What are my treatment options?

There are a variety of treatment options, each of which depends on what stage of the disease you are in. These include simple casting, joint-leveling procedures, core decompression, revascularization, limited intercarpal fusions, proximal row carpectomy, denervation, total arthrodesis, or wrist arthroplasty. The exact procedure will be determined by you and your doctor based on your stage, but also your needs, work, hobbies, and activities.

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I've read that the vascularized bone graft is usually done in stages 3a and under. Why doesn't it work in Stage 3b cases?

One of the distinguishing events of stage 3b is total collapse of the lunate. Revascularization procedures are not likely to work in the face of severe collapse, for even if they are successful in re- establishing blood supply, lunate height and normal carpal kinematics will not be restored.

To better assess the degree of collapse in stage 3, one should establish the carpal height ratio. Carpal height is the distance between the base of the third metacarpal and the distal radial articular surface as determined on a posteroanterior roentgenogram of the wrist. The carpal height ratio is defined as the carpal height divided by the length of the third metacarpal. In normal individuals, this ratio is 0.54 ± 0.03. Carpal height ratio is becoming more important, as the factors determining results of treatment in stage 3 appear tied to the degree of collapse.

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Out of curiosity, why do the doctors shy away from doing the lunate implant.

There are a couple of main reasons. I think the biggest one is the retrospectively poor performance of the silicone replacement implants of the past. Beyond that, implants can become problematic, and most doctors, given a choice between an implant or a tried and trusted, repeatedly dependable, procedure are going to choose the latter.

Many years ago, KD was often treated by excising the lunate and replacing it with a silicone, or more specifically, a silastic replacement implant.

These silastic implants actually worked quite well, until they began to break down in the body resulting in some severe cases of silicone synovitis. Synovitis is inflammation of a synovial membrane, usually painful, particularly on motion, and characterized by fluctuating swelling, due to effusion in the synovial sac. In this case, the inflammation is caused by silicone particulate matter, and was extremely hard to "clean" out.

The silastic implants were used for several decades before being banned for this purpose. There are some people who had silastic implants for 20 years or more before failure.

The new class of titanium implants are much more durable then silastic implants, but they are still subject to wear and tear. Their particular track record can only be known over the course of time, but is expected to be far longer periods before erosion, along the same lines as an artificial hip, for instance.

I think for this reason, doctors are reluctant to put them in, and encourage the patient to accept a more traditional treatment. It's technically easier to do a fusion, for instance, and the results more reliable, so from the doctor's point of view, "one and done" is usually the course rather then take a chance with a potentially problematic implant.

What makes an implant problematic though? Aside from the aforementioned synovitis, there are many technical considerations. I think foremost may be age and activity level. Generally speaking, they try to avoid putting any kind of implants in young people because the likelihood is that it will need to be replaced (general wear and tear) several times within that person's life. Younger people are generally much more active and abusive with their joints and implants tend to fail rather quickly under those circumstances.

Another big consideration is the general condition of the joint itself. There should be no carpal instability, and all the ligaments and tendons must be in good shape. It is also very important to have the correct size implant. An oversized implant will certainly cause problems.

Other possible complications with a lunate implant are infection or inflammation. It's possible to break the implant, or implant rotation or subluxation, or (though rare) to have an allergic reaction to the implant material.

If you are the right candidate, I think it's a great solution. If you are older, calmed down in life, understand that you must be at least somewhat mindful of having foreign parts in ya, then it's worth looking into. If you are young and do yoga and weight lifting, rock climbing and mountain biking, and those kinds of things, then forget it.

If you feel that it might be appropriate for you, go for it! The only other problem you may have is actually finding a doctor who is properly trained and has experience with this procedure. A good place to start your search is at the manufacturers website.

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What if I opt for no treatment?

If you opt for no treatment, it is very likely that your Kienbock's disease will progress, and the joint will become unstable and severely arthritic. There are some people who choose to have no treatment and are able to live with and manage the disease, but it is usually with anti-inflammatories, analgesics, wrist bracing, and babying the affected joint. For most people, the pain becomes so crippling that they seek surgical relief.

