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KIENBOCK'S DISEASE

Introduction

Kienböck’s disease, or lunatomalacia, is idiovascular avascular necrosis of the lunate. Essentially, the blood supply to this carpal bone is compromised leading to lunate collapse and radioulnate degeneration. The pathogenesis of Kienböck’s disease is debated, but likely attributed to multiple inter-related factors, including individual patient differences in carpal anatomy, biomechanics and repetitive trauma. Ulnar negative variance, variations in lunate morphology, anatomic variations in lunate vascular supply, and certain wrist kinematics have all been implicated in the pathogenesis of Kienbock's Disease.

Related Anatomy

  • Lunate
  • Capitate
  • Hamate
  • Distal radius
  • Triangular fibrocartilage (TFC)
  • Ulnar variance

Incidence and Related Conditions

  • Kienböck’s disease usually affects those aged 20-40 years; most are male manual laborers
  • Typically unilateral; both sides can be equally affected
  • Frequently associated with a specific traumatic event

Differential Diagnosis

  • Ulnocarpal impaction syndrome
  • Fracture
  • Enchondroma
  • Intraosseous ganglion
  • Osteoid osteoma

Staging

  • Most common staging system developed by Stahl (1947)1 and modified by Lichtman et al (1977)2,3:
    • Stage 0 - Wrist pain with normal X-rays and normal MRI
    • Stage I - X-rays are generally normal, but a linear fracture through the lunate may be noted. MRI will demonstrate a diffuse T1 signal decrease in lunate. Bone scan will be positive.
    • Stage II - Sclerosis of the lunate will be seen on X-rays. Multiple fracture lines may be seen through the lunate. Collapse of the lunate has not occurred.
    • Stage IIIA - Lunate collapse has occurred, but the carpal height and alignment have been maintained.
    • Stage IIIB - Lunate collapse has occurred, and the capitate has migrated proximally. The scaphoid assumes a flexed position.
    • Stage IIIC - Lunate fragmentation or coronal fracture.
    • Stage IV - This is a continuation of stage IIIB disease with the addition of radiocarpal and/or midcarpal arthritis.
ICD-10 Codes

  • KIENBOCK'S DISEASE

    Diagnostic Guide Name

    KIENBOCK'S DISEASE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    KIENBOCK'S DISEASEM93.1   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Kienbock's Disease (Avascular Necrosis of Lunate)
    Kienbock's Disease (Avascular Necrosis of Lunate)
  • Kienbock's Disease (Avascular Necrosis of Lunate)
    Kienbock's Disease (Avascular Necrosis of Lunate)
  • Kienbock's Disease (AVN of Lunate) secondary to fracture which is rare.
    Kienbock's Disease (AVN of Lunate) secondary to fracture which is rare.
  • Kienbock's Disease (AVN of Lunate) Necrotic painful lunate excised
    Kienbock's Disease (AVN of Lunate) Necrotic painful lunate excised
Symptoms
Wrist pain
Wrist swelling dorsally
Decreased wrist motion (stiffness)
Decreased grip strength
Typical History

The typical patient with Kienbock’s disease is a young male with a mechanical job such as carpentry.  The complaint is usually unilateral dorsal wrist pain with a history of trauma or lees specific repetitive injuries.  Also, patients frequently complain of associated wrist swelling, decreased wrist motion and loss of grip strength.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • MRI Wrist T1 Kienbock's Disease
    MRI Wrist T1 Kienbock's Disease
  • MRI Wrist 2 Kienbock's Disease
    MRI Wrist 2 Kienbock's Disease
Treatment Options
Conservative
  • A short-arm cast can control pain and allow the lunate to revascularize, especially in children and teenagers.
Operative

Unloading

  • Stage I: short-term immobilization and activity modification
  • Stage I-IIIA: joint leveling procedure, radial shortening osteotomy, osteotomy and ulnar lengthening, capitate shortening, scaphoid-trapezoid-trapezium (STT) fusion
  • Various stages: closing radial wedge osteotomy

Revascularization

  • Various stages: vascularized bone grafts (VBG)
  • Capitohamate arthrodesis

Salvage procedures

  • Various stages: STT arthrodesis, scaphocapitate arthrodesis, proximal row carpectomy (PRC)
  • Stage IV: total wrist arthrodesis, PRC with dorsal capsular interposition
CPT Codes for Treatment Options

