Year : 2017 | Volume
: 5 | Issue : 1 | Page : 12--15
Surgical interventions for Kienbock's disease: An update
Hisham AbdulAziz Alsanawi
Department of Orthopaedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Hisham AbdulAziz Alsanawi
Department of Orthopaedics, College of Medicine, King Saud University, Riyadh
Numerous surgical interventions have been reported for the treatment of Kienbock's disease. However, there is no consensus on the appropriate surgical interventions for the different stages of Kienbock's disease. The present review aims to evaluate and summarise the various surgical interventions and their outcomes in Kienbock's disease. Various electronic databases were searched to identify articles related to surgical interventions. Based on the stage of disease, various surgical options are available that can provide a successful outcome. These surgical procedures include proximal row carpectomy, total wrist arthrodesis, scapho-trapezio-trapezoid arthrodesis, excisional arthroplasty, vascularised bone grafting (VBG), radial shortening osteotomy, radial corrective osteotomy, capitate shortening osteotomy combined with or without VBG and tendon ball arthroplasty and are commonly utilised. Majority of surgical procedures had shown good results in selected patients with advanced Kienbock's disease. In this review, the surgical interventions at an early and late stage of Kienbock's disease will be discussed.
|How to cite this article:|
Alsanawi HA. Surgical interventions for Kienbock's disease: An update.J Health Spec 2017;5:12-15
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Alsanawi HA. Surgical interventions for Kienbock's disease: An update. J Health Spec [serial online] 2017 [cited 2020 Nov 29 ];5:12-15
Available from: https://www.thejhs.org/text.asp?2017/5/1/12/198799
Avascular necrosis of the lunate, also known as Kienbock's disease, results in wrist pain and disability in its early stage commonly affecting men in the age of 20 - 40 years. Advanced condition of the disease can lead to carpal collapse and degenerative joint disease of the wrist.,, Varieties of treatment options, ranging from nonsurgical treatment to surgical procedures, are available and chosen based on the severity of the conditions. However, there is no general agreement on the ideal treatment procedures for Kienbock's disease. Varieties of factors, including the Lichtman stage, absence or presence of arthritic changes and ulnar variance, are important to decide the treatment procedure. Lichtman classification is commonly used to stage Kienbock's disease. In Stage I, no visible changes or a simple linear fracture is seen on plain radiography, but the diagnostic changes are only seen on magnetic resonance imaging. In Stage II, sclerotic changes are seen in the lunate on plain radiographs of the wrist. Stage III is characterised by lunate collapse which is further sub-classified into A and B. In Stage III A, lunate collapse is evident but its alignment and height are maintained. In addition to lunate collapse in Stage III B, there is loss of carpal height, fixed scaphoid rotation – ring sign, and proximal migration of the capitate. In Stage IV, severe lunate collapse is evident as well as degenerative joint disease at mid-carpal joint, radio-carpal joint or both.
The surgical procedures are classified into three major categories. These categories include unloading the lunate, revascularisation of the lunate and salvage procedures. In a previous review, Kuschner et al., recommended a joint levelling procedure; however, they also reported high success rate of other procedures as well. Innes et al., in a systematic review, concluded that radial osteotomy and vascularised bone grafting lead to significant improvement of range of motion and grip strength in early-stage patients. Salvage procedures, such as proximal row carpectomy and wrist arthrodesis, are indicated for advanced stage disease (Lichtman Stages III B and IV) aiming to reduce pain and control symptoms.
Surgical Interventions in Early Stages (Lichtman Stages I, Ii and Iii-A)
Varieties of surgical procedures have been described for early stages of the disease. Ulnar variance is an important factor; thus, patients with Kienbock's disease may be divided into the following categories: Negative ulnar-variance, neutral ulnar-variance or positive ulnar-variance wrists. In the negative ulnar-variance wrists, joint-levelling procedures, either radial shortening osteotomy ,,,,,, or ulnar lengthening osteotomy,, have been reported to yield good results. In the positive and neutral ulnar-variance wrists, the capitate shortening with or without capitohamate arthrodesis  and radial wedge osteotomy  have yielded good results. Horii et al., and Viola et al., found a significant reduction in radiolunate load, following capitate shortening in Kienbock's disease.
