Staging of Kienböck s disease. F. Hahn
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1 Staging of Kienböck s disease F. Hahn
2 Introduction Why staging? Standardisation Communication Prognosis Treatment options
3 X-rays 1910 First description by Kienböck 1947 Ståhl(Rx) 1957 Decoulx(modif. Ståhl, Rx) 1977 Lichtman(Rx) 1982 Lichtman Stage IIIA/IIIB 2010 Lichtman Stage 0 and IIIC
4 Ståhl normal shape of lunate, compression fx 2. resorbtion around lunate fx 3. sclerosis and flattening of lunate 4. fragmentation and cystic degenerations of lunate 5. arthritis radiocarpal/midcarpal Ståhl F. Acta Chir Scand 1947, 95(126):120
5 Decoulx(modif. Ståhl) normal form of lunate, increased density 2. cystic changes within lunate 3. fragmentation and collapse 4. arthritis radio- and/or midkarpal Decoulx P, Lille Chir 1957; 12:65
6 Lichtman Based on Decoulx but: suspicion of an occult initial stage with normal plain Rx (1977) differentiation of stage IIIA/IIIB (1982) proposition of stage 0 and IIIC (2010) Lichtman. J Bone Joint Surg Am 1977;59:899 Lichtman. J Hand SurgAm 1982, 7:343 Lesly, N.., Lichtman, D. HaMiPla 2012, 42:171
7 Lichtmanclassification Stage 0: prenecrotic Stage I: osteonecrosis without changes in x-rays Stage II: osteonecrosiswith changes in x-rays, no collapse of lunate Stage IIIA: osteonecrosis with lunate collapse, no carpal collapse Stage IIIB: as IIIA + scaphoid rotation (RS-angle > 60 ) Stage IIIC: coronal lunate fracture Stage IV: arthritis radiocarpal or midcarpal Lesly, N.., Lichtman, D. HaMiPla 2012, 42:171
8 Lichtman0 (not yet validated) prenecrotic stress-test with gadolinium i.v. in an extended and axial loaded position. to detect very early stages of Kienböckwith normal MRI
9 LichtmanI (MRI) osteonecrosis without changes in x-rays Normal radiographic findings, uniformly decreased MRI signals on T1 and T2
10 LichtmanII Diffuse osteosclerosis, sometimes flattening of proximal pole, no lunate collapse
11 Differentiation LichtmanIIIA / IIIB Key point: carpal collapse! Lunate collapse by Ståhl Index: In sagittal Rx : high/length of lunate Carpal collapse/instability: Ståhl index Gilula lines Ring sign Youmindex: carpal high/ length of MC III, Radio-scaphoid angle >60 Youm-index
12 LichtmanIIIA Lunate collapse (prox. Pole) but no carpal collapse!
13 LichtmanIIIB Lunate collapse with carpal instability by radioscaphoid angle > 60
14 LichtmanIIIC (not yet validated) Coronal lunate fracture Based on the poor healing potential of coronal fractures in the vascular compromised lunate. Based on the arthroscopic and clinical evaluation according to Bain and Begg(Stage 2b) Bain, GI. Tech Hand Up ExtremSurg2006; 10:8
15 LichtmanIV (KDAC= kienböck disease advanced collapse) Lunate collapse with radiocarpal or midcarpal degenerative arthritis
16 MRI Stages (Schmitt 1997) For osteonecrosis of carpal bones, T1 always with low signal stage enhancement pathology I homogenous edema II patchy-inhomogenous partial necrosis III absent complete necrosis Schmitt, R. EurJ Rad :92
17 ArthroscopicStaging (Bain2006) number of non-functional articular surfaces Bain, GI. Tech Hand Up ExtremSurg2006; 10:8
18 SUMMARY Classifications based on X-rays/CT/MRI/arthroscopy Lichtman most widely used and evaluated Schmitt classification supplementary to Lichtman Bain/Begg still needs to be evaluated
19 OUTLOOK Based on vascular + osseous + cartilage Integrated Classification System
20 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 IIIA -B -3 Instructional Course 20, ASSH Annual Meeting 2012
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