A Descriptive ppt to have a look at different available option for the reatment of a mysterious disease in short which further needs a lott digging into the available data. Hope you will find it usefull!!

1. Kienbock’s Disease
Presenter: Dr GODARA NEERAJ
Dr Monusha M
Moderator: Dr PRAVEEN BHARDWAJ

2. THE QUESTIONS IS?
•1. Can we reliably define the stage of the
disease?
•2. Is surgical or nonsurgical treatment
indicated?
• 3. If we choose surgery, which
procedure is best?

3. Investigations
•X-ray: sclerosis/collapse of lunate,
scaphoid rota8on, pan-carpal arthri8s
•(CT)
•Bone scan
•MRI (vascularity/edema, fracture)
•Arthroscopy – staging

4. Modi%ied Lichtman Classi%ication
•Decoulox et al. 1957; Lichtman et al., 1977/1993/1994, Stahl

15. Treatment re)lects disease stage
Pain relief, preserve ROM, maintain strength and func8on, preserve/restore
carpal kinema8cs
1.Revascularise (II)
2.Unload (II/IIIA)
3.Salvage (IIIB/IV)

17. Stage I
•Non-specific wrist pain/syno3vi3s (sprain)
•Plain films may be normal (or show compression #)
Rx: Conserva3ve ~3/12 cas3ng/NSAIDS (Role of hand therapy)

18. Stage II/IIIA
•Sclerosis/collapse
•No scaphoid rota2on
•Lunate appears widened
•Swelling, varying s2ffness,
progressive pain
•Sclerosis on X-ray àheight
maintained

19. 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 graBs, capitate shortening, radial
closing wedge osteotomy
•VBG/core decompression

20. Core Decompression
•The surgical treatment of Kienbock’s disease by radial and
ulna mataphyseal core decompression, Illarramendi et al, JHS,
2001

21. Radial shortening osteotomy
• Approach :- volar > dorsal
• 2-3mm ( not > 4mm )
• Meaphyseal / meta-diaphyseal
• Not decrease ROM
• Not in ulnar posiBve wrist

22. Distal radius wedge osteotomy
- Stage II or IIIA with ulna-neutral or posi8ve wrist
- Lateral closing wedge osteotomy : decrease RU-inclina8on thus shi?ing
stress from lunate (Koh et al J Hand Surg 2003;28A:)
- Medial closing osteotomy or lat opening wedge osteotomy
- Step cut osteotomy/dome osteotomy

23. Capitate shortening osteotomy (Afshar et at reported lunate
revasculariza4on)
CSO + capito-hamate
fusion

24. REVASCULARISATION:
Sources:
-Base of 2nd or 3rd metacarpal
-Neck of 2nd meatacarpal
-1,2 ICSRA
-2,3 ICSRA
-4th or 5th ECA(Most Common)
-Hori technique(Vascular pedicle inserMon with graP)
-Pisiform
-PQ
+ unloading procedure:
- external fixator or
- temporary STT-pinning or
- radius osteotomy

26. 4th or 5th ECA(Most
Common)
Moran et al J Hand Surg 2005;30A:50–58.

27. 4th or 5th ECA(Most
Common)•Moran et al showed 31 months average follow-up.
•supplemental external fixa;on or scaphocapitate pinning.
•Repoted that 71% of lunates revascularized.
•Pa;ents experienced:-
• pain relief,
• Improvement in grip strength, and
• Increased range of mo;on (ROM)
•23% of pa;ents showed evidence of
radiographic progression of disease.

28. Vascularised Pisiform
Daecke W J Hand Surg 2005;30A:915–922.

29. Vascularised Pisiform
•Pain and func+on improved in 20 of 23 pa+ents.
•Range of mo+on and grip strength were 84% and
80% of the contralateral side,
respec+vely.
•Radiographic progression was noted in 6 (33%).

30. 2,3 ICSRA

31. Stage IIIB
•Collapse, proximal capitate migra2on, diminished carpal
height, DISI pa9ern
Goals: Stabilise/prevent progressive
collapse/decrease load
PRC àtransfer load to capitate
SC/STT arthrodesis àcorrect
scaphoid malalignment, stabilise
midcarpus, prevent further collapse
?Arthroplasy / Lunate excision &
interposi<on

38. PEDIATRIC KIENBOCK
•Kienbock disease in a child is rare.
•Conserva4ve treatment with a cast or splin4ng for 15 weeks to 6 months.
OR
•Temporary STT/ST fixa4on is a brief procedure and avoids long
immobilisa4on.

39. Treatments:-

42. • New Techniques

43. CEMENT LUNATOPLASTY at Cadaver
level

44. Temporary STJ ,ixation
•Temporary scaphotrapezoidal joint fixa6ons 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/fragmentaTon, improved MRI

45. Temporary STJ ,ixation (Yasuda, 1998)

46. •Advanced disease àPRC/arthrodesis (loss of alignment and
revascularisa:on poten:al)
•GOAL: Address pain while preserving mid-carpal mobility and
preven:ng progression

47. •Lunate excision/replacement with pedicled vascularised scaphoid
gra8 and par9al radioscaphoid arthrodesis
•2002-2008, n = 13, 41 years, Stage IIIB (4) or IV (10)
1.Excised lunate
2.Filled gap with rotated scaphoid as a pedicled vascularised
osteochondral autogra8
3.Radioscaphoid arthrodesis

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

49. Enucleation
•Dorsal ligament sparing capsulotomy
•SL and LT sec7oned, lunate excised
•Dorsal scaphoid enuclea7on

50. Insetting
•Rota'on of scaphoid through it’s flap with medial transla'on
•Radiolunate facet denuded
•Lunate facet dorsal and trapezoidal facet volar

51. Radioscaphoid arthrodesis

52. Outcomes

53. Outcomes
•Outcomes (4 years):
•‘Be4er’ or ‘excellent’, n = 10
•No rest pain, n = 6 non-restricted acCvity
•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

54. SUMMARY
•Staging and Geometry affects treatment choices!
•Combina7on of approaches may be necessary.
•When the ar7cular surfaces of the capitate and radius are preserved,
proximal row carpectomy might be a valid op7onal salvage procedure in
advanced cases.
•S7ll there is no defina7ve Algorithm as all studies shows good results
with all different methods AT different stages.
•Vascularized bone graGing for pa7ents with stage III Kienböck disease can be recommended based
on the favorable long-term results. J Hand Surg 2013;38A:904– 908.
•Radial Shortening Osteotomy Reliable for Lichtman stage-II and IIIA disease &
Reasonable op7on for pa7ents with stage-IIIB disease. @ JBJS 2009
•Capitate shortening osteotomy combined with VBG is effec7ve in the treatment of ulnar-posi7ve Kienböck’s II/IIIA & IIIB.
J Hand Surg 2008;33A:1267–1273. MNN

55. THANK YOU