Kienböck's Disease Research Articles

Radiography versus computed tomography for osseous staging of Kienböck's disease.

This retrospective study compared the diagnostic accuracy of conventional radiography (CR) and computed tomography (CT) in classifying Kienböck's disease (KD) according to Lichtman staging. Besides age, cartilage condition and vascularity, bone morphology is important in choosing the most appropriate treatment in KD. In 278 patients, two musculoskeletal radiologists performed a consensus reading of 281 lunate necroses according to the Lichtman classification, based on CR and CT. Stage IIIc was most common in CR (43%) and CT (61%), followed by stage IIIa for CR (25%) and stage IV for CT (15%). In 67%, KD was classified as the same in both modalities. The KD stage had to be upgraded in CT in 34% of cases, notably with stage IIIa progressing to IIIc in 24 out of 69 patients and stage IIIb to IIIc in 23 out of 38 cases. Overall, the Lichtman score was significantly higher on CT. The findings suggest that CT is better than CR in accurately determining the stage of KD stage, indicating a potential shift towards more surgical salvage procedures.Level of evidence: III.

Clinical-functional evaluation of a patient undergoing proximal row carpectomy for Kienböck's disease: A literature review and a case report

BackgroundProximal row carpectomy (PRC) is often recommended for advanced-stage Kienböck's disease (KD), although there is no standardized treatment protocol. This study aimed to evaluate the efficacy of the PRC in managing KD. MethodsA literature review and a clinical case study were conducted on a 40-year-old male with stage 3 KD. ResultsPostsurgery, the patient reported mild discomfort but significant functional improvement, with the Disabilities of the Arm, Shoulder, and Hand (DASH) score decreasing from 87 to 44. Observations included reduced pain, enhanced wrist trophism, and an expanded range of motion. ConclusionsThe PRC demonstrated positive outcomes, including symptom alleviation and functional restoration, supporting its viability as a tailored surgical intervention for KD, improving quality of life and reducing hospital stay.

Simplifying the Decision-Making Process in the Treatment of Kienböck's Disease.

Background In recent years, the classification and treatment algorithm for adult Kienböck's disease (KD) has expanded. However, the priority of the investigations done in determining its management has not been discussed, as not every patient with KD requires magnetic resonance imaging (MRI) or wrist arthroscopy. Materials and Methods We discuss the role of these investigations and emphasize the importance of computed tomography (CT) imaging in evaluating the cortical integrity of the lunate and its role in the decision-making process and management of KD. Results We put forward an investigative algorithm that places into context the investigative roles of MRI, arthroscopy, and CT. Conclusion KD is a rare condition, and there is a lack of comparative studies to help us choose the preferred treatment. The decision on the management options in adult KD may be made by determining the integrity of the lunate cortex and deciding whether the lunate is salvageable or not by CT scan. MRI may provide useful information on the vascular status if the lunate cortex is intact, and the lunate is salvageable. If the lunate is fragmented, it is not salvageable, and MRI does not provide useful information. Arthroscopy has a role in selective cases.

The Pathoanatomy and Biomechanics of Kienböck Disease

Kienböck disease (KD) involves osseous, vascular, and chondral aspects of the lunate and wrist. We present our theories on the etiology and pathogenesis of the condition based on basic science models, seminal literature, personal case experience, and kinematic observations of the Kienböck wrist. Three phenotypes of Kienböck disease occur, and each tends to have different morphology, rates of progression, and disease pattern. The lunate fracture in KD is well-recognized but different fracture types can occur. Dynamic assessment of the Kienböck wrist allows assessment of the complex kinematics of KD. Disease onset and progression require a "perfect storm" of risk factors.

