Kienbock’s Disease: Treatment Options – A Search for the Apt!

Abstract

Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients’ with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock’s disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.

Comminuted lunate fracture combined with distal radius fracture and scaphoid fracture: A case report

“…According to literatures, metacarpal longus muscle reconstruction or metal prosthesis reconstruction after lunate bone resection has achieved satisfactory results in the treatment of Kienbock’s disease. [12,13] Referring to the treatment of Kienbock’s disease, we finally chose PMMA reconstruction after lunate bone resection to treat the comminuted lunate bone fracture. Three months later, the wrist function was completely recovered, and there was no swelling or pain of the wrist in 1-year’s follow-up.…”

Recent Advances in Assessment and Treatment in Kienböck’s Disease

“…Overall, radial shortening osteotomy remains the most popular option regarding joint-leveling procedures [24]. This can be explained by the stronger scientific evidence favoring radial shortening and the occurrence of union-related complications associated with ulna lengthening [14,16,17,25]. For patients with positive/neutral ulnar variance, a capitate shortening osteotomy and radius wedge osteotomy are recommended options.…”

“…Furthermore, lunate unloading/decompressionoriented procedures are simpler and offer comparable results. At this stage the lunate is compromised, so the goal of the treatment should be set on lunate reconstruction via revascularization and/or unloading [14,25]. Of note, Patients in IIIA with negative ulnar variance benefit from joint leveling procedures similarly to patients in stage II [16].…”

“…Preventing progression [14] Usually nonoperative (immobilization with a splint or short arm cast for at least three months) [14,15] II With a negative ulnar variance Lunate unloading, decompression and revascularization [14] radial shortening osteotomy (selectively or with vascularized pisiform bone grafting) [16][17][18] or lunate core decompression [29,30] With a positive or neutral ulnar variance Lunate unloading, decompression and revascularization [14] capitate shortening osteotomy or radial closing wedge osteotomy [26,27] or lunate core decompression [29,30] And/or revascularization indirect: radial core decompression [33,34] or direct: VBG 4 + 5 ECA [37,38] III A Lunate reconstruction through lunate unloading and revascularization [14,25] With negative ulnar variance: radial shortening osteotomy [16][17][18] and/or revascularization indirect: radial core decompression [33,40] or direct: VBG 4 + 5 ECA [37,38] or Vascularized medial femoral trochlea graft (MFT) [41] With positive or neutral ulnar variance: radial closing wedge osteotomy [26] and/or revascularization indirect: radial core decompression [33,40] or direct: VBG 4 + 5 ECA [37,38] B Preventing carpal collapse [8] C Preventing carpal collapse [8] Choice according to a highly individualized approach among: -Scaphocapitate (SC) fusion [8] -Scaphotrapezio-trapezoid (STT) Fusion [42] -Radioscapholunate (RSL) arthrodesis…”

Arthroscopic Lunate Excision for Stage 3 Kienbock's Disease

“…[1][2][3][4][5] Management decisions are influenced by patient age, radiological stage, ulnar variance, patient demands, and surgeon preferences. 6 In general, the management of patients without lunate collapse or loss of carpal height ("early disease," corresponding to stage I or II on the modified Lichtman classification) errs toward lunate preservation. 6,7 In those with carpal collapse or arthritis (stage 3B onward, known…”