Kienboeckdisease Treatment options F. Hahn
General points (no) Evidence from the literature?!? Confounding data: Small series Heterogeneous stages Multiple techniques
General points Treatment depending on disease stage Lunate preserving strategies vs Lunate replacing strategies vs Salvage strategies
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)
Lunate preserving unloading strategies In caseof ulnar-variance Radial shorteningosteotomy Unloading of the radial part of the lunate
Lunate preserving unloading strategies In caseof ulnar0/+ variance Radial angle correctingosteotomy Unloding of the radial lunate by transferof carpalloadto scaphoid
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
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
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
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
Lunate preserving revascularisating strategies Vascularbonegrafts-palmar - Os pisiforme Beck 1971 - Distal radius Kuhlmann 1981 - 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
Lunate preserving revascularisating strategies Vascularbonegrafts-dorsal -2,3 ICSRA -4 ECA Bishop& Berger 1995-2nd 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
Lunate preserving revascularisating strategies Vascularbonegrafts-free Very demanding techniques!! - Free ilac crest Gabl 2002 - 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
Lunatereplacingtechniques Silicone implants(historical) Cement(historical) Tendon grafts Pyrocarbon implants
Salvageprocedures PRC Spacer Total Wrist Prosthesis Total Wrist Fusion Wrist denervation
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
Limitations Treatment algorithm based on osseous and vascular factors only. Osseous(x-rays) + Vascular(MRI) + Cartilage(arthroscopy)
Outlook New integratedclassificationsystem withtreatmentalgorithm.
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
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