Keinbock's Disease: Surgery No Surgery?

[EKUSue]

I have been diagnosed with Keinbock's disease by a hand specialist and followed it with a second opinion by another hand specialist who concurred. I am a 60 year old WF in good enough health (meaning I'm a little overweight, active, and on no medications).

I sustained a bad thumb spring about 3 years ago and my wrist symptoms appeared about 2 years later. So, in July 2007 I noticed pain and swelling of the wrist after a day of gardening. I did the customary interventions of ice, antiinflamatories, and physical therapy before being diagnosed with Keinbock's in December 2008.

I am right hand dominant and it is my right hand that is effected. I am a college professor and talk and type for a living--to date my typing has not been overly effected. I am mainly treating it with a wrist splint and occasional tylenol. I wear the wrist splint 90% of the time including at night. I would say that I have a constant low level of manageable pain, and it seems to effect my entire arm/shoulder area (probably because I had some arm/shoulder pain before this diagnosis and it made it worse because of the limitations of the use of my hand).

The first hand specialist xrayed my hand and showed me the lunate bone which appeared bright white on the xray indicating that the bone had died. The second opinion said that pain usually occurs about 2 years after the bone dies and is associated when the bone actually begins to break up. I assume this was what I experienced in July 2007.

Both hand surgeons stressed "no cause, no cure". Althought instinctively I feel like it is related to several factors: a) I have small wrists; b) I like to do alot of manual labor; c) I sustained a bad thumb spring 3 years ago. Both surgeons said there were several surgeries but the general sense was that a wrist fusion would probably be the best solution.

Now to the questions:
1. What will happen if I don't do anything? Will it just keep getting worse and worse and eventually the pain will force me to do something? Is waiting bad and will it make it worse to wait by causing other damage in other parts of my hand?

2. What is the worst common thing that can go wrong with a wrist fusion surgery?

Any thoughts you have would be appreciated.
Sue Strong

[tmckeown85]

I am 6 weeks post-op Radial Shortening Osteotomy. I felt amazing for 3 days after surgery, and even took very little pain meds. After day 3, things started going down hill. I may be expecting too much, but I am having constant swelling and increased pain in my wrist. I have even more limited motion than before surgery. My strength is significantly impaired. I am unable to do every day things that I had no problem with before surgery such as showering, writing, brushing my teeth, shaving, etc. I am right hand dominant and had the operation on that side. My doctor says I do not need therapy or any follow up at this time. I, however, feel very dissatisfied with the surgery. He says my only other option is a PRC, or wrist fusion. I am 26 years old, and am a cosmetologist and RN by trade. Neither surgery seems to be a viable option for me.

[dr_simran]

Hello EKUSue,
Viennese radiologist named Robert Kienböck introduced the term "lunatomalacia" to describe the condition that bears his name. Kienböck believed that traumatic rupture of the ligaments and vessels around the lunate produced lunate fracture with subsequent collapse. Kienböck disease usually affects the dominant wrist of men aged 20-40 years. Although the underlying etiology is not known, the final results of fragmentation and collapse are secondary to osteonecrosis. Intrinsic and extrinsic factors have been implicated.
Numbers of options are available for surgical management of Kienböck disease. The 2 most important pieces of information are the stage of the disease and the presence or absence of ulnar variance.
Directly comparing the results of different techniques is difficult because most studies have a fairly small number of patients and short follow-up. However, review of the literature reveals that many of the techniques result in very similar rates of good outcomes.
Operative treatment can be classified broadly into 6 categories, as follows: Lunate excision with or without replacement, Joint-leveling procedures, Intercarpal fusions, Revascularization, Salvage procedures.
The following additional information would be of help,
Although initial success was seen with the use of a silicone spacer following lunate resection, this implant is no longer indicated. Alexander presented a 5-year follow-up of a group of 10 patients with silicone lunate replacements and noted 50% unsatisfactory results. Sixty percent of patients who had radiographs at final follow-up demonstrated evidence of silicone particulate synovitis. Lunate excision is not commonly recommended because of concerns of progression of carpal collapse. A fascial or palmaris anchovy replacement has had variable success in preventing subsequent collapse, although Carroll reported long-term (>10 y) success in a series of 10 patients treated with a fascial implant following lunate excision. He noted no evidence of carpal collapse, and all patients had unrestricted use of their hands.
Refer: http://www.emedicine.com/orthoped/TOPIC398.HTM

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