review of kienbocks disease cover

Review of Kienbӧck Disease

Introduction

Kienbӧck’s disease is considered an uncommon condition that affects approximately 0.0066% of the population (1). The population most commonly affected are men between the ages of 20 and 40 years old (3). Kienbӧck’s disease is defined by osteonecrosis of the lunate carpal bone (1). The lunate is found within the midportion of the proximal carpal row and lies adjacent to the distal radius (5). There are also articulations with the scaphoid, capitate, and hamate (6). The term Kienbӧck comes from Dr. Robert Kienbӧck, an Austrian radiologist who identified the condition based on radiographs in 1910 (3).

joint articulations of the lunate

Joint articulations of the lunate (6)

The pathophysiology for patients developing Kienbӧck’s is controversial. One prevailing etiology is secondary to intra-osseous venous thrombosis, which can form and lead to an “intra-osseous compartment syndrome” (1). The compartment syndrome may lead to necrosis of the subchondral bone (1). There are also theories regarding the shape and location of the lunate acting as risk factors for developing necrosis (5).

The most common site for the development of necrosis within the lunate is within the proximal articular surface (6).

proximal lunate necrosis

Jagged line represents necrosis within the proximal articular surface of the lunate with the radius (9)

Diagnosis

Patients will typically complain of pain localized in the midportion of the dorsal wrist (1). There may also be complaints of hand and wrist swelling, a decrease in wrist range of motion, and weakness in the hand (3). There does not need to be an injury or trauma that triggers the pain and it typically occurs spontaneously (1). Patients will sometimes complain about pain that is associated with activity (3).

Physical exam will focus on pain to palpation to the lunate (3). There may be localized soft tissue swelling overlying the radiocarpal joint (3). Providers may also find reductions in wrist flexion and extension (3).

Standard three view radiographs are taken to evaluate the lunate. The Lichtman classification is used to stage Kienbӧck disease (3). A summary of the criteria is provided in the figure below (3). What stands out is that in stage II, sclerosis of the lunate can be seen compared to normal radiographs in stage I (9).

lichtman staging kienboch disease

Lichtman staging (3)

lichtman stage ii kienbock disease

Example of Licthman stage I and 2 (8)

Evaluating for ulnar variance on radiographs are typically done (4). However, the role of positive ulnar variance and the development of Kienbӧck disease is not clearly defined (4).

More advanced imaging with a CT scan will help provide further detail into the lunate structure (4).  An MRI can beneficial because it can identify edema within the lunate that may not be seen on standard radiographs (5). The MRI staging is based on the Schmitt staging and will evaluate the viability of the lunate based on gadolinium enhancement(6).

swanson classification kienbock disease

Swanson classification (9)

Treatment

There are limited nonsurgical options for Kienbӧck’s disease. Typically for stage I disease, immobilization in a short arm cast for three months is attempted (3,10). If the disease continues to progress after three months of immobilization, surgical options are considered (3). Immobilization is typically more successful in pediatric patients, as the lunate has more remodeling potential compared to a skeletally mature lunate (10).

Surgical options for Kienbӧck’s disease can vary and typically depend on the stage of disease. Stage two treatments typically involve revascularization to the lunate (5). For patients who have a negative ulnar variance, surgeons will typically perform a joint level procedure, which may include a radial shortening osteotomy or a capitate shortening osteotomy (2,9). Depending on lunate collapse, patients may be a candidate for proximal row carpectomy or core decompression of the lunate (2,9).

Conclusion

Kienbӧck’s disease is defined as lunate osteonecrosis. The pathophysiology is still unknown and multiple theories exist. Standard radiographs assist in staging and help dictate treatment options. First line is typically a three-month period of immobilization. A host of surgical treatments exist for those patients who continue to show signs of worsening necrosis.

By Gregory Rubin, DO
rubinsportsmed.com

– More Hand Pain: https://www.sportsmedreview.com/by-joint/hand/

– More on Wiki Sports Medicine: https://wikism.org/Kienbocks_Disease

References

1)      Camus, Emmanuel J., and Luc Van Overstraeten. “Kienböck’s Disease in 2021.” Orthopaedics & Traumatology, Surgery & Research: OTSR, vol. 108, no. 1S, Feb. 2022, p. 103161. PubMed, https://doi.org/10.1016/j.otsr.2021.103161

2)      Saremi, Hossein, et al. “Arthroscopic Treatment of Kienböck Disease: Mid-Term Outcome of Arthroscopic Lunate Core Decompression.” The Journal of Hand Surgery, Mar. 2023, pp. S0363-5023(23)00114-4. PubMed, https://doi.org/10.1016/j.jhsa.2023.02.011

3)      Cross, Danielle, and Kristofer S. Matullo. “Kienböck Disease.” The Orthopedic Clinics of North America, vol. 45, no. 1, Jan. 2014, pp. 141–52. PubMed, https://doi.org/10.1016/j.ocl.2013.09.004

4)      Daly, Charles Andrew, and Alexander Reed Graf. “Kienböck Disease: Clinical Presentation, Epidemiology, and Historical Perspective.” Hand Clinics, vol. 38, no. 4, Nov. 2022, pp. 385–92. PubMed, https://doi.org/10.1016/j.hcl.2022.03.002

5)      Lutsky, Kevin, and Pedro K. Beredjiklian. “Kienböck Disease.” The Journal of Hand Surgery, vol. 37, no. 9, Sept. 2012, pp. 1942–52. PubMed, https://doi.org/10.1016/j.jhsa.2012.06.029

6)      Asmar, Samir, and David Dickson. “Kienböck’s Disease: Pathophysiology, Classification and Treatment of This Insidious Condition.” Orthopaedics and Trauma, vol. 35, no. 4, Aug. 2021, pp. 208–15. Semantic Scholar, https://doi.org/10.1016/j.mporth.2021.06.004

7)      MacLean, Simon B. M., et al. “The Pathoanatomy and Biomechanics of Kienböck Disease.” Hand Clinics, vol. 38, no. 4, Nov. 2022, pp. 393–403. PubMed, https://doi.org/10.1016/j.hcl.2022.03.00

8)      Taoussi, Reda, et al. “Kienbock’s Disease: A Radiological Case Report.” Radiology Case Reports, vol. 17, no. 6, June 2022, pp. 2115–19. PubMed, https://doi.org/10.1016/j.radcr.2022.03.073

9)      Lockwood, W. Charles, and Alexander Lauder. “Classification and Radiographic Characterization of Kienböck Disease.” Hand Clinics, vol. 38, no. 4, Nov. 2022, pp. 405–15. PubMed, https://doi.org/10.1016/j.hcl.2022.03.004

10)   Catapano, Joseph, and James P. Higgins. “An Algorithmic Approach to the Treatment of Kienböck Disease.” Hand Clinics, vol. 38, no. 4, Nov. 2022, pp. 417–24. PubMed, https://doi.org/10.1016/j.hcl.2022.03.005