Vascularised bone grafting procedures utilising vascularised distal radius graft,,,, pisiform ,, or free vascularised iliac bone graft  have been discussed in the literature. Previous studies recommended the combination of vascularised bone grafting with joint-levelling procedure for cases with negative ulnar-variance to achieve optimum results., Combined vascularised bone grafting and joint-levelling procedure have shown greater improvement of the radiographic appearance of the lunate as compared to a joint-levelling procedure alone. Daecke et al., reported the long-term significant effects of radial shortening along with vascularised pisiform bone grafting in cases with the negative ulnar-variance. In another study, Kakinoki et al., proposed short-term good results of capitate shortening combined with vascularised bone grafting in a few cases with positive ulnar-variance wrists. Furthermore, Waitayawinyu et al., showed the effectiveness of capitate shortening osteotomy combined with vascularised bone grafting in positive ulnar-variance cases. In addition, unloading procedures including external fixation, pinning of the scapho-trapezio-trapezoidal (STT) or scapho-capitate joints are recommended to minimise mechanical stresses on the lunate., Illarramendi et al., have investigated core decompression of the radius and ulna for Stages I to III A and they found good restoration of motion and relieve pain.
Surgical interventions in late-stage patients (Lichtman Stages III-B and IV)
Several surgical interventions have been described for late-stage patients. Previous studies have reported a significant clinical improvement after lunate resection,,, and others reported a significant improvement with radial osteotomy for late-stage patients.,, Tatebe et al., reported significant results of radial osteotomy in advanced stage of Kienbock's disease with displaced fracture of the lunate. The radial osteotomy reduced the load on the lunate by enhancing the lunate-covering ratio. As an extra-articular procedure, the radial osteotomy had minimal or no effect on the intra-articular structure and cartilage of the wrist. Furthermore, many studies reported significant improvement in long-term clinical outcomes of radial osteotomy in late-stage cases.,, With many vascular anastomoses around the radius, the radius osteotomy may induce enough hyperaemia to increase revascularisation of the lunate.,
Reconstructive procedures are also indicated at this stage to revascularise the affected necrotic lunate. In the literature, early and intermediate results of pronator quadratus bone flap, the vascularised os pisiform transfer  or the 4 + 5 extensor compartmental vascularised bone grafts have been reported. Arora et al., reported the long-term effects of free vascularised iliac bone grafting in Stage III Kienbock's disease. They found significant improvement in the average flexion–extension arc, wrist deviation arc, pain, grip strength, DASH score, Green and O'Brien score, average Stahl index and average Youm index.
The proximal row carpectomy (PRC) is a salvage procedure usually indicated in advanced stages. Croog and Stern found PRC a reliable and useful procedure in advanced cases of Kienbock's disease (Lichtman Stage III A or III B). However, they cautioned its uses in the cases of Stage IV due to the risk of early degeneration of symptomatic radiocapitate. DiDonna et al., investigated the long-term effect of PRC on clinical and radiological outcomes; they reported improved wrist motion, grip strength, high patient satisfaction and pain relief. Begley and Engber  reported improved wrist arc of motion from an average of 79° preoperatively to 90° postoperatively and gripped strength 72% of the contralateral side, following PRC procedure in stage III cases of Kienbock's disease. DeSmet et al., reported improved wrist arc of motion from an average of 67° preoperatively to 76° postoperatively and average grip strength 65% of the unaffected side, following PRC procedure in Stage III and IV cases of Kienbock's disease. The PRC and wrist arthrodesis are recommended for cases with Stage IV Kienbock's disease.
Lee et al., reported good recovery of function and pain relief following STT arthrodesis with lunate excision for advanced stage Kienbock disease. Sauerbier et al., reported significant recovery of functional wrist mobility, grip strength and pain relief after STT arthrodesis in patients with Stage III. Recently, Mir et al., reported significant recovery of functional abilities after lunate excision and replacement with pedicled vascularised scaphoid graft and partial radio-scaphoidal arthrodesis compared to the conventional procedures in advanced stage Kienbock disease. In addition, denervation procedure alone or in combination with other procedures can reduce symptoms in stage IV patients. Schweizer et al., reported subjective improvements in two-third of the patients and complete or substantial relief of pain in about one-half of the patients after complete wrist denervation.
Surgical interventions remain controversial in the treatment of Kienbock's disease. Recent surgical advancement such as local vascularised pedicle grafts from the distal radius and lunate excision and replacement with pedicle vascularised scaphoid graft and partial radio-scaphoidal arthrodesis has shown promising results to improve the symptoms. In long-term studies, the classical surgical procedures including radial shortening osteotomy and PRC have also shown optimal recovery of function in cases with advanced stage.
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