Kienbock's disease

1. Kienbock's
Disease
Birimong, MS ortho.CMC vellore(14/03/18)
Hand surgery Department
Ref; Green's Operative Hand Surgery, 6th 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 stoneCarpal 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;
o 33% have a single palmar and dorsal vessel for anastomosis, 66% have a three-vessel
anastomosis, and
o 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;
o Pirmary; circulatory problems, traumatic interference, poor circulation, ligament
injury with collapse, and single or multiple
fractures resulting in secondary vascular impairment.
o 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
o Type I lunate coexists with ulnar-negative variance.
o Type II and type III lunates coexist with zero and ulnar-positive variance.
o 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:
1. procedures to unload the lunate,
2. procedures to promote revascularization
of the necrotic lunate, and
3. salvage 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.

26. 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
•

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

28. 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

29. 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

30. 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.

31. 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

32. Stage IIIB
• pyrocarbon arthroplasty
,

33. 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,

34. Stage IV
• Proximal row carpectomy
•

35. Thank you