthroscopy)
Staging and Geometry affects treatment choices (PRC/radial shortening)
Combination of approaches may be necessary