Outcomes of Arthroscopic Lunate Core Decompression Versus Radial Osteotomy in Treatment of Kienböck Disease

The purpose of the study was to evaluate the functional and radiographic outcomes of arthroscopic lunate decompression versus radial osteotomy in the treatment of Kienböck disease (KD). In a prospective cohort design, we enrolled 82 patients with KD with Lichtman stages I to IIIb. Participants assigned themselves to groups by choosing either arthroscopic lunate core decompression and synovectomy (group A; n= 54) or radial osteotomy (group B; n= 28). For radial osteotomy, a distal radius volar approach was used and a shortening osteotomy (in negative and neutral ulnar variance) or lateral closing wedge osteotomy (in positive ulnar variance) was performed. Arthroscopic lunate core decompression was performed under direct visualization from the 3-4 portal using a shaver (through the 6R portal) and a cutting burr (through the trans-4 portal). The shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, visual analog scale (VAS) score for pain, wrist passive flexion/extension, grip strength, and radiographic assessments (Lichtman classification, radioscaphoid angle, carpal height ratio) were recorded before surgery and at the final follow-up. Sixty-four patients were included in the final analysis (44 in group A and 20 in group B). The mean ages of participants were 33 ± 11 years in group A and 31 ± 8 years in group B. The mean follow-up periods were 44 ± 20 months in group A and 37 ± 23 months in group B. The QuickDASH score, VAS score, and passive wrist movements significantly improved in both groups. Grip strength showed a significant increase in group A only. The postoperative functional analysis between the 2 groups showed no significant difference, except for the wrist passive extension, which was higher in group A. Lichtman staging remained the same in 79.5% and 73.6% of patients in groups A and B, respectively. An arthroscopic lunate core decompression and wrist synovectomy has comparable midterm results to radial shortening osteotomy in the treatment of KD. Therapeutic II.

Medium-term clinical and radiological results of surgically treated stage 3A Kienböck’s disease

The purpose of this study was to compare the methods of distal radial shortening osteotomy (RSO), lateral closing distal radial wedge osteotomy (RWO), and scaphotrapeziotrapezoid (STT) fusion in the treatment of stage 3A Kienböck's disease (KD). The research was planned as a single-center and retrospective study for the period 2008–2018. Patients were allocated to three groups according to surgical method: group 1, patients with negative ulnar variance, undergoing RSO; group 2, patients with non-negative (neutral or positive) ulnar variance, undergoing RWO; and group 3, patients with non-negative ulnar variance, undergoing STT fusion. Radiological measurements were compared: pre- and postoperative Stahl index, radioscaphoid angle, and carpal height ratio. Clinical comparison used QuickDASH and modified Mayo wrist scores. Fifty-one patients, with a mean age of 34 ± 12 years (range; 16–69 years), were included. Mean follow-up was 4.47 ± 1.8 (range 2–9) years. No statistically significant difference was observed between the groups in terms of change in carpal height ratio or Stahl index (respectively; P = 0.08, P = 0.065). A significant difference was observed in change in radioscaphoid angle between patients undergoing STT fusion versus RWO (P < 0.05). There was no statistically significant difference in postoperative functional scores between groups, and similar postoperative functional scores were achieved with STT fusion and with RWO in the surgical treatment of stage 3A KD with positive or neutral ulnar variance. Good medium-term radiological and clinical results were obtained with RSO in patients with stage 3A KD with negative ulnar variance.

Vascularized Capitate Transposition for the Treatment of Stage IIIB Kienböck Disease

The treatment of Kienböck disease (KD) continues to be controversial. In this study, we report the long-term follow-up outcomes of patients who were diagnosed with stage IIIB KD treated with vascularized capitate transposition. A total of 16 patients were retrospectively reviewed. Baseline clinical information was extracted from medical records, and wrist function was clinically evaluated, including x-ray images. At the final follow-up, wrist pain was severe in 0 patients, moderate in 2 patients, mild in 5 patients, and absent in 9 patients. The mean postoperative active flexion and extension of the affected wrist was significantly improved after surgery compared with before surgery. The postoperative and preoperative mean grip strength was 35 kg and 27 kg, respectively. The Disabilities of the Arm, Shoulder, and Hand score was significantly improved after surgery compared with before surgery. Vascularized capitate transposition for the treatment of Lichtman stage IIIB KD is feasible and associated with improvements in wrist function and pain. Therapeutic IV.

Varisized 3D-Printed Lunate for Kienböck's Disease in Different Stages: Preliminary Results.