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Common Procedure Name
Proximal row carpectomy
CPT Description
Carpectomy all bones of proximal row
CPT Code Number
25215
Common Procedure Name
Ulnar or radial shortening osteoplasty
CPT Description
Osteoplasty radius or ulna shortening
CPT Code Number
25390
Common Procedure Name
Fascial arthroplasty, e.g. thumb fascial arthroplasty, (LRTI includes 26480)
CPT Description
Interposition arthroplasty, intercarpal or carpometacarpal joints
CPT Code Number
25447
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications

Unloading

  • Joint leveling: distal radioulnar joint (DRUJ) complications, partial wrist denervation
  • Radial shortening osteotomy: ulnar impaction syndrome, DRUJ dysfunction, nonunion
  • Capitate shortening: increased scaphotrapezial load

Revascularization

  • Infection

Salvage procedures

  • STT: surgical failure, nonunion
  • PRC: synovitis
Outcomes

Unloading

  • Immobilization: conflicting findings; some studies show improvement in pain and others show disease progression
  • Closing radial wedge osteotomy: ROM, grip strength and pain continue to improve after 10 years; however, 73% showed osteoarthritic changes and radiographic progression

Revascularization

  • VBG: ROM, grip strength, pain scores improved; 77% of patients showed no further collapse; 71% showed evidence of revascularization
  • Capitate shortening: 83% lunate healing and revascularization

Salvage procedures

  • PRC: satisfactory results; grip strength increased to 65% of opposite side
  • Total wrist fusion: fewer surgical failures, better post-op pain scores, higher patient satisfaction (vs carpal fusion)
Key Educational Points
  • When staging Kienböck’s disease, the most reliable method of differentiating between stages IIIA and IIIB is radioscaphoid angle of greater than 60 degrees. Lichtman stage IIIB of Kienböck’s disease implies sclerosis and fragmentation of the lunate accompanied by scaphoid rotation and carpal collapse/instability. Scaphoid position can be assessed by measurement of the radioscaphoid angle.
  • Negative ulnar variance is statistically associated with Kienböck’s disease.
  • Based on proximity the 4 +5 extensor compartmental artery graft is the recommended choice of bone graft for the treatment of early stages of Kienbock’s disease.
  • Vascularized reconstruction of the lunate in Kienbock’s disease is contraindicated for lunate fracture or collapse with extruded fragments.
  • Pediatric Kienbock's disease is more likely to heal with immobilization than adult Kienbock's disease especially in patients younger than age 12 with intact lunate morphology.
References

New Articles

  1. Stahl S, Hentschel PJ, Held M, et al. Characteristic features and natural evolution of Kienböck's disease: Five years' results of a prospective case series and retrospective case series of 106 patients. J Plast Reconstr Aesthet Surg 2014;67(10):1415-26.
  2. Viljakka T, Tallroth K, Vastamäki M. Long-term outcome (20 to 33 years) of radial shortening osteotomy for Kienböck's lunatomalacia. J Hand Surg Eur 2014;39(7):761-9.
  3. Lichtman DM, Pientka WF, Bain GI.  KIENBÖCK DISEASE: MOVING FORWARD. J Hand Surg (Am) 2016; 41 (May): 630-638.

Reviews

  1. Stahl S, Stahl AS, Meisner C, et al. A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration. BMC Musculoskelet Disord 2012;13:225.
  2. Lichtman DM, Lesley NE, Simmons SP. The classification and treatment of Kienbock's disease: the state of the art and a look at the future. J Hand Surg Eur 2010;35(7):549-54.

Classics

  1. Stahl, F. On lunatomalacia (Kienböck’s disease). A clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment. Acta Chir Scand Suppl 1947:126.
  2. Lichtman DM, Mack GR, MacDonald RI, et al. Kienböck's disease: the role of silicone replacement arthroplasty. J Bone Joint Surg Am 1977;59(7):899-908.
  3. Kienböck R. Über traumatische Malazie des Mondbeins und Kompression Fracturen. Fortschr Roentgenstrahlen 1910-11;16:77-103.
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