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We report two cases of Kienböck's disease associated with systemic lupus erythematosus SLE. The characteristics of these cases associated with SLE differed from those previously reported for Kienböck's disease. Corticosteroid may be a cause of Kienböck's disease in SLE.

Thirty-eight patients with advanced Kienböck's disease treated by limited wrist arthrodesis (LWA: n = 10) or radial osteotomy (RO: n = 28) for a fragmented lunate were retrospectively examined after an average of 47.9 and 68.1 months, respectively. Compared with pre-operative values, the active flexion-extension range of motion decreased by about 16.0° in LWA and increased approximately 9.7° in RO and the grip strength improved by approximately 7.5 kg in LWA and 8.0 kg in RO. In both groups, radiographs showed no significant progression of carpal collapse. Although LWA caused some decrease in wrist flexion-extension, both procedures are appropriate for surgical treatment of advanced Kienböck's disease. Most patients experienced a reduction in pain and were able to return to work.

Avascular necrosis involving more than one carpal bone is rare, and the appropriate treatment for this condition has not yet been established. In this report, two patients with concomitant Preiser's and Kienböck's disease who also had severe wrist pain without obvious traumas were treated by closing radial wedge osteotomy (CRWO). Clinical evaluation showed that CRWO was effective against both conditions and indicated that it is more suitable for early stage than stage II diseases of the Hebert and Lichtman classifications.

Elderly patients suffering from avascular necrosis of a carpal bone in both wrists are extremely rare. We report a case of an elderly kendo (Japanese fencing) competitor who sustained Preiser's disease in the left hand following the occurrence of Kienböck's disease in the right hand. The current case demonstrates the importance of raising awareness of these diseases as potential sports-related problems in the elderly.

In this report, two cases presenting with CTS including a fracture of the silicone implant for Kienböck's disease after replacement over 20 years postoperatively where CTR ceased the symptoms of CTS. The major symptom characteristic was the median nerve impairment with less emphasis on the limited range of motion of the wrist or wrist pain due to a fracture of the silicone implant. There was an unlikely association between the fracture of the implant and CTS, which was confirmed by the operative findings of tenosynovitis and thickness of the degenerated transverse ligament without a significant protrusion of the silicone implant.

The purpose of this study was to assess vascularity of the lunate by number of foramina and radiography of vessels of the wrist. The genesis of lunatomalacia requires some vascular risk and mechanical predisposition. The findings were correlated with the cause of Kienböck's disease. The vascular foramina were more than two in 91.33% of the lunate. The lunate had consistent dorsal and palmar branches from radial artery. The additional branches from anterior interosseous artery in 72.22% and a branch of palmar inter carpal arch in 69.44% cases contributed in arterial anastomosis on palmar aspect of lunate. The dorsal blood supply was found by anterior interosseous artery in 85.71% of specimens and dorsal branch from dorsal intercarpal arch in 50% of specimens. The blood supply of lunate comes along with various ligaments which may be disrupted due to trauma or strain leading to avascular necrosis. The present observations are suggestive of rich blood supply of lunate in comparison of other investigations. Therefore Kienböck's disease is less common in northern India.

Purpose: The objective of this research was to investigate the reliability of Lichtman's classification for Kienböck's disease.

Methods: Interobserver reliability and intraobserver reproducibility were investigated by interpreting both anteroposterior and lateral X-rays of the wrist joint twice in 99 patients with Kienböck's disease using the modified Lichtman's classification system. Observers comprised three orthopaedic surgeons, and no information was exchanged between observers either before or during the study.

Results: Intraobserver reliability was moderate (0.313–0.628), and interobserver reliability was fair (Siegel's kappa = 0.228).

Conclusion: Low values were obtained regarding interobserver reliability for the modified Lichtman's classification of Kienböck's disease. This classification is thus inadequate for use in clinical settings. A new classification should be established.