ObjectiveTo evaluate the feasibility of arthroplasty with varisized three‐dimensional(3D) printing lunate prosthesis for the treatment of advanced Kienböck's disease (KD).MethodsFrom 2016 November to 2018 September, a retrospective study was performed for the patients of KD in our hospital. Five patients (two males, three females) were included in this study. The mean age of the patients at the time of surgery was 51.6 years (range, 37–64 years). Varisized prosthesis identical to the live model in a ratio of 1:0.85, 1:1, and 1:1.1 were fabricated by 3D printing. All patients (one in Lichtman IIIA stage, two in Lichtman IIIB stage, one in Lichtman IIIC stage, and one in Lichtman IV stage) were treated with lunate excision and 3D printing prosthetic arthroplasty. Visual analog scale score (VAS), the active movement of wrist (extension, flexion) and strength were assessed preoperatively and postoperatively. The Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) Score, and patient's satisfaction were evaluated during the follow‐up.ResultsProsthesis identical to the live model in a ratio of 1:0.85 or 1:1 were chosen for arthroplasty. The mean operation time (range, 45 to 56 min) was 51.8 ± 4.44 min. Follow‐up time ranged from 11 months to 33 months with the mean value of 19.4 months. The mean extension range of the wrist significantly increased from preoperative 44° ± 9.6° to postoperative 60° ± 3.5° (P < 0.05). The mean flexion range of the wrist significantly increased from preoperative 40° ± 10.6° to postoperative 51° ± 6.5° (P < 0.05). The active movement of wrist and strength were improved significantly in all patients. VAS was significantly reduced from 7.3 preoperatively to 0.2 at the follow‐up visit (P < 0.05). The mean DASH score was 10 (range, 7.2–14.2), and the mean MMWS was 79 (range, 70–90). There were no incision infection. All patients were satisfied with the treatment.ConclusionsFor patients suffering advanced Kienböck's disease, lunate excision followed by 3D printing prosthetic arthroplasty can reconstruct the anatomical structure of the carpal tunnel, alleviate pain, and improve wrist movement.

Evaluation for Kienböck Disease Familial Clustering: A Population-Based Cohort Study

Kienböck disease (KD) is rare and its etiology remains unknown. As a result, the ideal treatment is also in question. Our primary purpose was to test the hypothesis that KD would demonstrate familial clustering in a large statewide population with comprehensive genealogical records, possibly suggesting a genetic etiologic contribution. Our secondary purpose was to evaluate for associations between KD and known risk factors for avascular necrosis. Patients diagnosed with KD were identified by searching medical records from a comprehensive statewide database, the Utah Population Database. This database contains pedigrees dating back to the early 1800s, which are linked to 31 million medical records for 11 million patients from 1996 to the present. Affected individuals were then mapped to pedigrees to identify high-risk families with an increased incidence of KD relative to control pedigrees. The magnitude of familial risk of KD in related individuals was calculated using Cox regression models. Association of risk factors related to KD was analyzed using conditional logistic regression. We identified 394 affected individuals linked to 194 unrelated high-risk pedigrees with increased incidence of KD. The relative risk of developing KD was significantly elevated in first-degree relatives. There was a significant correlation between alcohol, glucocorticoid, and tobacco use and a history of diabetes, and the diagnosis of KD. Familial clustering of KD observed in the Utah Population Database cohort indicates a potential genetic contribution to the etiology of the disease. Identification of causal gene variants in these high-risk families may provide insight into the genes and pathways that contribute to the onset and progression of KD. This study suggests that there is a potential genetic contribution to the etiologyof KD and that the disease has a significant association with several risk factors.

Kienböck Disease: Quality, Accuracy, and Readability of Online Information.

