eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Kienbock Disease: Treatment

Author: Brian J Divelbiss, MD, Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City
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: Jan 28, 2010

Treatment

Medical Therapy

The primary methods of nonoperative treatment are immobilization and anti-inflammatory medications. As noted previously, the natural history of Kienböck disease is not well determined. Therefore, treatment is primarily directed by the level of symptoms. Certainly, a very young patient, although an unusual presentation of Kienböck disease, should be given an adequate trial of immobilization in hopes of allowing revascularization of the lunate and preventing disease progression.

Surgical Therapy

A number of options are available for surgical management of Kienböck disease. The 2 most important pieces of information are the stage of the disease and the presence or absence of ulnar variance.

Directly comparing the results of different techniques is difficult because most studies have a fairly small number of patients and short follow-up. However, review of the literature reveals that many of the techniques result in very similar rates of good outcomes.

Operative treatment can be classified broadly into 6 categories, as follows:

  • Lunate excision with or without replacement
  • Joint-leveling procedures
  • Intercarpal fusions
  • Revascularization
  • Salvage procedures
  • Others

Lunate excision with or without replacement

  • Simple lunate excision
  • Excision with soft-tissue (fascial or palmaris longus tendon graft) replacement
  • Silicone replacement arthroplasty

Joint-leveling procedures

Radial shortening and ulnar lengthening are the 2 options to level the joint. The goal is to produce a wrist with neutral ulnar variance, although correction should probably not exceed 4 mm, because nearly all strain reduction occurs in the first 2 mm of correction. Strains at the lunate can be reduced by 70% with an appropriate radial shortening or ulnar lengthening. Currently, radial shortening with a volar distal radius locking plate is preferred over ulnar lengthening because there is a lower complication rate with the volar-shortening procedure and because the 2 procedures have shown similarly good outcomes. In patients with neutral or positive ulnar variance, shortening the radius is contraindicated. In this clinical situation, radial wedge osteotomies designed to decrease the radial inclination have been proposed.6,7

Intercarpal fusions

Various intercarpal fusions for the treatment of Kienböck disease have been reported. The goal is to reduce lunate strain and, in procedures that involve the scaphoid, to correct and maintain proper scaphoid position.

Of the limited intercarpal fusions reported, the greatest experience has been with scaphotrapeziotrapezoid (STT) (triscaphe) fusion. STT arthrodesis does decrease lunate strain but merely by shifting it to the radioscaphoid joint. STT fusion in a cadaver model was found to provide strain reduction similar to that of joint-leveling procedures but with greater loss of motion. The use of STT fusion has waned in recent years because of complications and longer-term follow-up that has revealed decreased success rates.

Several authors have reported scaphocapitate (SC) fusion. Biomechanically, this fusion has been shown to reduce strain at the radiolunate joint by about 10%. Some authors prefer this fusion because it requires only one fusion site and is technically easier to perform.

Finally, capitohamate fusion has been reported in a study with a short follow-up. However, this fusion alone has been shown to be biomechanically ineffective in reducing lunate strain. If this fusion is combined with capitate shortening, significant reductions of load across the radiolunate and SC joints have been noted. This load reduction is offset by large force increases at the ulnotriquetral, triquetrohamate, and scaphotrapezial joints. This method also does not address the scaphoid rotation that occurs with stage IIIb disease.

At the present time, intercarpal fusions are more likely to be reserved for patients with neutral or positive ulnar variance in whom a joint-leveling procedure is contraindicated.

Revascularization

In the late 1970s, Hori presented his initial work on the use of a vascular pedicle directly implanted into the lunate. Nearly all of his patients showed improvement in their pain at later follow-up. Currently, most revascularizations use vascularized bone pedicles.8,9,10 There are several sources for the pedicles, including the distal radius,11 pisiform,12 and pronator quadratus (Braun). Results with the use of pedicled distal radius grafts have shown improved grip strengths and progressive MRI evidence of revascularization over an 18- to 36-month period.13 Revascularization techniques may also be combined with other previously mentioned approaches. Revascularization is especially attractive for the young patient with ulnar-neutral or -positive variance in whom a radial shortening is not an option and in a patient who wishes to avoid an intercarpal fusion and resultant loss of motion.

Salvage procedures

Salvage procedures are reserved for later stages of disease and for failures of other treatments. Proximal row carpectomy (PRC) has been shown to provide relatively good results for Kienböck disease, as well as for other wrist problems.14 Wrist arthrodesis is the final option for patients with global wrist degeneration. Arthrodesis can be achieved successfully following a failed PRC.

Other procedures

Possible other procedures include the following:

  • Cancellous bone grafting plus external fixation
  • Arthroscopic debridement
  • Wrist denervation
  • Metaphyseal decompression

A reasonable approach to determining the surgical treatment of Kienböck disease based on stage is as follows:

  • Stage 0, I, II, or IIIa with ulnar-negative variance – Radial shortening, revascularization, denervation
  • Stage 0, I, II, or IIIa with ulnar-neutral or positive variance – Revascularization, coracohumeral (CH) fusion with capitate shortening, distal radius wedge osteotomy, denervation
  • Stage IIIb – SC fusion, radial shortening, denervation
  • Stage IV – PRC, total wrist arthrodesis, denervation

More on Kienbock Disease

Overview: Kienbock Disease
Workup: Kienbock Disease
Treatment: Kienbock Disease
Follow-up: Kienbock Disease
References
Further Reading
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References

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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, Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City
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: eMedicine Salary Employment

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
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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