Discover the Latest Techniques for Managing Kienbock's Disease: Vascularized Bone Grafts and More

Table of Contents:

1. Introduction

2. Epidemiology

• most common in males between 20-40 years old
• Risk factors: history of trauma

3. Etiology and Pathophysiology

• thought to be caused by multiple factors

4. Anatomy and Blood Supply to Lunate

• three variations: Y-pattern, X-pattern, and I-pattern

5. Classification (Lichtman)

Stage	Description	Treatment
I		No visible changes on x-ray, changes seen on MRI. Immobilization and NSAIDS.
II		Sclerosis of lunate. Joint leveling procedure (ulnar negative patients). Radial wedge osteotomy or STT fusion (ulnar neutral patients). Distal radius core decompression. Revascularization procedures.
IIIA		Lunate collapse, no scaphoid rotation. Same as Stage II with the addition of vascularized bone grafts.
IIIB		Lunate collapse, fixed scaphoid rotation. Proximal row carpectomy, STT fusion, or SC fusion.
IV		Degenerated adjacent intercarpal joints. Wrist fusion, proximal row carpectomy, or limited intercarpal fusion.

6. Clinical Presentation

• Symptoms: dorsal wrist pain
• Physical exam: inspection and palpation

7. Imaging

• Wrist radiographs recommended views: AP, lateral, oblique views of wrist
• CT: most useful once lunate collapse has already occurred
• MRI: best for diagnosing early disease

8. Treatment

• Nonoperative treatment: observation, immobilization, NSAIDS
• Operative treatment: depends on severity and symptoms

9. Techniques

• Vascularized bone grafts
• Impact of surgical procedure on radiolunate contact stress

Ulnar Variance Diagram

Ulnar
Radius
History
Incidence
Risk Factors
Ulnar Negative Variance
Repetitive Trauma
Diagnosis
Treatment
Adolescent Patients
Radial Shortening Osteotomy
Wrist Fusion
Prognosis
Kienbock's Disease is the avascular necrosis of the lunate, leading to wrist pain and abnormal carpal motion.
Incidence is highest in males between 20-40 years old.
Risk factors include a history of trauma.
Ulnar negative variance and decreased radial inclination increase radial-lunate contact stress, leading to the disease.
Repetitive trauma and anatomic factors such as lunate geometry and vascular supply also play a role in the development of Kienbock's Disease.
Diagnosis can be made with wrist radiographs, but MRI may be needed for early disease detection.
Minimally symptomatic patients may be treated with NSAIDs and observation. Operative procedures may be considered depending on the severity of the disease and patient's symptoms.
Patients with adolescent radiographic evidence of Kienbock's and progressive wrist pain are candidates for temporary pinning.
Stage I, II, and IIIA disease with ulnar negative variance may be treated with radial shortening osteotomy or ulnar lengthening.
Wrist fusion or total wrist arthroplasty may be necessary for Stage IV disease.
If unrecognized and untreated, Kienbock's Disease can progress and become debilitating.