Application of magnetic resonance imaging to ischemic necrosis of the lunate

Twenty patients (22 wrists), in whom ischemic necrosis of the lunate was suspected clinically, were studied prospectively by physical examination, conventional radiography, radionuclide bone scintigraphy, and magnetic resonance imaging. Magnetic resonance imaging showed more specificity than radiography or radionuclide bone imaging in making the diagnosis of ischemic necrosis of the lunate. Two patterns of lunate signal defect were seen on magnetic resonance imaging with focal or generalized signal loss on T1-weighted and T2-weighted images. Generalized loss of lunate signal on T1-weighted images was diagnostic for ischemic necrosis of the lunate. Focal signal loss on the radial one half of the lunate suggested early involvement. Normal or increased signal on the corresponding T2-weighted image implied an earlier stage and a better prognosis. Magnetic resonance imaging evaluation of the lunate may be useful for subclassification of Lichtman's radiographic stage 2 and can be employed to follow lunate revascularization after treatment. Magnetic resonance imaging is a low risk, noninvasive diagnostic technique, which can modify diagnosis, staging, treatment and prognosis of ischemic necrosis of the lunate.     

月骨摘除及豆状骨植入腕骨的应力研究

目的：为腕月骨摘除后，应用带蒂豆状骨植入与腕骨间融合术联合治疗腕月骨缺血性坏死，提供生物力学依据。方法：选用１０只离体上肢标本，在摘除月骨前、后及植入豆状骨以后，行舟骨－头状骨（ｓｃａｐｈｏｉｄ－ｃａｐｉｔａｔｅ Ｓ－Ｃ）融合及舟骨－大多角骨－小多角骨 （ｓｃａｐｈｏｉｄ－ｔｒａｐｚｏｉｄ－ｔｒａｐｅｚｉｕｍ Ｓ－Ｔ－Ｔ）融合，在持续缓慢加载下，采用电阻应变片测定各腕骨的应力。结果：（１）腕骨完整时，头状骨及月骨的应力最大；（２）月骨摘除后，腕骨的应力变化无一定规律性；（３）豆状骨植入后，豆状骨的应力最大；（４）行Ｓ－Ｃ或Ｓ－Ｔ－Ｔ融合后，豆状骨的应力减小。结论：实验结果证实，为了减少豆状骨植入后承受的应力，行局限性腕骨间融合是有效的。     

自体骨膜联合带蒂骨瓣移植替代月骨

目的 探讨治疗晚期月骨无菌性坏死、月骨陈旧性脱位的新术式。方法 对2例晚期月骨无菌性坏死及1例陈旧性月骨脱位行月骨摘除后,自体骨膜联合带血管筋膜蒂骨瓣移植替代月骨术。结果 随访8～36月,2例腕痛消失,1例腕痛缓解,保持了腕高、腕骨间的稳定和腕关节功能。X线照片示替代月骨骨瓣的位置及密度基本正常。结论 应用自体骨膜联合带蒂骨瓣移植作为月骨的替代物,对晚期月骨无菌性坏死及陈旧性脱位的治疗,操作简便、创伤小、临床效果好。     

Arthroscopic assessment of avascular necrosis

Avascular necrosis of the lunate is a process that is not well understood. The cause is uncertain, but a common theory persists that it is caused by disruption of the vascular supply to the lunate. This article discusses an approach to assessment that respects the articular cartilage and places at the front of the decision-making process the pathoanatomic components of the articular cartilage. It primarily respects the articular cartilage in the patient with avascular necrosis. This approach was developed for avascular necrosis of the lunate, but in principle applies to other joints with avascular necrosis as well.     

桡骨远端骨折合并月骨脱位的治疗

目的 探讨桡骨远端骨折伴月骨脱位的治疗方法.方法 2001年1月-2006年6月,对28例桡骨远端骨折伴月骨脱位的患者,其中新鲜损伤16例,采用手法复位石膏固定6例,微创撬拨复位、克氏针加石膏固定10例.陈旧性损伤12例,采用保守治疗后月骨再脱位3例,月骨漏诊9例;其中4例行掌侧入路月骨复位术,克氏针加石膏固定,8例行背侧入路月骨复位术,修复桡月背侧韧带,克氏针加石膏固定.腕关节功能按Lidstrom评分标准评定及腕部X线片检测有无月骨坏死.结果 术后28例获得随访时间为1～4年(平均2.2年),腕关节功能评分:新鲜损伤组优良率为93.8%,陈旧性损伤组优良率为75.0%.腕部X线片显示:新鲜损伤组月骨坏死率为0,陈旧损伤组月骨坏死率为25.0%.陈旧性损伤组掌侧切口入路月骨坏死率为50.0%,背侧入路月骨坏死率为12.5%.结论 桡骨远端骨折伴月骨脱位的治疗关键在于及时诊断和处理月骨脱位,避免发生陈旧性月骨脱位,后者手术以背侧入路复位固定并同时修复桡月背侧韧带为宜.     

