Kienbock's Disease - John Va Faye 4/3/2002

BACKGROUND

Lunatomalacia, rare diagnosis usually by exclusion of other aetiologies for dorsal wrist pain.

Insidious with/without trauma.

Single insult vs repetitive microtrauma.

Anatomy may be predisposition. Radial positive-ulnar negative relationship, intra osseous vascular pattern.

Stage I: no visible change, II: sclerosis of lunate, IIIA or B: lunate collapse +/-combined degerative changes at adjacent intercarpal joints, B- static rotatory subluxation of scaphoid. IV: Surrounding joints involved.

Rx: immobilisation, joint levelling, revascularisation, proximal row carpectomy, fusions, wrist arthrodesis

Authors

Salmon J, Stanley J, Trail IA , (Wrightington)

Title

Kienbock’s Disease: Conservative management versus radial shortening

Reference

J Bone Joint Surg [Br] 2000 Aug 82(6) 820-823

Summary

12 year study, 18 conservative & 15 surgical managed patients (33). Mean F/U 3.6 yrs (1.5-9). All stage II (30%) & III (70%). Half manual workers. Male dominant. Evaluation by Harvard pain score, Wrightington functional score card, ROM, Grip strength (Jama dynamometer), X-rays: Glisson technique. Ulnar variance: –1.7mm in conservative gp, -2.5mm in surgical gp. Assess progression , sclerosis, fractures of lunate, flattening, collapse, cyst formation, OA changes.

Radial shortening group had less pain and better grip strength 75% vs 61% cf contralateral side and better ROM (75% vs 61%) . Stage III group treated conservatively lead to very rapid carpal collapse. Stage III treated surgically slowed progression of disease. For stage II disease suggests conservative management initially.

Critique

Overall good paper. 4 patients not assessed by physical examination but included in the outcome! No mention of stats.

Authors

Weis AP, Weiland AJ, Moore JR, Wilgis EF. Baltimore

Title

Radial Shortening for Kienbock’s Disease

Reference

JBJS (Am) 1991 73A 384-391

Summary

7 year, prospective study, 30 wrists, Kienbock’s without degenerative change. Stahl-Lichtman stage I: 3, stage II: 7, stage IIIA: 16 stage IIIB:4., mean age 29 (17-49) 18:11 male:female, 45% traumatic, 8 manual workers. Evaluation: pain, ROM, grip strength, carpal stability. X-ray: mean ulnar variance –2.8mm. Results: 50% showed no X-ray progression, 17% had carpal collapse. No change in appearance of lunate. Increase in ROM by 30%, grip strength by 50%, Pain decresed by 87% . Complications 1 nonunion, 1 xs shortening,, 1 arthrodesis.

Critique

Classic paper. Does not mention pain score.

Authors

Condit DP, Idler RS, Fischer TJ, Hastings H

Title

Preoperative factors and Outcome After Lunate Decompression for Kienbock’s Disease.

Reference

J Hand Surg (Am) 1991993 18A 691-696

Summary

Retrospective, 10 year, 24 patients. 15 treated with radial shortening, 9 had Scapho-trapezium-trapezoid arthrodesis (STT) .Mean F/U 62 months, minimum 24 months.. Mean age 30yrs, similar male:female. Evaluation of ADLs, occupation, avocation, ROM, strength, devised own scoring system. X-ray evaluation of ulnar variance, lunate compression: Stahl ratio, lunate index, carpal height index, radioscaphoid angle, OA of radiocarpal +/- DRUJ, Swanson classificatio stages I to VI. Results: in Radial shortening group all patients returned to work (50% manual workers). In STT gp 50% returned to work. ROM increase by 50% in RS gp whislst decreased by 14% in STT gp. Strength increased by 44% in RS gp and only 10% in STT gp. Lunate collapse continued in both groups. Only parameter which predicted outcome was radioscaphoid angle. Good results in 8/15 pts in RS gp vs 3/9 in STT gp which later went on to arthrodesis. Suggest scaphoid angle of 60’ to subdivide Lichman stage III.

Critique

Retrospective, pain score eliminated. They suggest more strict selection criteria for the patients.

Other Relevant Papers

Basic Science:

J Hand Surg 1996 Sep 21(5) 754-8, Schiltenwolf M, Martini a, Eversham S

Further investigation of intraosseous pressure characteristics in necrotic Lunate.

New advances:

J Hand Surg (Am) 2001 March 26(2) 252-260. Illarramenti AA, Shultz C DeCarli P.

Surgical treatment of KD by radius and ulna metaphyseal core decompression.

Review papers:

J Am Acad Orthop Surg 2001 Mar-Apr ((2) 128-36. Allan CH Joshi A Lichtman DM

KD: diagnosis and treatment.



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