Kienbock's Disease

Introduction
Avascular necrosis of the lunate leading to abnormal carpal
motion
Epidemiology
incidence
most common in males between 20-40 years
old
risk factors
history of trauma
Pathophysiology
thought to be caused by multiple factors
biomechanical factors
ulnar negative variance 1
leads to increased radial-lunate contact stress
decreased radial inclination
repetitive trauma
anatomic factors
geometry of lunate
vascular supply to lunate
patterns of arterial blood supply have differential incidences of
AVN
disruption of venous outflow leading to increased intraosseous
pressure
Prognosis
progressive and potentially debilitating condition if unrecognized and untreated

Anatomy
Blood supply to lunate
3 variations
Y-pattern 2
X-pattern 3
I-pattern 4
31% of patients
postulated to be at the highest risk for avascular necrosis

2 3 4
1
Classification
 Lichtman Classification
Stage Description Treatment Image
Stage I No visible changes on Immobilization and NSAIDS 5
xray, changes seen on MRI
Stage II Sclerosis of lunate Joint leveling procedure (ulnar negative 6
patients)
Radial wedge osteotomy or STT
fusion (ulnar neutral patients)
Distal radius core decompression
Revascularization procedures
Stage IIIA Lunate collapse, no scaphoid Same as Stage II above 7
rotation
Stage IIIB Lunate collapse, fixed scaphoid Proximal row carpectomy, STT fusion, or 8
rotation SC fusion
Stage IV Degenerated adjacent intercarpal Wrist fusion, proximal row carpectomy, 9
joints or limited intercarpal fusion

5 7

8
9

Presentation
Symptoms
dorsal wrist pain
usually activity related
more often in dominant hand
Physical exam
inspection and palpation
+/- wrist swelling
often tender over radiocarpal joint
range of motion
 decreased flexion/extension arc
decreased grip strength

Imaging
Radiographs
recommended views
AP, lateral, oblique views of wrist
findings (see table above)
CT
most useful once lunate collapse has already occurred
best for showing
extent of necrosis
trabecular destruction 10
lunate geometry
MRI
best for diagnosing early disease
rule out ulnar impaction
findings
decreased T1 signal intensity 11,12
reduced vascularity of lunate

10
11 12
Treatment
Nonoperative
observation, immobilization, NSAIDS
indications
initial management for Stage 1 disease
outcomes
a majority of these patients will undergo further degeneration and
require operative management
Operative
temporary scaphotrapeziotrapezoidal pinning 13
indications
adolescent with radiographic evidence of Kienbock's and progressive wrist
pain
joint leveling procedure
indications
Stage I, II, IIIA disease with ulnar negative variance
initial operative managment
 technique
can be radial shortening osteotomy or ulnar lengthening
more evidence on radial shortening
radial wedge osteotomy
indications
Stage I, II, IIIA disease with ulnar positive or neutral variance
vascularized bone grafts
indications
Stage I, II, IIIA disease
outcomes
early results promising, but long-term data lacking
greatest success in Stage II patients
distal radius core decompression
indications
Stage I, II, IIIA disease
technique
creates a local vascular healing response
partial wrist fusions
STT
scaphocapitate
indications
Stage II disease with ulnar neutral or positive variance
Stage IIIA or IIIB disease
must address internal collapse pattern (DISI)

proximal row carpectomy (PRC)

indications
stage IIIB disease
stage IV disease
outcomes
some studies have shown superior results of STT fusion over PRC for stage
IIIB disease
wrist fusion
indications
stage IV disease
technique
must remove arthritic part of joint
total wrist arthroplasty
indications
Stage IV disease
outcomes
long-term results not available
 13 15
Techniques
Vascularized bone grafts
technique
many options have been described including
transfer of pisiform
transfer of distal radius on a vascularized pedicle of pronator
quadratus
transfers of branches of the first, second, or third dorsal metacarpal
arteries
4 + 5 extensor compartment artery (ECA) 14,15
temporary pinning of the STT joint, SC joint or external fixation may be used
to unload lunate after revascularization
Impact of surgical procedure on radiolunate contact stress
Operative Procedure % decrease on radiolunate contact stress
STT fusion 3%
Scaphocapitate fusion 12%
Capitohamate fusion 0%
Ulnar lengthening of 4mm 45%
Radial shortening of 4mm 45%
Capitate shortening and capitohamate fusion 66%, but 26% increase in radioscaphoid load

Complications
pending
 14

(OBQ11.112) Figures A through E depict various conditions affecting the pediatric hand and wrist.
For which of the depicted conditions is temporary scaphotrapeziotrapezoidal pinning most
indicated? Review Topic
FIGURES: A B C D E

A D
E

B C

1. A
2. B
3. C
4. D
5. E
PREFERRED RESPONSE 4
Temporary scaphotrapeziotrapezoidal (STT) pinning is indicated for treatment of Kienbocks disease
in adolescents as shown in Figure D. The radiograph shows increased density and slight lunate
collapse. The result is a decrease in radiolunate contact stress while increasing the load on the
radioscaphoid articulation. STT pinning is not indicated in any of the conditions explained below.

