The surgical treatment in Kienbock disease

Abstract

Introduction. Kienbock disease is a disorder of lunate bone vascularity that can lead to marked degeneration of the wrist, reduce grip strength and causes pain, getting to joint disability. The etiology of the avascular necrosis of the lunate is uncertain, but theories relate to ulnar variance, the variability of the bone vascularity and intraosseous pressures. Clinical symptoms are very variable, requiring a high index of suspicion for the diagnosis. Dr. Robert Kienbock an remarkable radiologist from Vienna (Austria), first described lunato-malacia in 1910 in his clinical series and initially felt that the cause of the collapse of the lunate was repetitive trauma to the lunate from work activities. This opinion was support by Muller in 1920 who proposed the term occupational lunato-malacia. Stahl’s classification, modified by Lichtmann in 1977, has historically been used to guide management. Despite this disease being described more than a century ago, the treatment for Kienbock disease still remains controversial. Aim of the study. We present a review of Kienbock disease and the main objective is to report our personal experience of surgical treatment of this condition at The Clinical Hospital of Orthopedics and Traumatology from Chisinau. Materials and methods. Our experience is based on the surgical treatment of 45 patients with Kienbock disease, aged between 19 and 59 years, who underwent various surgical treatment. At 19 patients was performed Graner procedure, scaphoid-trapezium-trapezoid arthrodesis in 10 cases, scapho-capitate arthrodesis in 8 cases, radio-lunate arthrodesis in 4 cases, removing the first row of carpal bones in 2 cases, by 1 cases with radio-scaphoid and capitato-lunate arthrodesis. Results. Arthrodesis directed to obtain ankylosis of the carpal bones by losing the amplitude of movements but allows to achieve a stable joint, without pain and to restore gripping power. The advantage of the Graner procedure is restoring the carpal height and maintaining the load transmitted by the articular surface of the radius in the articular facets of the scaphoid and semilunar. Long-term results were followed up in 23 patients: good - 12, satisfactory - 9. Unsatisfactory outcomes were in 2 cases because of the absence of the ankylosis and presence of the pain. Conclusions. While the exact cause of Kienbock disease is still poorly understood, several treatment options are available: revascularization, denervation, intraosseous decompression, osteotomy in ulnar variants, selective arthrodesis with or without excision of the lunate. From our experience, the most of patients have good long-term results.