State fo the art on Kienbock's disease (avascular necrosis of the lunate). One handred years after its first description, it remains a source for controversies. What is new and what is outdated? Where do we go next?

1. Kienböck’s disease
(what we haven’t learned in the first 100
years…)
Nickolaos A. Darlis, MD, PhD
To access this presentation on the web:

2. “Traumatic Malacia”
Robert Kienböck

3. Courtesy Dr Stephanie Low

5. Contributing Factors:
• Trauma/stress
May simpl aggr
y
avat a pr
e
eexist condit (cat yst
ing
ion
al )
– Acute Fracture
– Occupational
– Anatomic variations
• Vasculopathies
–
–
–
–
–
Septic emboli
Vasculitis
Raynaud’s
Scleroderma
SLE
• Viral disorders
– Reactive arthritis
(Hepatitis, HIV)
• Coagulopathies
– Sickle cell anemia
– Secondary factor
• Miscellaneous stuff
– Steroid exposure
– Caisson’s disease
– Fat storage
• Role of Genetics
• Role of Osteoclasts

6. Pathophysiology
Early – Vascular
•
•
•
Ischemia
Necrosis
Revascularization
Intermediate – Osseous
•
•
•
•
Sclerosis
Subchondral collapse
Coronal fracture
Remodeling
Late – Chondral
•
•
•
Subchondral bone collapse
Articular surface non-functional
Opposing surface non-functional

7. Vascularity
• Palmar vs Dorsal
• Intraosseous pattern
Gelberman, JHS, 1980

8. Morphology
Trabecular pattern weakest
Zapico 1966

9. Ulnar variance- Radial
inclination
Negative ulnar variance
and flattened radial
inclination m
ay
predispose certain
patients to develop
Kienböck's disease, but
neither is likely the sole
cause
2001)
(Allan, JAAOS,

10. MRI

11. Not all MRI abnormalities =
Kienbock’s

13. Pronated grip view
Highlight ulnacarpal impaction

14. Pronated Grip View
Radiographs

18. Stage I
Normal radiographs or linear fracture, MRI
changes in vascularity

19. Stage II
Lunate sclerosis, one or m fracture lines with
ore
possible early collapse of lunate on radial border

20. Stage IIIA
Lunate collapse normal carpal alignment and height

21. Stage IIIB
Lunate collapse, carpal collapse, scaphoid rotation,
carpal height decreased, capitate migration proximally
•S angle > 600
L

22. Stage IV
Severe lunate collapse with intra-articular
degenerative changes at the midcarpal
joint, radiocarpal joint, or both

23. Is Stage I really “The
B
eginning”?
• There may be (probably is) an earier
l
st
age when… wrist pain is present onl
y
wit st ess, and… the standard MRI is still
h r
normal.
“Angina of the wrist”

24. Lunate Stress Test
(Similar in concept to cor
onar st ess t )
y r
est
• Repetitive axial wrist loads followed by:
• Gd. enhanced fat suppressed T-1
sequences
– Normal signal at rest
– Schmitt-Lanz pattern A (bone edema) with stress
• Gd. perfusion scan
– compare bilateral flow rates pre and post
exercise

25. Stage “III-C” Kienböck’s
• Coronal plane fracture:
– Poor prognosis
(even if itot wise r
her
esembl st
es age II orIIIA)

26. Stage “III-C” Kienböck’s
More aggressive
treatment
• Lunate excision w.
fusion (STT/SC)
• PRC

27. Different pathway in children?
Irisarri:
Infantile Kienböck’s (5-10 yrs)
Excellent prognosis with non operative
management
Juvenile Kienböck’s
10 -15 yrs – similar to infantile
>15 yrs – more likely to need surgical Rx, but
better prognosis than adult as seen on MRI
“Teenböck’s” disease?

28. 16 y.o. female gymnast
• 5 months wrist pain @ diagnosis

29. 16 y.o. female gymnast
• @ diagnosis

30. 16 y.o. female gymnast
• 2 month post diagnosis
(7 mo post presentation)

31. 16 y.o. female gymnast
• 9 month post diagnosis
(14 mo post presentation)

32. 15 yo male stage IIIA

33. Kienböck’s in the “Elderly”
Taniguchi et al…Studied 14 pts with onset >60
• Etiology different?
– Ul minus l
nar
ess f equent
r
– Women mor f equent
e r
• Related to osteoporosis?
• Natural history different?
– C olapse pr essed in al
l
ogr
l
Conservative treatm
ent

34. Treatment by Stage/
Variance
Current
Stage
I
II/III-A
II/III-A
III-B
IV
Variance
Treatment
(+/-)
Immobilization (3-6 mos)
(-)
Radial shortening
(+)
VBG /Capitate shortening
(+/-)
PRC or STT/SC fusion
(+/-)
Wrist Arthrodesis/PRC

35. Non-operativeTreatment
(I/II/IIIA)
• Conservative vs operative (various) in 43 pts at 5 years
found no superiority of surgery over non-surgical
outcomes
(Delaere, JHS Br, 1998)
• Non-operative trial and careful selection of operative
candidates
• However… the natural history is PROGRESSION

36. R
EVASCULARIZATION
UNLOADING
St
age II
St
age II, IIIA
SALVAGE
St
age IIIB, IV

37. DRILLING
VBG
FREE PEDICLE
LT AR
THRODESIS
RADIAL SHORTENING
W
EDGE OSTEOTOMIES
CAPITATE
SHORTENING
STT/ ARTHRODESIS
SC
EX-FIX
PRC
W IST FUSION
R
LUNATE EXCISION
W
RIST DENER
VATION

