100 Jahre nach Kienböck

Vascularized Bone Flaps for the Treatment of Kienböck Disease

Of the many treatments for Kienböck disease, only lunate revascularization procedures provide a direct mechanism for reversing the process of osteonecrosis. Owing to the redundant blood supply of the distal radius and carpus, pedicled flaps are versatile solutions for patients with bone loss but intact cartilage. With the advent of free vascularized flaps, the indications for lunate revascularization procedures are expanding. These flaps can be used when the articular cartilage has been compromised and are suitable options to restore native anatomy in patients previously thought to have unreconstructible disease.

Radial shortening osteotomy vs partial capitate shortening osteotomy in Kienböck's disease: Medium-term radiological and clinical results

This study aimed to compare medium-term results for partial capitate shortening (PCS) and radial shortening (RS) osteotomies on lunate bone revascularization and disease progression in patients with stage II or IIIA Kienböck's disease. Patients who underwent surgery for Kienböck's disease between March 2010 and July 2020 were retrospectively evaluated. Clinical evaluation included assessment of pain, joint range of motion, strength, DASH, visual analog scale (VAS) for pain, Modified Mayo Wrist Score (MMWS), satisfaction and time to return to work, with comparison as appropriate to the contralateral side. Preoperative and postoperative plain radiographs and magnetic resonance imaging (MRI) were used for radiological evaluation. Lichtman staging and signal changes in the lunate were evaluated using MRI. Group 1 (PCS) included 14 patients and Group 2 (RS) 14. Mean follow-up was 57.8 months (range 24-102) in Group 1 and 49.4 months (range 36-73) in Group 2. Clinical evaluation included pain on VAS, DASH score, MMWS, range of motion, and grip, palmar and key pinch strength. Regarding lunate bone vascularization, increased signal on final follow-up MRI was observed in 10 of the 14 patients in Group 1 and 7 of the 14 patients in Group 2. There was a positive correlation between revascularization and final follow-up MMWS (p = 0.006). The present study thus showed that functional scores were improved by revascularization in Kienböck's disease. Both osteotomies had clinically and radiologically satisfactory results. However, we believe that PCS osteotomy is preferable, as it leads to higher revascularization rates without increasing ulnolunate load.

Lunate biomechanics: application to Kienböck's disease and its treatment

Kienböck's disease was initially considered as lunate osteomalacia due to lesions of its nutrient arteries during carpal ligament tears. It has also been suggested following primary fractures, or because of repeated microtrauma. It is only in the past 20 or 30 years that it has appeared as aseptic necrosis. Based on Hultén's hypothesis that a negative radioulnar index was the cause of Kienböck's disease, equalization osteotomies (shortening of the radius or lengthening of the ulna) were developed. The observation of Kienböck's disease in subjects with a positive index and the risk of ulnar abutment after osteotomy led to the introduction of new osteotomies to get around these difficulties, still in the hope of treating the cause of Kienböck's disease. While it has been confirmed that a negative radioulnar index promotes lunate fracture, it clearly does not induce the pathology in the form of necrosis. In this scenario, perilunar osteotomies produce durable decompression, limiting the risk of lunate fracture in case of necrosis by removing the compressive constraints. After comparing the different osteotomies used to treat Kienböck's disease, it seems that the Camembert osteotomy for radius shortening, combined with selective shortening of the ulnar head as described by Sennwald, decompresses the lunate maximally, and protects it long enough for potential natural revascularization to occur.

Treatment of Advanced Kienbock's Disease (Lichtman Stage IIIB with Carpal Collapse) by a Shortening Osteotomy of the Radius: 21 Cases

Purpose  To review the results of shortening osteotomies of the radius in our stage IIIB Kienbock's disease patients. Materials and Methods  In the past 30 years, we treated 52 cases of Kienbock's disease by a shortening osteotomy of the radius, of which 21 already had carpal collapse. All patient charts and X-rays were reviewed, but only the cases already with carpal collapse (stage IIIB) are presented here. Results  All patients improved after surgery. Pain, on a scale of 0 to 3, generally 2 or 3 before surgery (median: 2.3), was normally 1 or 0 afterward (median: 0.9); median flexion-extension of the wrist improved from 77 to 99 degrees; and grip strength of the other hand improved from 26 to 76%. The last clinical and radiological review was performed 1 to 23 years after surgery (median: 8 years). Conclusion  Advanced Kienbock's disease with carpal collapse is not a contraindication for carpal-sparing surgery radial shortening osteotomy.

A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration

BACKGROUND

We systematically reviewed etiological factors of Kienböck's disease (osteonecrosis of the lunate) discussed in the literature in order to examine the justification for including Kienböck's disease (KD) in the European Listing of Occupational Diseases.

METHODS

We searched the Ovid/Medline and the Cochrane Library for articles discussing the etiology of osteonecrosis of the lunate published since the first description of KD in 1910 and up until July 2012 in English, French or German. Literature was classified by the level of evidence presented, the etiopathological hypothesis discussed, and the author's conclusion about the role of the etiopathological hypothesis. The causal relationship between KD and hand-arm vibration was elucidated by the Bradford Hill criteria.

RESULTS

A total of 220 references was found. Of the included 152 articles, 140 (92%) reached the evidence level IV (case series). The four most frequently discussed factors were negative ulnar variance (n=72; 47%), primary arterial ischemia of the lunate (n=63; 41%), trauma (n=63; 41%) and hand-arm vibration (n=53; 35%). The quality of the cohort studies on hand-arm vibration did not permit a meta-analysis to evaluate the strength of an association to KD. Evidence for the lack of consistency, plausibility and coherence of the 4 most frequently discussed etiopathologies was found. No evidence was found to support any of the nine Bradford Hill criteria for a causal relationship between KD and hand-arm vibration.

CONCLUSIONS

A systematic review of 220 articles on the etiopathology of KD and the application of the Bradford Hill criteria does not provide sufficient scientific evidence to confirm or refute a causal relationship between KD and hand-arm vibration. This currently suggests that, KD does not comply with the criteria of the International Labour Organization determining occupational diseases. However, research with a higher level of evidence is required to further determine if hand-arm vibration is a risk factor for KD.