Kienboeckdisease. Treatment options. F. Hahn

Transcription

1 Kienboeckdisease Treatment options F. Hahn

2 General points (no) Evidence from the literature?!? Confounding data: Small series Heterogeneous stages Multiple techniques

3 General points Treatment depending on disease stage Lunate preserving strategies vs Lunate replacing strategies vs Salvage strategies

4 Lunatepreservingstrategies Lunateunloadingprocedures Radius shortening osteotomy Reorientation of distal radius Partial wrist arthrodesis Capitate shortening osteotomy Lunaterevascularisingprocedures Drilling Pedicle implantation Vascular bone grafts(palmar, dorsal, free grafts)

5 Lunate preserving unloading strategies In caseof ulnar-variance Radial shorteningosteotomy Unloading of the radial part of the lunate

6 Lunate preserving unloading strategies In caseof ulnar0/+ variance Radial angle correctingosteotomy Unloding of the radial lunate by transferof carpalloadto scaphoid

7 Lunate preserving unloading strategies In caseof ulnar0/+ variance Capitateshorteningosteotomy Principle: Shortening of capitate results in less axial pressure onto the lunate Advantage: Correction only within the wrist. no affection of DRUJ

8 Lunate preserving unloading strategies Principle: Partial wristarthrodesis Partial fusionof midcarpaljointlineto fix thescaphoidin an erected position and therefore to discharge the lunate during wrist motion STT arthrodesis SC - arthrodesis

9 Lunate preserving revascularisating strategies Radius core decompression No evidence based rationale Idea of changing the intracarpal blood flow Only early stages without collaps Intention: to stop the necrotic process Illaramedin, J Hand SurgAm 2001, 26(2):252

10 Lunate preserving revascularisating strategies Directpedicleimplantation Preparation of a dorsal vascular pedicle with direct implantation into the lunate after curettage of the necrotic zone Horiet al, J Hand SurgAm 1979; 4(1): 23-33

11 Lunate preserving revascularisating strategies Vascularbonegrafts-palmar - Os pisiforme Beck Distal radius Kuhlmann M pronator + radius Braun 1983 Leung 1990 Lee 1997 Beck; Handchirurgie. 1971, 3(2):64 Lee; J Hand SurgAm. 1997, 22(3): 408 Braun 1983

12 Lunate preserving revascularisating strategies Vascularbonegrafts-dorsal -2,3 ICSRA -4 ECA Bishop& Berger nd Metacarpal bone Mathoulin&Brunelli 1998 Khan 1998 Makino 2000 Sheetz; J Hand SurgAm. 1995, 20(6):902 Mathoulin; J Hand Surg Br. 1998, 23(3):311 Makino; J Reconstr Microsurg. 2000, 16(4):261

13 Lunate preserving revascularisating strategies Vascularbonegrafts-free Very demanding techniques!! - Free ilac crest Gabl Free medial femoral condyle Larson 2007 Gabl; J Hand Surg Br. 2002, 27(4):369 Larson; Tech Hand Up Extrem Surg. 2007, 11(4):246

14 Lunatereplacingtechniques Silicone implants(historical) Cement(historical) Tendon grafts Pyrocarbon implants

15 Salvageprocedures PRC Spacer Total Wrist Prosthesis Total Wrist Fusion Wrist denervation

16 Treatment algorithm Stage Ulnar negative Ulnar positive 0 Preventive treatment on etiology I II Immobilisation for 3-6 month DRSO after no healing noted DRSO Immobilisation 3-6 month CSO, revascularisation procedure Immobilisation CSO, revascularisation procedure III A DRSO CSO, revascularisation procedure III B SC or STT arthrodesis, PRC III C Excise lunate with SC or STT arthrodesis, PRC IV PRC, TWF, TWA STT=scaphotrapezium-trapezoid, SC=scaphocapitate, DRSO=distal radius shortening osteotomy, CSO= capitate shortening osteotomy, PRC= proximal row carpectomy, TWA=total wrist arthroplasty, TWF= total wrist fusion

17 Limitations Treatment algorithm based on osseous and vascular factors only. Osseous(x-rays) + Vascular(MRI) + Cartilage(arthroscopy)

18 Outlook New integratedclassificationsystem withtreatmentalgorithm.

19 Outlook Proposed by Bain/Lichtman/Garcia-Elias/Schmitt/Amadio Osseous Vascular Cartilaginous (RX/CT) (MRI) (Arthroscopy) 0 A 0 I A, B or C 0 or 1 II A, B or C 0,1 or 2 III-A,B or C A, B or C 3 or 4 IV C 4 = 35 possible combinations! Instructional Course 20, ASSH Annual Meeting 2012

20 Summary Kienböck disease is a rare but often debilitating entity Progressive, but possibly autolimitative in early stages different stages various clinical presentations Many treatment options no consensus Consider osseous + vascular + cartilage status Combine with the clinical situation and demands of the patient