38. Metaphyseal Core Decompression
(II/IIIA negative ulnar variance)
•
22 patients, 10 year follow up
–
–
–
–
16 patients pain free
Slightly improved ROM
20 patients returned to occupation
No patients underwent additional
surgical procedure
(Illarramendi, JHS, 2001)
•
No Biomechanical analysis

39. Treat or Salvage?

40. Gadolinium Infused MRI
(fat suppressed T-1)
Patterns (Schmitt and Lanz) :
Pattern A - Marrow edema with intact
(viable) bone trabeculae
- Increased (homogenous) signal
Pattern B - Early marrow necrosis with
fibro-vascular reparative tissue
- Mixed (inhomogenous) signal zones
Pattern C - Necrotic bone marrow with
collapse
- Decreased (homogenous) signal

41. A
B
C

42. Arthroscopic assessment
Stage II-b: Poor prognosis>> PRC
Courtesy, Gregory Bain, MD

43. Arthroscopic assessment
• Differentiate between
Lichtman IIIA-B and
IV disease
• Exact location of
arthrosis in stage IV
– is PRC indicated?
• Diagnose stage IIIC
– Poor prognosis

44. UNLOAD
Radial Shortening Osteotomy
(II/IIIA negative ulnar variance)
• Only 2-4 mm of
shortening
– consider saw kerf size
(1-2mm)
– beware of ulnocarpal
impaction
• Diaphyseal straight plate
• Distal metaphyseal w
fixed angle plate

45. UNLOAD
Radial Shortening Osteotomy
(II/IIIA negative ulnar variance)

46. Radial Wedge Osteotomy (closed)
UNLOAD
(II/IIIA positive/neutral ulnar variance)
Giannikas 1968
Biomechanics
•
2-D Mathematical model
– Lunate offloaded by 23%
(Wantanabe, JHS, 1993)
•
Cadaveric
– 24% increased lunate strain in extension
(Kam, JHS, 2002)
•
Pressure sensitive film
– Increased lunate fossa pressure on radius
(Werner, Hand Clinics, 1993)

47. Courtesy Prof A. Beris

48. UNLOAD
•
Radial Wedge Osteotomy (opening)
(II/IIIA negative ulnar variance)
Increased forces across ulna and nearly
eliminated forces across radiolunate
joint
(Viegas, JHS, 1989)
•
26% decrease on lunate cortical strain
(Kam, JHS, 2002)
•
Decreased pressure across lunate fossa
measured on pressure sensitive film
(Werner, Hand Clin, 1993)

49. UNLOAD
2D Radial Wedge Osteotomy
(II/IIIA negative ulnar variance)

50. UNLOAD
Capitate Shortening
(II/IIIA positive/neutral ulnar variance)
• Must ensure hamate
does not abut on the
lunate after shortening
• If present, removal of
proximal tip of hamate
• Usually requires
capitohamate fusion
– ? Impact on ROM

51. UNLOAD
Capitate Shortening
(II/IIIA positive/neutral ulnar variance)

52. STT Fusion
SALVAG
E
(Stage IIIB)
UNLOAD
•
Decreases lunate loading
– Significant decrease in wrist ROM
(Trumble, JHS, 1986)
•
Increased force transmission
through radioscaphoid and
midcarpal joints may lead to
early degenerative changes
1998)
(Iwasaki, JOR,

53. REVAS
C
Drilling
Arthroscopic directed forage (drilling) of the lunate in a
patient with an arthroscopic grade O Kienbock’s disease.
(from Bain and Durrant, THUES 2011.)

54. REVAS
C
Reverse Flow Pedicle/Bone Graft
from Distal Radius

56. 15 yo male stage IIIA

57. Courtesy D.G. Sotereanos,
MD

58. REVAS
C
Capsular Based Bone Graft
from Distal Radius
Sotereanos, Darlis et al. , JHS(A), 2006

59. REVAS
C
Capsular Based Bone Graft
from Distal Radius

60. REVAS
C
Capsular Based Bone Graft
from Distal Radius

61. REVAS
C
Vascular Pedicle with Cancellous
Bone Graft
(
Hori, Tami
Moneim, Iowa Ortho J, 1998

62. REVAS
C
Vascularized Bone Graft
from Metacarpals
Bengoechea-Beeby, JHS, 2001

63. REVAS
C
Vascular Grafts
• Cartilage shell of lunate
must not be
compromised
• Post op immobilize &
unload lunate
– Ex-fix
– Temporary STT fusion
• Does not preclude other
treatment options
(revasularize + unload)

64. REVAS
C
Lunotriquetral Arthrodesis
Unpublished data
rationale based on bone grafting a scaphoid
nonunion with AVN of the proximal fragment
where healing is achieved by “creeping
substitution”
Courtesy: Martin Posner, Steve Green

65. 1 year Post-Op

66. SALVAG
E
Proximal Row Carpectomy
(Stage IIIB)
• Relative Contraindication if
capitate head or radiolunate
fossa demonstrate degenerative
changes
– Can be technically overcome
• Beware of palmar ligaments
(RSC), avoid ulnar tanslocation of
the wrist
• Not universally accepted
– Better pain relief, ROM, and strength
with limited wrist arthrodesis
JHS, 1998)
(Nakamura,

67. SALVAG
E
Lunate Excision
(Stage IIIB)
• Tendon Ball Implant (palmaris longus, plantaris)
•
Silicone Replacement Arthroplasty, Titanium
Implant
– No longer widely used

68. SALVAG
E
Stage IV
• Proximal row carpectomy
• Wrist fusion
• Wrist denervation
• Wrist arthroplasty?

69. Take home messages
• S ple surgery –patient tailored
im
– Etiology? Ulnar plus? Inclination?
• Get as m
uch info as you can
– Gd MRI, Arthroscopy
• VB do not restore cartilage
Gs
• R
adial S
hortening and P C t
R ime t ed
est
oper ions
at

70. THANK YOU
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