Transient vascular compromise of the lunate after fracture-dislocation or dislocation of the carpus

Although classic avascular necrosis of the lunate is rare after fracture-dislocation or dislocation of the carpus, these severe carpal injuries can compromise the vascular supply of the lunate. The lunate thus develops a relative increase in radiodensity. Our finding of an incidence of 12.5%--three of 24 cases--suggests a relatively frequent occurrence. The clinical course was transient with resolution of abnormal radiodensity and subjective findings. Moreover, none of the three cases progressed to classic avascular necrosis of the lunate, Kienb?ck's disease. The clinician should not confuse this transient vascular compromise of the lunate with Kienb?ck's disease, but should be aware of the entity and its benign, self-limited course and should treat it expectantly.     

腕月骨无菌性坏死的病因学研究

目的：探讨月骨无菌性坏死的病因。方法：通过对腕关节机能解剖、月骨内微组织结构及腕关节X线影像学的研究，阐明月骨无菌性坏死的致病因素。结果（1）月骨的血运有20％由掌侧或背侧单一滋养血管供血或主要供血，这类单侧主干型血供的月骨易发生无菌性坏死。（2）月骨内骨小梁的走行方向由远端行向近端，相互平行，这与月骨的应力传导方向相一致。（3）月骨内微血管中央段的数量多而小，掌侧段血管稍粗大，血管面积及其与骨截面积比值最大。（4）病变组月骨呈掌屈畸形。结论：月骨无菌性坏死的病因是月骨内外多种因素作用的结果。     

头状骨移位替代坏死月骨的解剖研究及其临床应用

目的　介绍一种治疗晚期月骨无菌性坏死的新术式。方法　对 5 0侧上肢标本进行显微解剖并观测腕部的血管结构。对 10 0侧腕骨标本中头状骨与月骨进行对比观测 ,并做相关性分析。设计以骨间前动脉背侧支为蒂的头状骨移位术 ,替代坏死碎裂的月骨。临床应用 2 0例 ,术后随访 1～ 13年。结果　头状骨与月骨的几何形状、外径和关节面的弧高、弧长极其相似 ,相关性显著。移位的头状骨有可靠的血运。 2 0例头状骨移位替代坏死月骨者术后腕痛消失 ,保持了腕高、腕骨间的稳定和腕关节的功能。结论　该术式符合腕关节的功能解剖和力学传导 ,是治疗晚期月骨无菌性坏死的较好方法。     

Arthroscopic assessment and classification of Kienbock's disease

The authors have utilised arthroscopy to assess and classify Kienbock's avascular necrosis of the lunate. The classification is based on the number of articular surfaces of the lunate and adjacent articulation, which are non-functional. Kienbock's disease usually affects the proximal surface of the lunate first with subsequent secondary changes to the lunate facet of the radius. Advanced cases and those with a coronal fracture of the lunate will cause involvement of the mid carpal joint. Surgery is aimed to debride the joint, classify the level of disease and direct the definitive procedure to be performed. If the articular surfaces are intact, a synovectomy or radial shortening would be indicated. If there is involvement of the lunate but an intact lunate facet a proximal row carpectomy would be indicated. If there is involvement of the proximal lunate and lunate facet then a radio-scapholunate fusion could be utilised. More extensive involvement of the joint would require a wrist fusion. Arthroscopy provides a valuable assessment and subsequent classification of Kienbock's disease.     

Palmar dislocation of the scaphoid and lunate

A case of palmar dislocation of the scaphoid and lunate was complicated by a delay in the diagnosis and avascular necrosis of the lunate. Anatomic reduction was obtained 34 days after the injury. At 2 1/2 years follow-up the patient had good return of hand function and radiologic evidence of resolution of the avascular necrosis without evidence of collapse or intercarpal arthritis.     

Oblique shear fractures of the lunate

Traumatic fractures of the lunate are rare. This article presents two patients who had displaced oblique lunate fractures and distal radius fractures. Both fractures achieved union; however, transient avascular necrosis occurred in the proximal healing of one patient.     

Treatments for acute and old distal radius fracture with lunate dislocation

Purpose

Our study was undertaken to determine the correct treatment protocol for distal radius fracture with lunate anterior dislocation.