Ando et al retrospectively reviewed the results of six adolescents treated with temporary
scaphotrapezoidal (ST) pinning. All patients had an increase in wrist flexion/extension arc, strength,
and lunate intensity on MRI from their preoperative baseline.

Shigematsu et al published a case study on a single 11-year-old patient with wrist pain at rest and
with use who was treated with temporary scaphotrapeziotrapedoidal (STT) pinning and cast
immobilization for 8 weeks. Both wrist ROM and grip strength improved. Lunate revascularization
was also seen on subsequent MRI.

Incorrect Answers:
Answer 1,2,3: Radial clubhand, scaphoid fracture, and hypoplastic thumb are not treated with
temporary scaphotrapeziotrapezoidal pinning.
Answer 5: Gymnasts wrist is a distal radius physeal injury due to repetitive axial loading. Plain
films will show physeal widening and hazy irregularity. The condition is not treated with temporary
scaphotrapeziotrapezoidal pinning.

(OBQ11.144) A 39-year-old male presents with longstanding right wrist pain. He has failed
conservative measures including prolonged immobilization. His radiographs and MRI are seen in
figures A and B. Which of the following options is an accepted treatment option? Review Topic
FIGURES: A B

A B

1. Ulnar shortening osteotomy

2. TFCC repair
3. Radius core decompression
4. Arthroscopic lunate chondroplasty and debridement
5. Scapholunate ligament reconstruction

PREFERRED RESPONSE 3
The patient in the clinical scenario has Kienbock's disease. Treatment options include a joint
leveling procedure, or radius core decompression, which is thought to incite a local vascular healing
response in the lunate.

Sherman et al did a biomechanical study reviewing distal radius core decompression for Kienbock's
disease. Although the procedure has good clinical outcomes for this disease process, their findings
did not show any biomechanical explanation for these good outcomes.

Illarramendi et al reviewed results of curettage of the distal radius and ulna metaphyseal bone
through small cortical windows for the treatment of Kienbock's disease. They concluded that the
decompression procedure had good results without any complications. Most patients had
improvement in pain and were able to return to work.

Incorrect Answers:
Answer 1: Kienbock's disease is commonly associated with ulnar negative variance which is
thought to lead to increased forces on the lunate leading to this disease. Therefore a ulnar shortening
osteotomy would not be appropriate.
Answer 2,4,5: Are not treatment options for this disease process.

OBQ10.61) A 32-year-old carpenter complains of progressively worsening wrist pain for the last 2
months. He denies any recent history of trauma to the wrist or hand. An MRI is obtained and a
representative image is provided in Figure A. Which of the following surgical interventions is
thought to be effective for this condition by inciting a local vascular healing response? Review
Topic

FIGURES: A

1. Wrist fusion
2. Ulnar shortening osteotomy
3. Distal radius core decompression
4. Proximal row carpectomy
5. Scapholunate ligament reconstruction

PREFERRED RESPONSE 3
This clinical scenario and imaging studies are consistent with Kienbock's disease, avascular
necrosis of the lunate, in the pre-collapse stage. Core decompression of the distal radius is an
accepted treatment for Kienbock's disease. The procedure creates a local vascular healing response
facilitating vascular recovery prior to collapse and degeneration of the lunate. Other acceptable
interventions include revascularization with a pedicled graft and joint leveling procedures such as a
radial shortening osteotomy. The radial shortening osteotomy is ideal for patients with negative
ulnar variance who experience greater loads through the radiolunate fossa.

Sherman et al performed a cadaveric study demonstrating minimal change in the distribution of

force between the radiocarpal fossa and ulnocarpal fossa following core decompression of the distal
radius.

Illarramendi et al reviewed 22 cases of Kienbock's treated with radial and ulnar metaphyseal core
decompression. No surgical complications occurred, and 20 of 22 reported satisfactory clinical
outcomes while one patient developed intercarpal arthritis.

Incorrect Answers:
1. Proximal row carpectomy and wrist fusion would be options for the collapsed and degenerative
lunate.
2. Ulnar shortening osteotomy and scapholunate ligament reconstruction are incorrect as they do not
address the pathology of Kienbock's.
4. Proximal row carpectomy and wrist fusion would be options for the collapsed and degenerative
lunate.
5. Ulnar shortening osteotomy and scapholunate ligament reconstruction are incorrect as they do not
address the pathology of Kienbock's.
(OBQ10.74) A 30-year-old female undergoes arthroscopy for a chronically painful right wrist that
failed to improve with 4 months of immobilization and NSAIDS. Her clinical examination revealed
point tenderness dorsally over the lunate but no tenderness elsewhere in the wrist. A picture from
the procedure is shown in Figure A where 'R' identifies the distal radius, 'L' the lunate, and '*'
represents a chondral flap. The articular surface of the lunate is stable to probing. A radiograph and
MRI image of the patients wrist are shown in Figures B and C respectively. What is the most
appropriate next step in treatment? Review Topic
FIGURES: A B C