Background: Patients with limited health literacy require online educational materials to be written below a sixth grade level for optimal understanding. We assessed the quality, accuracy, and readability of online materials for Kienböck disease (KD). Methods: "Kienbock's Disease" and "Lunate Avacular Necrosis" were entered into 3 search engines. The first 25 Web sites from each search were collected. Quality was assessed via a custom grading rubric, accuracy by 2 residents and a fellow, and readability by Flesch-Kincaid grade level (FKGL) and New Dale-Chall test. Web sites were stratified according to the search term, FKGL, order of appearance, and authorship type. Results: A total of 38 unique Web sites were included, of which 22 were assigned to "KD" and 16 to "Lunate Avascular Necrosis." The average quality score out of 30, accuracy score out of 12, and FKGL for all Web sites were 13.3 ± 7.3, 10.4 ± 1.9, and 10.5 ± 1.4, respectively. Web sites assigned to the term "Kienbock's Disease" had a significantly higher FKGL. Web sites of higher FKGL had significantly worse accuracy scores. Order of appearance had no influence. Physician specialty societies (PSS) had a significantly lower FKGL than Web sites of other authorship types. Conclusions: Despite concerted efforts by national organizations, the readability of online patient materials is above the recommended level for KD. Patients with limited health literacy will be most affected by this reality. Until readability improves, patients should continue to consult their physicians when uncertain and prioritize Web sites that are easier to read and produced by PSS.

Dorsolateral Biplane Closing Radial Osteotomy and Lunate Fixation for Stage IIIC Kienböck Disease: A New Surgical Approach.

The treatment of advanced-stage Kienböck disease (KD) remains highly controversial. Particularly important is stage IIIC KD, which includes patients with a lunate coronal fracture. The purpose of this paper was to describe a new approach to KD in patients with Lichtman stage IIIC KD, and our results using it. The procedure combines a dorsolateral biplane closing radial osteotomy and lunate fixation. A total of 11 patients from January 2002 through December 2016 with documented KD who underwent this technique were included. The patients were assessed before surgery, then postoperatively at 1 and 10 days, 3 and 6 weeks, 3 and 6 months, and annually. Wrist range of motion, grip and pinch strength, the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, a Modified Mayo Wrist Score (MMWS), 10-point visual analog scale, radiologic measurements, and data related to consolidation were collected. All statistical analyses were performed using the statistical software package SPSS. Some degree of pain relief, improvements in the QuickDASH score, MMWS score, grip strength, and the degrees of flexion and extension were observed, the results being statistically significant (P<0.05). After surgery, the values for radial and sagittal tilt were statistically different than those measured before surgery. Carpal collapse was not evident either before or after surgery. In conclusion, combining a dorsolateral radial osteotomy and a lunate compression screw may expand the options for patients with Lichtman stage IIIC KD. Our experience indicates that it is a viable option in challenging clinical scenarios.

Results of a prospective clinical study on the diagnostic performance of standard magnetic resonance imaging in comparison to a combination of 3 T MRI and additional CT imaging in Kienböck's disease

PurposeThis prospective clinical study examined standard wrist magnetic resonance imaging (MRI) examinations and the incremental value of computed tomography (CT) in the diagnosis of Kienböck's disease (KD) with regard to reliability and precision in the different diagnostic steps during diagnostic work-up. Materials and methodsSixty-four consecutive patients referred between January 2009 and January 2014 with positive initial suspicion of KD according to external standard wrist MRI were prospectively included (step one). Institutional review board approval was obtained. Clinical examination by two handsurgeons were followed by wrist radiographs (step two), ultrathin-section CT, and 3T contrast-enhanced MRI (step three). Final diagnosis was established in a consensus conference involving all examiners and all examinations results available from step three. ResultsIn 12/64 patients, initial suspicion was discarded at step two and in 34/64 patients, the initial suspicion of KD was finally discarded at step three. The final external MRI positive predictive value was 47%. The most common differential diagnoses at step three were intraosseous cysts (n=15), lunate pseudarthrosis (n=13), and ulnar impaction syndrome (n=5). A correlation between radiograph-based diagnoses (step two) with final diagnosis (step three) showed that initial suspicion of stage I KD had the lowest sensitivity for correct diagnosis (2/11). Technical factors associated with a false positive external MRI KD diagnosis were not found. ConclusionStandard wrist MRI should be complemented with thin-section CT, and interdisciplinary interpretation of images and clinical data, to increase diagnostic accuracy in patients with suspected KD.

