Treatments for Kienböck disease: what the radiologist needs to know

Abstract

The etiology of Kienböck disease, or avascular necrosis of the lunate, is controversial, and there are a myriad of treatments aimed at correcting the various hypothesized pathologies. Interventions to reduce mechanical stress on the lunate have been used for decades, including radial osteotomy with or without radial shortening, ulnar lengthening and metaphyseal core decompression procedures. However, these procedures require preservation of lunate architecture. Newer procedures to revascularize the lunate bone have emerged in the last 10 years, such as pedicled corticoperiosteal vascularized bone grafting. Once there is collapse of the radiocarpal joint or midcarpal arthrosis, the conventional treatments have included proximal row carpectomy and complete or partial wrist joint arthrodesis. Newer salvage procedures such as lunate excision with autologous or synthetic interposition grafts are now being used when possible. As this disease is relatively rare, radiologists may not be familiar with the expected post-operative radiologic findings and complications, especially of the newer treatments. The goals of this paper are to review the available treatment options and their expected appearance on postoperative imaging, with discussion of possible complications when appropriate.

Recent Advances in Assessment and Treatment in Kienböck’s Disease

“…At this stage the lunate is often intensively enhanced after contrast application, reflecting bone marrow edema [5]. In Stage II, radiographs show increased lunate density and diffused sclerosis, however, the wrist's architecture is not compromised [5,8]. In Stage III the lunate collapses.…”

“…In stage I, the lunate maintains normal architecture and density, yielding normal plain radiographs [7]. However, on T1-weighted MR images, the signal is slightly decreased [5,12]. At this stage the lunate is often intensively enhanced after contrast application, reflecting bone marrow edema [5].…”

“…In Stage III the lunate collapses. In this stage hyperintensity of the lunate marrow can be seen on fluid-sensitive T2-weighted images [5]. In 1993, stage III was divided into two stages: 3A and 3B, and it was further modified in 2010 with the addition of stage 3C [5].…”

“…Kienböck's disease is classified as rare and its prevalence is about 7 per 100,000 [3,4]. Kienböck's disease shows male predominance, with a peak incidence in patients aged 20-40 years [5]. Repetitive manual labor was reported as a risk factor but currently is recognized as a factor aggravating symptoms of an already established disease [6].…”

“…Usually one hand is affected; only 4% of cases of the disease are bilateral. It is known that there is an association between Kienböck's disease and type 1 diabetes mellitus, systemic lupus erythematosus, and Legg-Calve-Perthes disease [5]. On examination, painful swelling on the dorsal side of the lunate can be observed.…”