Kienböck's disease is known for its difficulty in being diagnosed and treated at early stages; option treatments are few and most of them quite aggressive. The author describes his experience with arthroscopic assisted lunate bone grafting. Three patients with diagnosis of stage I avascular necrosis of the lunate (average age: 45 years), were treated. Before surgical procedure, the patients underwent to a conservative treatment. After harvesting the bone graft from the volar surface of the radius, arthroscopic bone grafting was performed.

At an average follow-up of 13.5 months (9–15), all the patients show a normal density of the lunate and no arthritic changes in radiographs. The MRI confirmed the lunate vascularity.

The number of patients is definitely small, due also to the rarity of the disease and the difficulty in diagnosis, but, despite the very high learning curve, could be the proper first choice of treatment.

We have carried out a replacement of the lunate in 12 patients with advanced Kienböck's disease, with excision of the lunate and insertion of an iliac bone flap wrapped into palmaris longus. The aims of this study were to determine the effect of this procedure for advanced Kienböck's disease. At a mean follow-up period of 45.3 months, the mean clinical score was excellent in all cases. Radiographically, progression of osteoarthritis (OA) in the radiocarpal joint was found in two patients. At follow-up, the X-ray findings indicated a reduced of osseous core in four patients. On the other hand, carpal height ratio showed no significant change at follow-up. Excision arthroplasty using a tendon ball with osseous core for advanced Kienböck's disease leads to OA progression in some cases. However, clinical results were excellent in all cases. Therefore, this current study provides effective therapeutic procedure for advanced Kienböck's disease.

Kienböck disease is a disorder of impaired lunate vascularity which ultimately has the potential to lead to marked degeneration of the wrist and impaired wrist function. The aetiology of the avascular necrosis is uncertain, but theories relate to ulnar variance, variability in lunate vascularity and intraosseous pressures. Clinical symptoms can be subtle and variable, requiring a high index of suspicion for the diagnosis. The Lichtmann classification has historically been used to guide management. We present a review of Kienböck disease, with a focus on the recent advances in assessment and treatment. Based on our understanding thus far of the pathoanatomy of Kienböck’s disease, we are proposing a pathological staging system founded on the vascularity, osseous and chondral health of the lunate. We also propose an articular-based approach to treatment, with an arthroscopic grading system to guide management.

Background: Radius osteotomy is one of the standard surgical procedures for the treatment of Kienböck’s disease. Unfortunately, radius osteotomy can result in an incongruous distal radio-ulnar joint (DRUj) postoperatively, because the procedure is performed proximal to the DRUj.

Methods: A very distal radius wedge osteotomy was performed as a 15-degree lateral closing wedge osteotomy with the apex of the wedge distal to that of conventional lateral closing wedge osteotomy; this procedure was developed to avoid postoperative incongruous DRUj. We performed this procedure on 6 patients (stage III-A: 1, stage III-B: 5) with a mean age of 49 years. Clinical and radiographic evaluations were performed at a mean follow-up of 32 months.

Results: Wrist pain disappeared in all patients. Mean grip strength improved from 35% to 87% of the contralateral side (p = 0.0255). Mean range of motion, measured as flexion-extension arc, improved from 93 to 128 degrees. Nakamura’s score was good in all patient. Mean lunate covering ratio increased from 61% to 90% (p = 0.0151) and mean sigmoid notch inclination angle, a radiographic parameter of DRUj congruency, was not significantly different between pre-operative and final follow-up evaluation. No clinical or radiographic DRUj osteoarthritis findings were observed.

Conclusions: Our procedure of very distal radius wedge osteotomy provided satisfactory clinical results without an incongruous DRUj. This technique might prevent the occurrence of postoperative DRUj osteoarthritis.

