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Kienbock disease ( an overall View ). Mohamad Othman , MD 4-10 - 2012. Definition & history. - KD ( or lunatomalacia ) is an idioopathic AVN of carpal lunate which may lead to collapse of the bone and arthritis in the advanced stage.

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slide2

Kienbock disease

( an overall View )

Mohamad Othman , MD

4-10- 2012

slide3

Definition & history

- KD ( or lunatomalacia ) is an idioopathic AVN of carpal lunate which may lead to collapse of the bone and arthritis in the advanced stage

- first described in 1843 by Peste in cadaver dissections.

- Robert Kienbock ( 1910) , a radiologist, described the x-ray changes associated w KD.

slide4

Epidemiology

  • 15 and 40 years
  • dominant wrist of men engaged in manual labor

Natural history of KD remains unclear & un-predictable

slide5

Aetiology :

- unknown ; theories :

Fault plate hypothesis:

Intrinsic ( lunate) & extrinsic factors ----- elastic deformation of trabeculae 2ry to loading ----- fault plates ---- wall off & interfere w capillary bl. Flow ----- AVN

- repetitive microtrauma in the lunate at risk ( predisposed lunate ) ;

slide6

Extrinsic factors:

  • capitate
  • - lunate loading
  • - ulnar variance :
  • ulnar-negative variant wrist is common association ( Hulten, 1928).
  • ulnar-positive variant
  • - load type
  • - instability
slide7

Intrinsic factors:

- shape of lunate

- trabecular pattern

- cortical load

- lunate vascular anatomy

slide8

Staging

( Modified Lichtman Classification )

  • Stage I: Radiographicallynormallunate or with small fracture lines
  • Stage II: Sclerosis of lunate
  • Stage III A: Collapse or fragmentation of lunate
  • Stage IIIB: Lunate collapse with carpal malalignmentie; proximal migration of capitate (carpal height ratio <0.54 ± 0.03) and fixed hyperflexed rotation of scaphoid( DISI)[radioscaphoid angle > 60]
  • Stage IV: Generalized wrist arthrosis
slide9

Stage-I

Stage-II

Stage-III

Stage-IV

slide10

Clinical picture

- Complaint may precede XR changes

- Varies according to stage

- Pain. Tenderness ,swelling, clunk w deviation, dec ROM , weak grip

Investigations

- Plain XR : views….. Measurements…. Staging.

- CT

- Scintigraphy

- MRI : earliest diagnosis : uniform low signal in T1

slide12

Stahl index:

Normally;B/A= 50%

Carpal height ratio

slide15

Differential diagnosis:

- ulnar impaction synd. ( MRI)

- DRUJ arthritis

- LunateFx , intraoss ganglion, enchondroma.

slide16

Treatment

Objectives: (a) precollapse (b) postcollapse

  • Methods:
  • Established methods:
  • Direct vascularization
  • Indirect vascularization ( unloading procedures):
  • joint-levelling procedures
  • limited carpal fusions
  • Salvage procedures:
  • PRC
  • wrist arthrodesis
  • Optional & controversial methods:
  • - conservative
  • Lunateexcision ± replacement ( PL tendon ball , silicon, titanium)
  • - Core decompression of distal metaphysis of R & U
  • - Temporary ST pinning ; 3-6 mo . Stage III
  • - External fixation
  • - RSO in stage IIIB
  • - RO + VBG in stage III
  • - Wrist denervation; stage IV
  • - Arthroscopic debridement
slide17

Treatment Algorithm

Stage I:

Controversial ; not completely-unload lunate.

Choice in transient ischemia. After 3 mo, aggressive management as stage II

Stage I, II, or IIIA with Ulnar-Negative Variance :

(1) Lunate unloading by joint-leveling procedures ( RS > UL) or

(2) Lunate revascularization by VBG

Stage I, II, or IIIA with Ulnar-Positive or Ulnar-Neutral Variance :

(1) unloading by Capitate shortening ± capitate-hamate fusion or radius ost.

(2) VBG ( ± STT-pinning)

slide18

Treatment Algorithm ( cont.)

Stage IIIB :

-intercarpal fusions (STT and SC )

- Proximal row carpectomy ( PRC)

-RSO

-Lunate excision

Stage IV :

- conservative

- Proximal row carpectomy

- wrist fusion-

slide19

Radial shortening osteotomy

  • Approach ; volar > dorsal
  • 2-3mm ( not > 4mm ; UC impaction )
  • Meaphyseal / meta-diaphyseal
  • Not decrease ROM
  • Not in ulna positive wrist
slide21

Distal radius wedge osteotomy

- Stage II or III w ulna-neutral or positive wrist

- Lateral closing wedge osteotomy: decrease RU-inclination thus shifting press from lunate

- Medial closing osteotomy or lat opening wedge o

- Step- cut osteotomy

slide22

Capitate shortening osteotomy

CSO + capito-hamate fusion

slide23

VBG

  • Sources:
  • - Base of 2nd or 3rd metacarpal
  • Neck of 2ndmeatacarpal
  • 1,2 ICSRA
  • - 2,3 ICSRA
  • - 4th or 5th CA
  • - Hori technique
  • - Pisiform
  • PQ
  • + unloading procedure:
  • - external fixator or
  • - temporary STT-pinning or
  • - radius osteotomy
slide25

2,3 ICSRA VBG

1,2 ICSRA VBG

slide28

Limited carpal fusion

  • - Objective : redistribute stresses away from lunate
  • - Correct scaphoidmalrotation 1st
  • - SC / STT
  • Decreases ROM
  • Excise lunate; only if fragmented w marked synovitis
slide29

Temporary STT-pinning

Triscaphe (STT) fusion

SC- fusion

slide30

Prox raw carpectomy

Total wrist fusion

slide31

Incisions for wrist denervation

Core decompression of distal metaphysis of R & U

slide32

وشكرا

THANK YOU

والسلام عليكم ورحمة الله وبركاته