Although there is no cure, there are several surgical options for treating the more advanced stages of Kienböck’s disease.. The right procedure for you will depend on several factors, including disease progression, your personal activity levels and goals and my experience with various procedures. We will need to discuss this several times. The two most important pieces of information are the stage of your disease and the presence or absence of ulnar variance (the length of the ulna to the length of the radius).
Directly comparing the results of different techniques is difficult because most studies have a fairly small number of patients and short follow-up. However, our experience is that many of the techniques result in very similar rates of good outcomes.
Operative treatment can be classified broadly into six categories, including (1) lunate excision with or without replacement; (2) joint-leveling procedures; (3) intercarpal fusions; (4) revascularization; (5) salvage procedures; and (6) others. Let me explain them, in as simple English as the complex problem allows:
Remove the lunate (the medical term for this is "excision") with or without replacement
Remove only the dead lunate ("simple lunate excision")
Remove the dead lunate and replace it with some wadded-up tendon ("excision with soft-tissue replacement", usually fascial or palmaris longus tendon)
If the bones of the lower arm are uneven in length, a "joint leveling" procedure (shortening the longer bone or lengthening the shorter bone) has been done. Bones can be made longer with bone grafts, or shortened by removing a section of the bone. This reduces the compressive forces on the lunate and seems to halt progression of the disease. Forces on the lunate, caused by using the hand forcefully, are thought to flatten down the lunate, advancing the stage of the disease. This collapsing force can be reduced by 70% with an appropriate radial shortening or ulnar lengthening. Currently, radial shortening with a 3.5-mm metal plate is preferred over ulnar lengthening, as there is a lower complication rate and similar good outcomes. In patients with neutral or positive ulnar variance, shortening the radius is a poor idead. In this clinical situation, radial wedge osteotomies designed to decrease the radial inclination have been proposed. If the lunate is severely collapsed or fragmented, it can be removed. The two bones on either side of it are also removed. This procedure is called a proximal row carpectomy and will relieve pain while maintaining partial wrist motion.
Another way to ease pressure on the lunate is to remove some of the wrist bone joints and make them grow together into one or more bigger bones. This is called a fusion. If you make all of the bones grow together, it is called a complete fusion. Usually, we only do some of the bones, this is called a partial fusion. However, this approach may or may not improve range of motion, depending on whether the fusion is complete or partial, and on the stage of the disease, and on the amount of motion you started with. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function, although motion is limited. A variety of intercarpal fusions for the treatment of Kienbock disease have been used. The goal is to reduce forces on the lunate, crushing it down, and, in procedures that involve the scaphoid, to correct and maintain proper scaphoid position.
Of the limited intercarpal fusions used, the greatest experience has been with scaphotrapeziotrapezoid (STT) (triscaphe) fusion. STT arthrodesis (fusion) decreases lunate compression forcesby shifting it to the radioscaphoid joint. This can cause later problems. STT fusion in a cadaver model was found to have similar strain reduction to that of joint-leveling procedures but had greater loss of motion. The use of STT fusion has waned in recent years due to complications and longer-term follow-up revealing decreased success rates.
Scaphocapitate (SC) fusion has been used by some surgeons. Biomechanically, this fusion has been shown to reduce compressive forces at the radiolunate joint by about 10%. Some surgeons prefer this fusion because it requires only one fusion site and is technically easier to perform.
At the present time, intercarpal fusions more likely are reserved for patients with neutral or positive ulnar variance in whom a joint-leveling procedure is a bad idea.
In some cases, returning the blood supply to the bone (revascularization) may be possible. This procedure uses a bone graft from the bone of the lower arm with a very little artery attached. This is called, in medical terms, a vascularized bone pedicle. I want you to get used to this term, as I will use it when I discuss your options. Results with the use of pedicled distal radius grafts have shown improved grip strengths and progressive MRI evidence of revascularization over an 18 to 36 month period (Mazur). Revascularization techniques may also be combined with other previously mentioned approaches, particularly it may be combined with an external fixator, a metal device that helps relieve pressure on the lunate and preserve the spacing between bones. Revascularization is especially attractive for the young patient with ulnar neutral or positive variance in whom a radial shortening is not an option and in one who wishes to avoid an intercarpal fusion and resultant loss of motion
I am a 26 year old physical therapist assistant with stage 1 Keinbock's disease. I began experiencing symptoms about 6 months after starting my career as a PTA. Currently I am receiving treatment from a hand specialist in my area. He has put me in a cast and ordered a bone stimulator to help stimulate growth and healing of the bone. The insurance company denied coverage of the bone stimulator so I am paying out of pocket for it.
My first question is, how important is the bone stimulator to my healing process?
My second question is, if it heals and I go back to my job which appears to have caused the problem in the first place, is it likely to recur?