Extensor tendon rupture of the finger is a very rare complication of Kienböck’s disease. However, advanced Kienböck’s disease can cause an attritional rupture of extensor tendons due to displaced lunate fragment. An extensor tendon of the thumb is frequently damaged in the distal radial fracture, and an extensor tendon of the fifth finger is mainly ruptured in arthritis of distal radio-ulnar joint. On the other hand, the extensor tendons of the 2^nd, 3^rd and 4^th fingers are usually ruptured in advanced Kienböck’s disease. We report two elderly patients diagnosed with advanced Kienböck’s disease after non-traumatic rupture of extensor tendon of the fingers. Since the extensor tendon rupture in Kienböck’s disease present as a loss of active extension of metacarpophalangeal joint in the central fingers, these patients should undergo imaging of the wrist joints to ascertain concomitant Kienböck’s disease.

Background: The etiology and natural history of Kienböck’s disease remain unclear. Traditionally it has been defined as avascular necrosis of the lunate. The authors tried to demonstrate different tissue distribution, the area ratio of necrotic tissue and vessel counts inside the whole Kienböck lunate to reveal a dynamic process of the lunate collapse.

Methods: Five lunates from patients with stage III Kienböck’s disease and one cadaveric lunate not involved by Kienböck’s disease were sampled. They were sectioned, H&E stained, and evaluated. The thickness of trabecular bone and the area of necrotic tissue were measured with Image-Pro Plus. The number of vessels was counted manually.

Results: In the normal lunate, the bone trabeculae showed a uniform distribution with fatty marrow filled the interspace between the trabeculae. In the lunates with Kienböck disease, the trabeculae fracture and necrosis located in the central part with massive fibrous granular tissue proliferation. There were also some chondroid metaplasia at the palmar and dorsal ends. The trabeculae of the lunates of the Kienböck’s disease [0.188 mm (0.153 mm, 0.236 mm)] was significantly thicker than the normal lunates [0.146 mm (0.124 mm, 0.164 mm)]. The necrosis was localized around the fracture sites instead of the whole lunate. The mean necrosis area only accounts for 16.3% ± 8.9% of the whole section. Such kind of focal necrosis is quite similar to those around the traumatic fracture ends of other bones. Even in stage III Kienböck lunates, the vessels are quite abundant (221 ± 42 in one sagittal section), while the vessels inside the normal lunate were 352 ± 28.

Conclusions: There is neither massive nor obvious generalized avascular bone necrosis in our histopathology observations. The focal necrosis and vessel damage were more likely associated with the broken trabeculae inside the lunate. Based on our histopathology observations, we suggested that the progressive process of Kienböck’s disease could be described as lunate nonunion advanced collapse instead of avascular necrosis.

Background: Numerous studies have indicated the presence of mesenchymal stem cells (MSCs) in the bone marrow aspirated from the vertebral body, distal femur, proximal tibia, humeral head, sternum, and iliac crest. However, their presence has not been reported in the radius thus far. In this study, we aimed to compare the number of MSCs in bone marrow aspirated from radius and iliac crest in patients with Kienböck’s disease. Furthermore, we examined the association between the number of MSCs in the bone marrow and patient age.

Methods: A total of 17 patients were recruited. Owing to difficulties in obtaining samples for 5 cases, only 12 cases were included. Hematological analyses and fibroblastic colony-forming unit (CFU-F) assay were performed using bone marrow samples aspirated from the radius (group R), the first sample aspirated from the iliac crest (group I-1), and the second sample aspirated from the iliac crest (group I-2). The CFU-F numbers among the three groups were compared using Mann–Whitney U-test. Pearson’s correlation coefficient was calculated to evaluate the association between the CFU-F numbers and patient age.

Results: The average numbers of CFU-Fs/ml in the bone marrow samples from the R, I-1, and I-2 groups were 3.4, 57.3, and 13.7, respectively. The CFU-F number in Group I-1 was significantly higher than that in the other two groups; the CFU-F number was lower in group R than in group I-2. The correlation coefficients were -0.168, 0.166, and 0.036 for samples from groups R, I-1, and I-2, respectively. No significant association between the CFU-F numbers and patient age was observed.

Conclusions: The presence of MSCs in the radius was indicated by CFU-Fs in patients with Kienböck’s disease. The number of CFU-Fs was lower in the radius than in the iliac crest; the CFU-F number was not associated with patient age.