Methods

From 2000 to 2007, 58 patients (36 with acute injury and 22 with old injury) with distal radius fracture with lunate anterior dislocation were enrolled in the study. Among acute injury patients, 15 were treated through manipulative reduction and plaster fixation and 21 were treated through minimal invasive poking reduction followed by Kirschner wire and plaster fixation. Among old injury patients, 8 underwent operative reduction of lunate dislocation through the palmar approach and Kirschner wire and plaster fixation, whereas 14 patients underwent operative reduction and fixation through the dorsal approach combined with reparation of the dorsal radiolunate ligament. Lidstrom wrist function scores and the morbidity of lunate necrosis and osteoarthritis were documented and evaluated.

Results

Lidstrom wrist function scores revealed that the rate of excellent and good scores was higher in acute injury patients than in old injury patients (91.7 versus 54.5%, respectively; P = 0.018). The lunate necrosis rate was lower in acute injury patients than in old injury patients (0 versus 27.2%, respectively; P = 0.027). For old injury patients, the lunate necrosis rate was higher in those treated with the palmar approach than in those treated with the dorsal approach (50 versus 14.3%, respectively; P = 0.033).

Conclusions

The key points for resolving distal radius fracture with lunate dislocation are prompt and precise diagnosis and treatment of lunate dislocation to prevent old lunate dislocation. We recommend that the surgical procedure is performed through the dorsal approach with reparation of the dorsal radiolunate ligament.     

Coexisting Kienböck's and Preiser's Disease of the Wrist: Experience with Proximal Row Carpectomy with Dorsal Capsular Interposition Technique

Background

Idiopathic avascular necrosis of the lunate is known as Kienböck's disease and that of the scaphoid is known as Preiser's disease. Because the prevalence of coexisting Kienböck's and Preiser's diseases is very low, standardized stages of disease and treatments are not established.

Case Presentation

We report coexisting avascular necrosis of the scaphoid and lunate in a 68-year-old woman with no history of steroids or other risk factors. We treated her with proximal row carpectomy with capsular interposition technique. A distal-based dorsal capsular flap was prepared and repaired the palmar capsule. At the last follow-up, she had no pain and had gained improved range of wrist motion. There was no arthritic change at the newly formed radiocapitate joint.

Conclusions

In the case of collapsed lunate and scaphoid with avascular necrosis, the proximal row carpectomy procedure has an advantage. Proximal row carpectomy with dorsal capsular interposition can be performed when the lunate or scaphoid cannot be saved. Arthritic changes of the capitate head and distal radius lunate facet can be covered with the dorsal capsule.     

腕骨间融合联合带蒂豌豆骨移位治疗月骨缺血性坏死

对采用腕骨间融合联合带蒂豌豆骨移位治疗月骨缺血性坏死的疗效作一评估。用此法治疗月骨缺血性坏死（Ⅲ期，Ｌｉｃｈｔｍａｎ）８例．月骨切除后用带血管蒂豌豆骨移位替代月骨；腕骨间融合采用舟骨、大多角骨、小多角骨融合５例，舟骨、头状骨融合３例。随访８～４４个月，平均２９个月。８例腕痛全部缓解，腕关节活动比术前改善：背伸达正常侧的５８．８％，屈曲达５１．４％。握力比术前增加４６．９％。Ｘ线片结果：带蒂豌豆骨移位骨位置正常，无骨硬化；１例术后２年发现豌豆骨萎缩。８例病人中有６例恢复原工作，２例因社会原因改换工作。我们认为腕骨间融合联合带蒂豌豆骨移位是治疗月骨缺血性坏死Ⅲ期的一种有效方法．     

Cyst-like lesions of the lunate resembling Kienböck's disease: a case report

A 33-year-old man presented with a cyst-like lesion of the lunate resembling Kienb?ck's disease. Radiographs showed collapse of the proximal portion of the lunate and a lucent lesion in the triquetrum. T1-weighted magnetic resonance images showed a low signal in the collapsed part of the lunate but not in the remaining area. During surgery the lesion of the triquetrum contained serous fluid and the lunate was partially collapsed. Histologically, the triquetrum consisted of fibrous connective tissue and the lunate consisted of a mixture of bone, cartilage, and fibrous tissue without necrosis. The lunate lesion was diagnosed as a collapsed cyst-like lesion, although radiographs resembled Kienb?ck's disease. The lesion was successfully treated surgically with curettage, bone grafting, and external skeletal fixation. The patient is asymptomatic 3.5 years after surgery with some recovery of the trabecular pattern of the lunate.     

