eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Kienböck Disease: Follow-up

Author: Brian J Divelbiss, MD, Consulting Staff, Dickson-Diveley Midwest Orthopaedic Clinic, Inc, Kansas City Orthopaedic Institute
Coauthor(s): Mark E Baratz, MD, Professor, Department of Orthopaedics, Drexel University College of Medicine; Residency Director, Department of Orthopaedics, Allegheny General Hospital; Consulting Staff, Allegheny Orthopaedic Associates
Contributor Information and Disclosures

Updated: Jul 11, 2007

Outcome and Prognosis

The natural history has not been well elucidated, primarily because few reported series focus exclusively on nonoperative treatment. Kristensen monitored 49 patients nonoperatively for an average of 20.5 years and found that 80% of the patients had no pain or had pain only with heavy labor.7 Most patients reported a gradual lessening of symptoms over time. This benign clinical picture was not mirrored by radiographic findings, as degenerative changes in the wrist were common and every lunate was deformed.

In a retrospective study comparing surgical treatment with nonsurgical treatment for patients with Kienböck disease, Delaere noted that surgical management did not appear to show superiority over nonsurgical treatment at 5 years of follow-up.8 Care should be taken in interpreting these results, however, because STT fusions were performed in the majority of those treated surgically. This procedure, as noted below, has not been shown to produce long-lasting good results. In addition, patients who had more advanced disease were more likely to undergo surgery.

Mikkelsen noted that 15 of 25 patients treated conservatively had daily problems with the wrist.9 He concluded that nonoperative treatment was not indicated for Kienböck disease. In the early stages of Kienböck disease, a short trial of casting may alleviate symptoms and obviate the need for surgery. These patients should be monitored closely so that surgery, if necessary, can be performed when radial shortening is still feasible.

Although initial success was seen with the use of a silicone spacer following lunate resection, this implant is no longer indicated. Alexander presented a 5-year follow-up of a group of 10 patients with silicone lunate replacements and noted 50% unsatisfactory results.10 Sixty percent of patients who had radiographs at final follow-up demonstrated evidence of silicone particulate synovitis. Lunate excision is not commonly recommended because of concerns of progression of carpal collapse. A fascial or palmaris anchovy replacement has had variable success in preventing subsequent collapse, although Carroll reported long-term (>10 y) success in a series of 10 patients treated with a fascial implant following lunate excision. He noted no evidence of carpal collapse, and all patients had unrestricted use of their hands.

Radial shortening remains a mainstay of treatment. It is a reliable, reproducible procedure with good results. Weiss and Quenzer have presented large series of radial shortenings.11,12,13 They have noted decreased pain in about 90% of patients, as well as improved motion and grip strength at 4-year follow-up. Weiss also demonstrated that good results can be obtained in patients with stage III disease who have evidence of lunate collapse. Despite good clinical outcomes, radiographic signs of continued collapse and degeneration are common. Although ulnar lengthening has demonstrated similar clinical outcomes, it is also associated with a higher complication rate. For this reason, radial shortening is the preferred joint-leveling method.

Watson reported on the use of STT (triscaphe) fusion for stage III disease and noted nearly 80% of his patients had good or excellent pain relief at 51-month follow-up.14 Caution should be used when evaluating these results, as nearly 40% of his patients required additional procedures to achieve this outcome. Compared to STT fusion, SC fusion has demonstrated similar pain relief rates but slightly decreased motion. Currently, no long-term results are available on the use of capitate shortening with or without capitohamate arthrodesis.

In a series of 51 patients who underwent vascular bundle implantation, 98% showed a reduction or resolution of pain at long-term follow-up. Again, these encouraging clinical results were not mirrored by radiographic improvement, as 20% had further degeneration and 10% had frank fragmentation. Results of the newer technique of distal radial vascular bone pedicle were noted previously.

The expected outcome following PRC is 75° in the flexion/extension arc and grip strength of 75% of the opposite side. Pain relief has been demonstrated in 80% of patients who underwent PRC for Kienböck disease. As noted, a PRC can be converted successfully to wrist arthrodesis.

Several other options for treatment have been reported. Ruby performed cancellous bone grafting supplemented by postoperative external fixation and found good pain relief in 80% of his patients.15 In patients with stage III disease and mechanical symptoms, arthroscopic debridement was found to decrease pain and increase motion. Finally, wrist denervation is a simple, safe option that can also be combined with other procedures to aid in postoperative pain reduction. In fact, denervation itself may provide much of the perceived pain reduction in cases where the dorsal capsule is incised to perform the index procedure.

 


More on Kienböck Disease

Overview: Kienböck Disease
Workup: Kienböck Disease
Treatment: Kienböck Disease
Follow-up: Kienböck Disease
References
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References

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Further Reading

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Keywords

avascular necrosis of the lunate, osteonecrosis of the carpal lunate, wrist injury, wrist pain, lunatomalacia, Kienbock disease, triangular fibrocartilage complex, TFCC, ulnar, ulnar variance, negative ulnar variance, positive ulnar variance, radial shortening, ulnar lengthening, lunate collapse, scaphoid rotation, lunate excision, scaphotrapeziotrapezoid, triscaphe, STT, STT fusion, STT arthrodesis, scaphocapitate, capitohamate, carpectomy, proximal row carpectomy, PRC, ulnar-negative variance, ulnar-positive variance

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Contributor Information and Disclosures

Author

Brian J Divelbiss, MD, Consulting Staff, Dickson-Diveley Midwest Orthopaedic Clinic, Inc, Kansas City Orthopaedic Institute
Brian J Divelbiss, MD is a member of the following medical societies: Alpha Omega Alpha and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Baratz, MD, Professor, Department of Orthopaedics, Drexel University College of Medicine; Residency Director, Department of Orthopaedics, Allegheny General Hospital; Consulting Staff, Allegheny Orthopaedic Associates
Mark E Baratz, MD is a member of the following medical societies: Allegheny County Medical Society, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Medical Editor

A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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