Houston Methodist. Leading Medicine

Hand FAQ

Question:

Do you think there's any way I can get by without surgery for stage 3 Kienböck disease? I'm trying to consider all my options.

Answer:

Kienböck disease is a condition in which one of the small bones of the wrist (the lunate) loses its blood supply and dies, causing pain and stiffness with wrist motion. In the late stages of the disease, the bone collapses, shifting the position of other bones in the wrist. This shifting eventually leads to degenerative changes and osteoarthritis in the joint. It's the progression of this disease that concerns physicians and why treatment is recommended in most cases. Surgical procedures are usually recommended based on staging of the disease. Staging of any disease is a way to classify the condition based on severity. In the case of Kienböck disease, X-rays are used to determine each stage. The following is a brief summary of the stages.
  • Stage 1: There is normal bone density without sclerosis; possible fracture lines; decreased signal throughout the bone is seen on MRI.
  • Stage 2: Sclerosis throughout the lunate bone can be seen on X-rays; fracture lines often present but bone is not collapsed and joint is not narrowed.
  • Stage 3: The lunate bone has collapsed causing narrowing of the joint surface; this stage is divided into two parts. Part A: lunate has collapsed but without loss of joint alignment. Part B: There is lunate collapse plus other bones around the lunate have now shifted causing changes in wrist alignment.
  • Stage 4: Lunate collapse and arthritis of the wrist. X-ray findings and staging direct treatment but not without consideration for your symptoms. Some people can have severe symptoms with Stage 1 disease. Others can have no symptoms despite Stage 4 disease. And every possible combination can occur between those two extremes. Most of the time, Stage 1 disease is treated conservatively with splinting or some other kind of immobilization. This gives the wrist a rest and the bone a chance to heal. When you have Stage 2 or even Stage 3A disease, the focus of treatment is to restore blood supply to the bone and prevent the disease from getting worse. In these cases, the surgeon has several options to choose from including the old tried and true "traditional" approaches as well as some new treatment procedures. Some of the more traditional methods include pinning the bone in place, taking a piece of bone out of the radius (forearm bone) to help take pressure off the wrist, or shortening one of the other wrist bones to unload the lunate. One of the newer procedures involves bone grafting (e.g., pedicled bone graft or vascularized bone transfer). This approach amounts to taking bone that still has a good blood supply and using it to help create new and improved circulation to the defected area in the wrist. There are limited long-term studies showing the results of these procedures but early results show no further bone collapse or disease progression. Stage 3B and Stage 4 require a different approach because the lunate bone has collapsed and sometimes the other bones have shifted as a result of the collapse. Choices of surgical treatment for Stage 3B disease include arthrodesis (bone fusion), osteotomy (partial bone removal), or complete excision (removal) of the lunate with soft tissue put in its place (called interposition arthroplasty). Removing all of the bones in the first row of the wrist (called carpectomy) may be done when the Stage 3 disease process is more severe. But studies show this isn't an ideal solution as patients often end up having the wrist fused. It is not recommended for anyone under the age of 35. Stage 4 disease is considered past the point of being able to restore or reconstruct the bone, joint space, or alignment. Arthritis has permanently altered the joint so that treatment is considered more of a salvage approach. In other words, the surgeon does what he or she can to save as much as possible without further destroying the wrist. The hope is to ease the patient's pain and prevent further progression of disease. In some cases, the nerves to the wrist have to be cut to achieve pain control. So you can see that some of the decision will be based on whether you have Stage 3A or 3B disease, your symptoms, and the need to prevent further deterioration. Your surgeon will be the best one to advise you. Don't hesitate to seek a second opinion if you need further reassurance of the best treatment path for your particular situation. Kevin Lutsky, MD, and Pedro K. Beredjiklian, MD. Kienböck Disease. In The Journal of Hand Surgery. September 2012. Vol. 37A. No. 9. Pp. 1942-1952.

    *Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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