Palmar dislocation of scaphoid and lunate as a unit

A case of closed palmar dislocation of the scaphoid and lunate as a unit is described. This was treated by closed reduction and resulted in a good functional result as assessed at 1-year follow-up. No aseptic necrosis of the lunate or of the scaphoid developed. The only residual abnormality was an asymptomatic x-ray VISI pattern of the lunate. This is attributed to the disruption of the lunotriquetral joint. A functional analysis of the x-ray films with the wrist in radial and ulnar deviation indicated a normal arthrokinematic pattern.     

Double bundle tendon graft for rotational stabilization of lunate implant arthroplasty

Kienbock's disease can lead to unsalvageable collapse of the lunate due to avascular necrosis but with reasonably intact cartilage surfaces preserved at the head of the capitate and lunate fossa of the radius. An emerging alternative to traditional treatments for this stage is lunate implant arthroplasty with a hard material. Although, the problem of osteolysis previously seen with silicone implant arthroplasty is expected to be overcome, stabilization of both the implant and the carpus as a whole remains a challenge. The described surgical technique uses a double bundle tendon graft to stabilize the lunate implant against both excessive translational as well as sagittal plane rotational motions. The strategy also stabilizes the scaphoid and the carpus against intercalated segment instability and collapse.     

100?Jahre nach Kienb?ck

Kienb?ck's disease (KD) leads to collapse of the lunate bone with severe consequences for the wrist function which for some patients may result in occupational invalidity. The many synonyms of KD (aseptic necrosis or avascular necrosis) insinuate that the true etiopathology remains poorly understood. This reviews aims at exploring the level of evidence which brought forward the different hypotheses on the origin of KD. The widespread theories about the origin were formed about 100 years ago but a specific therapy is still not within reach. Although the cause of the disease remains essentially unknown it is officially recognized as an occupational disease in Germany. Empirical attempts to explain the etiopathology are based on compression of the lunate, impaired vascularity through vibration exposition, fracture and dislocation of the lunate from the radiolunate fossa. The level of evidence urges a cautious interpretation of currently discussed hypotheses on the etiology of KD.     

Surgical outcome of radial osteotomy for Kienböck's disease-minimum 10 years of follow-up

PURPOSE: Long-term results of radial osteotomy for Kienb?ck's disease seldom are seen in the literature. The purpose of this study was to report the minimum 10-year results and to compare them with the 5-year results to determine whether the favorable intermediate-term results were maintained. METHODS: Twenty-five patients who underwent radial osteotomy were followed-up for a mean period of 14.5 years. They were examined for pain, grip strength, and wrist range of motion (ROM). Through a review of clinical records, 5-year postoperative results were collected. The carpal height ratio and St?hl's index were measured and the x-rays were inspected for osteoarthritic changes. We devised an original lunate grade to evaluate radiologic improvement of the ischemic lunate. Overall results were evaluated using Cooney's wrist function score and Nakamura's scoring system for Kienb?ck's disease. The long-term results were compared with both the preoperative status and the 5-year results. RESULTS: Pain, ROM, and grip strength were improved significantly after surgery, and the results were maintained for a long period. Carpal height ratio and St?hl's index did not show significant improvements but ischemic lunate showed certain radiologic improvements with time by the lunate grade system. Osteoarthritic changes were observed in 54% of patients at 5 years and in 73% of patients at the final follow-up evaluation, but the arthrosis generally was mild and did not affect the clinical results. Cooney's wrist function score was excellent or good in 96% of the patients, and the results with Nakamura's scoring system for Kienb?ck's disease were excellent or good in 68% of the patients at the final follow-up evaluation. The percentages were the same 5 years after surgery. CONCLUSIONS: Radial osteotomy for Kienb?ck's disease is a reasonable treatment option and clinical improvement lasts for a long period of time. Although radiologic improvement was not drastic, the inner structure such as sclerotic change or bone cysts of the lunate improved with time, indicating healing of the ischemic lunate. Severe osteoarthritic change or proximal migration of the capitate can be avoided.     

Morbus Kienböck

Kienböck’s disease (carpal lunate necrosis or lunatomalacia) is the most common aseptic osteonecrosis of the upper extremity. Other bone necroses in the hand occur less frequently. The name indicates a disease with unclear etiology which eventually always leads to necrosis of the lunate bone. It usually affects the dominant hands of males between 20 and 40 years of age. Treatment methods extend from immobilization to revascularization surgery on the affected bone. There is still no gold standard for the treatment of Kienböck’s disease.