Kienböck´s disease and treatment with ReHand Post-Surgery | Case Report
Kienböck disease or lunate osteonecrosis is a disabling and painful condition of the wrist, which can lead to major complications for patients, and can be difficult for Surgeons and Hand Therapists to manage.
That is why a multidisciplinary and individualised treatment for each case is key. Thus, in this post, we tell you our experience of a patient operated twice for this condition, and the possible therapeutic options after surgery with ReHand. You can directly access the clinical case in question here:
Kienböck´s Disease or Osteonecrosis of the Lunate
The first description of this affectation dates from 1843, when Peste described an involvement of the lunate with osteonecreosis in an autopsy of a patient who died from a fifth floor fall, which seems to be more consistent with a fracture. It was later, in 1910, that radiologist Robert Kienböck observed osteonecrotic changes in a patient at the lunate.
Cause of lunate osteonecrosis
It is thought that the appearance of osteonecrosis is mainly due to an alteration of the vascular supply to the lunate. Although the majority of cases present a double vascular supply at the dorsal and palmar level, around 26% of lunate only have a palmar vascular supply, increasing the risk of a vascular disorder. This is how they are differentiated:
-“I” vascular supply
-“Y” vascular supply
-“X” vascular supply
The latter two are protective for the appearance of vascular alterations of the lunate bone.
It has also been proposed that alterations in load distribution at the wrist, such as radial-lunate to ulno-lunate load transmission or negative ulnar variance, may be precursors to the onset of this condition.
Another possible factor is the type of lunate morphology; type I or type II, i.e. without or with the presence of an articular surface with the Hamate. The second case predisposes to greater carpal stability, being protective against the appearance of fractures or Kienböck’s disease.
Clinical Presentation of Kienböck´s disease
It usually appears in male patients between 20-40 years of age, with jobs that place great demands on the hands and unilaterally. They usually report pain in the wrist, such as when gripping or loading the wrist, and limited mobility.
For diagnosis, we can use the clinical history, physical examination and imaging tests. In addition, we can assess the presence of lunate collapse, fractures, scaphoid subluxation in flexion, carpal arthritis, etc.
Kienböck´s Disease Stages
The Lichtman classification is often used based on the changes and degeneration present in the lunate and carpus, ranging from mild changes to severe involvement with intercarpal arthritic degeneration.
Conservative Treatment of Kienböck Disease | Exercise Therapy
At the early stage, conservative treatment using immobilisation and pharmacological treatment has been implemented, especially in initial stages I and II, with proven improvements in pain and in the synovitis itself, although it does not reverse the progression of the disease.
Also, a protocol published in 2013 exposed how exercise therapy and orthosis might solve some early kienböck stages. Specifically, the Dart Thrower Movement is an oblique plane of motion that enables lunate unloading. This is caused by the fact that this DTM movement occurs mainly at the midcarpal joint, leaving the radiocarpal stable and with little or no movement.
Dart Thrower Movement combines flexion-ulnar deviation with extension-radial deviation. Those forces applied during those movements explain with Radiocarpal Joint is maintained stable.
Learn more about DTM and its clinical application
In cases where conservative approaches have failed, chronic pain interferes with ADLs, and we find stages IIIA or IIIB, and sometimes IV, surgical management such as Carpectomy might be used.
Carpectomy in Kienböck disease
As we have said, in cases where there is a collapse of the lunate without or with loss of height of the carpus, migration of the Capitate to proximal or scaphoid in flexion and rotation (Stages IIIA and IIIB), or on certain occasions when arthritic changes also appear (IV) that do NOT affect the Head of the Capitate, Carpectomy may be chosen.
Proximal row carpectomy (PRC) is a surgery indicated to preserve wrist mobility in cases of degenerative conditions such as Kienböck’s disease. Although it is generally considered a salvage procedure and significantly alters biomechanics, it has shown good results in pain and function.
It consists of a resection of the proximal row that includes the Triquetrum, lunate and scaphoid bones, allowing the Capitate bone to articulate with the lunate fossa of the radius, creating a new radius-capitate joint, and also allowing mobility of the wrist itself.
This technique shall not be performed if inflammatory flare-ups, tendonitis, fracture or acute ligament injury, or arthritic or degenerative changes of the Capitate-Semilunar joint are present.
Biomechanical Implications
This modification brings into contact both the proximal curvature of the capitate bone and the lunate fossa of the radius which are not congruent. In addition, increased pressure and decreased contact area between the carpus and radius has been reported, which may eventually lead to arthritic or degenerative changes.
After the surgical technique, the wrist would have this morphology:
If symptoms do not improve after this intervention and degenerative changes progress rapidly, another surgical technique known as complete arthrodesis is performed. This procedure limits wrist motion to flexion-extension by means of a dorsal plate, allowing only pronation-supination of the forearm. In this way, we achieve to improve the patient’s symptoms.
Croog et al (2008) conducted a 10-year follow-up of patients with stage III and IV Kienbock Carpectomies. Of those included, 3 patients required Radio-Capitate Arthrodesis due to no improvement in their condition. It is interesting to note that of these 3, two had stage IV, which makes the authors call for caution in these cases.
Case Report: Complete Arthrodesis after Carpectomy due to Kienböck’s Disease
After this introduction we show you our clinical case, a patient with Kienböck’s disease of his left hand, which required a Carpectomy of the Proximal Row. As the patient’s symptoms did not improve, it was decided to perform a second surgical technique to fix the carpus and alleviate the patient’s pain. In this case, it was decided to perform a Complete Arthrodesis of the wrist, thus remaining at the radiographic level:
In the images above you can see the condition of the wrist after proximal row carpectomy. Just below, the subsequent fixation with Complete Arthrodesis of the wrist.
After referral to the Hand Therapy Service, we agreed with the Hand Surgeon in charge of the case to start mobilisation of the fingers as early as possible, so some cuts were made in the surgical fixation plaster for this purpose.
In this way, our patient begins to work at a sensory-motor level on the joints free from surgery using ReHand, in order to accelerate recovery times and provide functionality as early as possible.
References
Wall LB, Stern PJ. Proximal Row Carpectomy. Hand Clin [Internet]. 2013;29(1):69–78. Available from: http://dx.doi.org/10.1016/j.hcl.2012.08.022
Rioux-Forker D, Shin AY. Osteonecrosis of the Lunate: Kienböck Disease. J Am Acad Orthop Surg. 2020;28(14):570–84.
Croog AS, Stern PJ. Proximal Row Carpectomy for Advanced Kienböck’s Disease: Average 10-Year Follow-Up. J Hand Surg Am. 2008;33(7):1122–30.
Cross D, Matullo KS. Kienböck disease. Orthop Clin North Am. 2014;45(1):141–52.
Lichtman D, Pientka W, Bain G. Addendum: Kienböck Disease: A New Algorithm for the 21st Century. J Wrist Surg. 2017;06(01):e1–2.
Pablo Rodríguez Sánchez-Laulhé
Physiotherapist | PT & eHealth Researcher.