Dorsal Distraction Plating and Lunate Decortication for Stage III Kienböck Disease: A Novel Technique.

Kienböck disease (KD) is a progressive condition and difficult to manage. A number of treatment algorithms exist but there is no clear consensus as to which method produces the best outcome, particularly for Lichtman stage III disease. The majority of the current treatment options for KD emphasize lunate unloading and restoration of biology with bone graft. However, less attention has been given to the protection of the lunate during revascularization process. We report a novel technique of lunate decompression and bone grafting, combined with wrist distraction with or without radial shortening osteotomy via dorsal wrist bridge plating for the treatment of stage II-IIIa/b KD. This technique provides the advantages of distraction of the carpus unloading the lunate after bone grafting and during revascularization without the issues inherent to external fixation. In addition, this technique allows compression through a radial osteotomy site when performed. Our approach to the treatment of KD has incorporated this technique for patients with stage II or IIIa/b disease.

Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment.

The assessment and management of Kienböck Disease (KD) has always been a conundrum. The Lichtman classification has traditionally been used to guide treatment based on imaging. Arthroscopy provides a direct visualization of the articular surface, allows probing of the surfaces, and enables minimally invasive techniques to be performed. The Lichtman-Bain classification is a new classification that takes into account the osseous, vascular, and cartilage aspects of the lunate and the secondary effects on the wrist. It identifies the important prognostic factors including age, the status of the lunate, and the status of the wrist. With arthroscopy, the articular surfaces of the lunate can be assessed to better understand the status of the lunate. The lunate can be defined as intact, compromised, or not reconstructable. If the lunate is intact then lunate decompression (forage) and arthroscopic assisted bone grafting can be performed. If the lunate facet and capitate are functional, then a proximal carpectomy can be performed. This can be performed as an arthroscopic procedure. Assessment of the wrist includes assessment of the adjacent articular surfaces of the central column articulations (radiocarpal and midcarpal articulations). Instability of the proximal carpal row can also be assessed. The radioscaphoid articulation is often preserved except in late KD, which allows the scaphocapitate fusion to be a good surgical option. This can now be performed as an arthroscopic procedure. Once the radioscaphoid articulation is degenerate, a salvage procedure is required.

An international opinion research survey of the etiology, diagnosis, therapy and outcome of Kienböck's disease (KD)

ObjectivesEvery fourth publication on Kienböck's disease (KD) is based for the most part on rather divergent expert opinion. We therefore surveyed expert opinion on KD in three European countries: (1) for the suspected aetiologies; (2) routinely used diagnostic tools; (3) recommended treatment and (4) expected outcome. MethodsA questionnaire consisting of 16 questions was handed out at the national meetings for surgery of the hand in Germany (DE), France (FR) in 2009 and in the United Kingdom (UK) in 2010. ResultsAmong the 126 surgeons who participated in the survey, 82 had a national diploma for surgery of the hand. None of the most commonly discussed etiopathological hypotheses were estimated as being very likely. Hand/arm vibration exposure was considered less likely among respondents in France and the UK than among respondents in Germany. Treatment recommendations are very heterogeneous for stage IIIB according to Lichtman. ConclusionsExpert opinions on diagnostic criteria, the pathogenesis and the choice of treatment are not consistent and may vary from one country to another.

Aetiology of Kienböck's Disease

A definite pathogenesis for Kienböck's disease (KD) has not been identifed yet. Considering our clinical experience, mechanical factors, acute trauma or repetitive minor trauma seem to not be a primary cause, but rather factors that cause symptom aggravation of an already present KD. I feel we should look for a biological more than for a mechanical cause. Probably a vascular non-traumatic process, with a minor infarction pattern in the proximal subchondral area, is nearest to the truth. Bone remodelling results from bone resorption by osteoclasts and the formation of new bone by osteoblasts. Why osteoclast action should overpass the osteoblastic activity in the repair process is still not known. Studies of genes related to osteogenesis with polymerase chain reaction (PCR) arrays are a new option. Considering avascular necrosis as a possible reactive arthritis, PCR and viral RNA analysis could help in making the diagnosis.