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Will Kienbock's disease go away with no treatment?

It is highly unlikely for Kienbock's disease to resolve spontaneously on its own. There is some reason it developed, and it's unlikely that underlying reason would change without some sort of intervention.

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Does more pain mean it's getting worse?

No. Pain is not indicative of stage or progression, but as the disease progresses, it is quite likely to hurt more.

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Does a lot of pain mean I'm far advanced?

No. Pain is not indicative of stage or progression. Many people are diagnosed early because the pain is so severe, while others may progress all the way to stage 4 with little or no discomfort.

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Should I see a specialist?

Absolutely! A hand specialist is specifically trained to deal with problems and diseases of the hand, while a regular orthopedic surgeon has a more general background. Hand specialists have additional training and are much more qualified to treat this condition.

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Can I ever do my hobbies again?

With a successful treatment, you will more then likely be able to resume your hobbies again. In some cases you may need to adapt to the way you do things, but only in rare cases would you be likely to have to give up a hobby altogether.

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What about sports?

With successful treatment, you will more then likely be able to resume most sports again. In some cases, more extreme sports may become impossible. Rock climbing for instance. Much will depend on the stage of disease when diagnosed and how much ROM was initially lost. Generally speaking, the later the staging, the more problems you will encounter.

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Is Kienbock's disease caused by my job?

Kienbock's disease is not officially regarded as a repetitive strain injury (RSI), although it may be a cumulative trauma disorder (CTD), and a good argument could certainly be made in some cases. There are certainly jobs that would contribute to a person developing KD if s\he were predisposed to developing it to begin with. Any job with heavy repetitive loading of the wrists. Package handlers, or assembly line workers for example. People who work with power or pneumatic tools, particularly those that vibrate or jar (power sanders or hammers for instance). People who use their hands intensely on their jobs such as bakers and cake decorators.

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Is Kienbock's disease covered by WC?

There are many things involved in whether Kienbock's disease would be covered by WC. The most important factor is probably what State you live in and if your Kienbock's disease was the direct result of a workplace injury. It generally is not covered without some sort of substantiating statement from a specialist and a bit of argument, but there have been people who have been successful in their battle against WC.

Here's a tip: Try to use avascular necrosis of the lunate, osteonecrosis, lunatomalacia, asceptic necrosis, or osteochondritis when dealing with WC. Try to avoid the word "disease" in your dealings with them.

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How does a radial shortening work?

The association of a negative ulnar variance in individuals with Kienböck's disease provides the basic rationale for a radial shortening osteotomy in the treatment of this particular condition.

Many biomechanical studies have demonstrated both high compressive and tensile forces on the lunate during normal ranges of wrist motion. An osteotomy to realign the radiocarpal joint by shortening the radius attempts to lessen the presumably increased compressive forces on the lunate in patients who have a negative ulnar variance.

By "unloading" the lunate through this procedure, the possibility for secondary revascularization exists. It appears that the lunate "stands still in time" after a radial shortening, with no significant further deterioration being noted by objective measures. Nevertheless, evidence to concretely support revascularization is sketchy and subjective. The radiographic observation of lunate collapse (stage 3 disease) does not, by itself, represent a contraindication to the use of a radial shortening. In fact, excellent symptomatic relief with improvement in objective parameters is noted in patients with stage 3 disease.

A distinct advantage of radial shortening, in all stages of disease, is the nature of the procedure itself, allowing quick postoperative recovery and the ability to undertake more complex carpal reconstructive procedures should the need arise.

Radial shortening is a relatively simple procedure that should give relief of pain, increased postoperative grip strength, and postoperative improvement of range of motion, and is strongly recommended as a safe, reliable, and consistently successful method of managing Kienböck's disease, although it is recognized that further collapse and progression of disease may occur in stage 3 and 4.

Although some subjective evidence of revascularization of the lunate has been presented by several investigators, it does not appear that the external architecture of the lunate (be it collapsed or of normal height) improves with time after a radial shortening.

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