David J. Slutsky

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3475 Torrance Blvd., Ste F
Torrance, CA 90503

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In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.



Avascular necrosis
A loss of the blood supply or avascular necrosis of a wrist or carpal bone can result in gradual collapse of the bone followed by progressive wrist arthritis. The lunate is the most commonly affected bone. This condition is termed Kienböck’s disease. The scaphoid may also be involved, which is termed Preiser’s disease, but this is much less common.

Kienböck’s Disease
Kienböck was a radiologist who in 1910, directed attention to a condition that resulted in softening of and collapse of the lunate. The etiology of this condition has been debated ever since, despite the wealth of knowledge that has accumulated. There is a consensus that the changes in the lunate are due to loss of it’s blood supply, or avascular necrosis. Various authors are divided as to whether the inciting event consists of a single transverse fracture of the lunate v.s. numerous compression fractures from repeated compressive strains. Due to the tenuous blood supply of the lunate it becomes avascular, setting up a sequence of events that are marked by collapse of and fragmentation of the lunate. As this occurs, the smooth articular surfaces of the lunate become irregular. The capitate, which articulates with the distal surface of the lunate, settles down into the newly created space. This ultimately leads to the development of scapholunate dissociation and progressive radiocarpal and midcarpal degenerative arthritis.

Clinical Presentation:
Most patients present with the gradual onset of wrist pain with no obvious history of trauma. The pain is mechanical in nature in that it is precipitated by activity and is temporarily relieved by rest in the early phases. It is more common in men between the 2nd and 4th decades, but can occur in women and the elderly. Many patients are engaged in heavy manual labor. The wrist examination may show thickening of the capsule over the lunate, along with diminished wrist motion, localized carpal tenderness and reduced grip strengths. Occasionally the symptoms of carpal tunnel syndrome may be present. Patients who develop Kienböck’s often have an increased incidence of a relatively longer radius as compared to the ulna on an AP wrist x-ray, i.e. a negative ulnar variance, when compared to the general population.

The diagnosis is established by various imaging techniques. The disease has been classified into four stages. Stage I, is the acute stage, and is indistinguishable from a wrist sprain. X-rays are normal except for the possibility of a linear or compression fracture that may show up on tomography. An MRI may be diagnostic and can show a loss of bone marrow fat. This finding is not necessarily specific to avascular necrosis, but is significant if it involves more than _ of the lunate. Bone scans may show an increased uptake in the lunate. Stage II is present when there is increased density of the lunate which causes it to appear whiter than the surrounding carpal bones, but without collapse. Stage III shows lunate collapse with proximal migration of the capitate. There may be fragmentation of the lunate. Advanced stage III is present when there is associated scapholunate dissociation (link to kienbocks 1-3). Stage IV is present when there are generalized arthritic changes in the radiocarpal and midcarpal rows. Arthroscopically one may see a marked loss of joint cartilage with cartilage fragments hanging down into the joint (link to kienbocks 4).

Wrist immobilization has been attempted by many authors but reports of unsatisfactory results and progressive collapse of the lunate are common. Stage I, II and early stage III may be treated with joint leveling procedures or revascularization procedures. If the patient has an ulnar minus variance, the forces across the lunate can be diminished by shortening the radius or lengthening the ulna, so that the ulna bears more of the load across the wrist. If the patient has an ulna neutral or positive variance, a capitate shortening osteotomy or a capitohamate fusion without shortening have been shown to have the same effects biomechanically and clinically. An alternative approach has been to revascularize the lunate directly. This can be done by inserting a vascularized bone graft pedicled on the pronator quadratus muscle, or by transplanting a vascularized bundle into the lunate. Results in a number of series are encouraging with either approach. These procedures cannot restore a lunate that has already collapsed, and they should not be used when carpal instability has occurred. In these cases, some type of partial wrist fusion is indicated, along with excision of the lunate and/or replacement with a soft tissue spacer, usually a rolled up tendon graft. Stage IV is generally managed by either resecting the 3 carpal bones of the proximal carpal row (i.e. a proximal row carpectomy) or a partial wrist fusion (link to Kienbocks 5). Both of these procedures preserve wrist motion to a variable degree. Occasionally, a total wrist fusion is indicated, especially for manual laborers who may need strength more than motion. Total wrist arthroplasty is generally not indicated for young vigorous patients.

No single treatment course has been universally successful. The treatment must be individualized to the patient’s specific anatomy and needs. In the early stages, efforts are directed towards salvaging the lunate and preventing the loss of the normal wrist architecture by altering the natural course of the disease. In the later stages treatment is directed towards restoring wrist architecture, and in the end stages the architecture is sacrificed to restore function.

Preiser’s disease
This is much less common than Kienbocks. It involves partial or complete involvement of the scaphoid bone (link to Preisers 1,2). There are no large studies on the treatment of this condition hence a standardized approach is still lacking. With partial scaphoid bone involvement, resection of the avascular portion and replacement with a soft tissue spacer such as freeze dried fascia lata, can provide short term relief (link to Preisers 3-5). Inevitably, radiocarpal arthritis ensues which may require a more extensive procedure (link to Preisers 6).