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Kienbock disease ( an overall View ) Mohamad Othman, MD 4-10 - 2012.

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Presentation on theme: "Kienbock disease ( an overall View ) Mohamad Othman, MD 4-10 - 2012."— Presentation transcript:

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2 Kienbock disease ( an overall View ) Mohamad Othman, MD

3 - KD ( or lunatomalacia ) is an idioopathic AVN of carpal lunate which may lead to collapse of the bone and arthritis in the advanced stage - first described in 1843 by Peste in cadaver dissections. - Robert Kienbock ( 1910), a radiologist, described the x-ray changes associated w KD. Definition & history

4 Epidemiology 15 and 40 years dominant wrist of men engaged in manual labor Natural history of KD remains unclear & un- predictable

5 - unknown ; theories : Fault plate hypothesis: Intrinsic ( lunate) & extrinsic factors elastic deformation of trabeculae 2ry to loading fault plates ---- wall off & interfere w capillary bl. Flow AVN Aetiology : - repetitive microtrauma in the lunate at risk ( predisposed lunate ) ;

6 Extrinsic factors: - capitate - lunate loading - ulnar variance : ulnar-negative variant wrist is common association ( Hulten, 1928). ulnar-positive variant - load type - instability

7 Intrinsic factors: - shape of lunate - trabecular pattern - cortical load - lunate vascular anatomy

8 Stage I: Radiographically normal lunate or with small fracture lines Stage II: Sclerosis of lunate Stage III A: Collapse or fragmentation of lunate Stage IIIB: Lunate collapse with carpal malalignment ie; proximal migration of capitate (carpal height ratio 60] Stage IV: Generalized wrist arthrosis Staging ( Modified Lichtman Classification )

9 Stage-I Stage-II Stage-III Stage-IV

10 Clinical picture - Complaint may precede XR changes - Varies according to stage - Pain. Tenderness,swelling, clunk w deviation, dec ROM, weak grip - Plain XR : views….. Measurements…. Staging. - CT - Scintigraphy - MRI : earliest diagnosis : uniform low signal in T1 Investigations

11 XR

12 Stahl index: Normally;B/A= 50% Carpal height ratio

13 CT scanning:

14 MRIMRI

15 Differential diagnosis: - ulnar impaction synd. ( MRI) - DRUJ arthritis - Lunate Fx, intraoss ganglion, enchondroma.

16 Objectives : (a) precollapse (b) postcollapse Methods : Established methods: Direct vascularization Indirect vascularization ( unloading procedures): joint-levelling procedures limited carpal fusions Salvage procedures: PRC wrist arthrodesis Optional & controversial methods: - conservative -Lunate excision ± replacement ( PL tendon ball, silicon, titanium) - Core decompression of distal metaphysis of R & U - Temporary ST pinning ; 3-6 mo. Stage III - External fixation - RSO in stage IIIB - RO + VBG in stage III - Wrist denervation; stage IV - Arthroscopic debridement Treatment

17 Stage I: Controversial ; not completely-unload lunate. Choice in transient ischemia. After 3 mo, aggressive management as stage II Stage I, II, or IIIA with Ulnar-Negative Variance : (1) Lunate unloading by joint-leveling procedures ( RS > UL) or (2) Lunate revascularization by VBG Stage I, II, or IIIA with Ulnar-Positive or Ulnar-Neutral Variance : (1) unloading by Capitate shortening ± capitate-hamate fusion or radius ost. (2) VBG ( ± STT-pinning) Treatment Algorithm

18 Stage IIIB : -intercarpal fusions (STT and SC ) - Proximal row carpectomy ( PRC) -RSO -Lunate excision Stage IV : - conservative - Proximal row carpectomy - wrist fusion- Treatment Algorithm ( cont.)

19 Radial shortening osteotomy Approach ; volar > dorsal 2-3mm ( not > 4mm ; UC impaction ) Meaphyseal / meta-diaphyseal Not decrease ROM Not in ulna positive wrist

20 Ulnar lengthening osteotomy Disadvantages;

21 Distal radius wedge osteotomy - Stage II or III w ulna-neutral or positive wrist - Lateral closing wedge osteotomy : decrease RU-inclination thus shifting press from lunate - Medial closing osteotomy or lat opening wedge o - Step- cut osteotomy

22 Capitate shortening osteotomy CSO + capito-hamate fusion

23 VBG Sources: - Base of 2 nd or 3 rd metacarpal -Neck of 2 nd meatacarpal -1,2 ICSRA - 2,3 ICSRA - 4 th or 5 th CA - Hori technique - Pisiform -PQ + unloading procedure: - external fixator or - temporary STT-pinning or - radius osteotomy

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25 1,2 ICSRA VBG 2,3 ICSRA VBG

26 4 th CA VBG : retrograde flow through 5 th CA from dorsal itercarpal arch

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28 Limited carpal fusion - Objective : redistribute stresses away from lunate - Correct scaphoid malrotation 1 st - SC / STT -Decreases ROM -Excise lunate; only if fragmented w marked synovitis

29 Triscaphe (STT) fusion SC- fusion Temporary STT-pinning

30 Prox raw carpectomy Total wrist fusion

31 Core decompression of distal metaphysis of R & U Incisions for wrist denervation

32 THANK YOU والسلام عليكم ورحمة الله وبركاته وشكرا


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