A
B C

1. Continue Immobilization and NSAIDS

2. Radial shortening osteotomy
3. Proximal row carpectomy
4. Scaphotrapeziotrapezoid fusion
5. Wrist fusion

PREFERRED RESPONSE 2
The patients clinical presentation and radiographs are consistent with Stage 2 Kienbock's disease in
the setting of negative ulnar variance. Radial shortening osteotomy is the most appropriate
treatment option listed for Stage 2 disease which is defined as lunate sclerosis without significant
collapse. Shortening osteotomy can alter DRUJ contact pressures leading to remodeling, especially
in the presence of a Tolat Type II DRUJ, such as that shown in the radiographs. However, this
remodeling has been shown to occur without the development of arthritis, and therefore is not a
contraindication to this procedure.

This patients radiographs shows some slight sclerosis of the lunate and negative ulnar variance, and
the MRI shows diffuse edema and early osteonecrosis of the lunate. The arthroscopic image shows
a cartilage flap with a stable base left on the lunate. Based on these images, the patient has Stage 2
disease and should be treated with a joint leveling procedure; or radial shortening osteotomy in this
case.

Sltusky et al provide a review article which focuses on the methodology behind a normal
arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures
along with the expected outcomes.

Bain et al review the arthroscopic staging of Kienbock's disease, and state that this techinique is a
valuable assessment tool which allows for not only classification of Kienbock's disease, but also
may guide treatment.

Schuind et al. provide a review of the pathogenesis of Kienbock's. They conclude that the natural
history of the condition is not well known, and the symptoms do not correlate well with the changes
in shape of the lunate and the degree of carpal collapse. They also state that there is no strong
evidence to support any particular form of treatment.
Illustration A shows a table which outlines the Stages of Kienbock's Disease.

Illustration B shows a table which outlines the general treatment options for each stage of
Kienbock's Disease.

Incorrect Answers:
Answer 1: Immobilization and NSAIDS is indicated in Stage I disease or as a first line of treatment
for Stage 2, which this patient has failed.
Answer 3: Proximal row carpectomy is indicated in Stage 3B.
Answer 4: STT Fusion is indicated in Stage 3B.
Answer 5: Wrist fusion is indicated in Stage 4.

Illustrations: A B

B
 (OBQ07.244) A 37-year-old man has a 2-year history of increasing right wrist pain that is worse at
night and aggravated by activity. He denies systemic symptoms, history of trauma, or recent weight
loss. On physical exam he has tenderness over the dorsal radiocarpal joint. Radiographs of the right
wrist are shown in Figure A. Which of the following imaging studies would be most sensitive for
determining the stage of this patient's underlying condition? Review Topic

FIGURES: A

1. Ultrasound
2. Angiography
3. CT scan of the wrist
4. Clenched fist AP radiograph of wrist
5. Bone scan of the wrist

PREFERRED RESPONSE 3
The clinical presentation of dorsal radiocarpal wrist pain is suggestive of Kienbocks disease. Figure
A shows an AP radiograph of the right wrist with evidence of lunate sclerosis with no obvious
collapse. The imaging study most sensitive for identifying early lunate collapse in Kienbock's
disease is CT scanning of the wrist.

Kienbocks disease is defined by avascular necrosis of the lunate. It is classified into 4 stages under
the Lichtman Classification. In stage 1, plain radiographs appear normal and magnetic resonance
imaging is required for diagnosis. MRI is useful for detecting early disease when sclerosis is not
evident on plain film radiographs. In stage 2, plain radiographs and/or CT scan images will show
sclerosis of the lunate but no evidence of collapse. In stage 3, radiographs and/or CT scan images
will show lunate collapse. For stage 4, radiographs show degenerative changes to the adjacent
carpus and intercarpal joints.

Imaeda et al. examined the use of MRI for the diagnosis and staging of Kienbock's disease. They
found that MRI was most sensitive in detecting early focal loss of signal intensity in the lunate on
T1-weighted images. This was a key diagnostic feature in early stages of Kienbck's disease when
plain radiographs appear normal.

Cross et al. reviewed the latest concepts for diagnosis, staging, and management of Keinbock's
disease. They suggest that computed tomography (CT) or tomography will better characterize
lunate necrosis and trabecular destruction once collapse or sclerosis has occurred in late stage
disease.

Illustration A is a collection of CT scanning images that show osteonecrosis of the lunate. The blue
arrow shows lunate flattening and sclerosis. The red double arrow shows a loss of lunate height and
the yellow shows fragmentation of the bone.

Incorrect Answers:
Answer 1: Ultrasound is not used in the staging of Kienbock's disease.
Answer 3: Angiography would not be warranted in this scenario.
Answer 4: A clenched fist AP radiograph of the wrist is used to evaluate widening of the
scapholunate interval.
Answer 5: A bone scan of the wrist is a non-specific test, which would likely be positive in almost
all patients with chronic wrist pain.

Illustrations: A