|
Abstract:
Aseptic
osteonecrosis of the lunate bone is a rare disease of unknown
etiology. The mechanical theory of shearing of the lunate
underneath the radius is generally accepted, especially in the
presence of a short ulna, even if it is insufficient. The
diagnosis is exclusively radiographic and in the early stages,
the use of MRI which is more sensitive and specific than bone
scan. Plain X-rays allow the disease to be classified into
various stages, which determine the therapeutic indications.
Many treatments have been proposed, but the follow-up is often
inadequate and there is no strong evidence to support the use of
one procedure over the other.
J.Orthopaedics 2008;5(1)e4
Keywords:
AVN, Lunate , approach
Introduction:
Kienbock's disease
is a isolated disorder of the lunate which occurs mainly among
patients between 20 and 40 and is twice more common in men than
in women (1). It is felt to be more common in
laborers, as described by Kienbock,s in his original article,
"all the women were housemaids" and all but one of the
men were laborers of various types including; "quarry
workers, coachmen, bricklayers and soldiers". Nakamura
(1991) (2) demonstrated a similar clinical history
with sports related Kienbock's disease. Often carpal AVNs get to
definitive imaging findings only after longstanding clinical and
conventional diagnostic procedures. However, according to
current results it is possible to diagnose these lesions at a
stage where the medullary and osseous tissue is not yet
irreparably damaged (3). In addition, computed
tomography (CT) and magnetic resonance imaging (MRI) provide a
more detailed imaging of the reparation processes.
ETIOLOGY
AND PATHOGENESIS
Due to the unclear etiology of Kienbock's disease several
predisposing conditions and initiating as well as modulating
factors are up to now, controversially discussed. Mainly in
manual workers chronic repetitive trauma is considered to damage
supplying arteries of the lunate.. Gelberman (4)
described the vascular supply to the lunate, with three general
patterns, Y, X, I (see figure 1). The vessels can enter the bone
only at the dorsal and palmer poles, due to the articular
cartilage surrounding the rest of the surface.
figure 1. schematic representation of Y, X, I vascular
patterns in the lunate
Panagis
et al. (5) demonstrated only a volar blood supply in
the 20% of the lunates. The remaining 80% of the specimens had a
volar and dorsal supply and X, Y, I pattern of anastomosis.
Gelberman et al.’s studies (4) showed that in
7–26% of specimens there is only a single volar or dorsal
blood supply to the lunate.
According to an observation by Hulten (6),
lunatomalacia is associated with a negative ulnar variance in
78% of the test population. Due to inadequate force transmission
from the ulna to the wrist, the lunate is exposed to an
increased axial load in the radiolunate articular cornpartnient.
In Kienbock's disease, a dynamic process of bone
remodelling is found in pathoanatomical studies, Due to the
effect of initiating and modulating factors, the remaining areas
of viable osseous tissue facilitate reparation and
revascularization processes. Increased perfusion causes zonal
osteopenia which is regarded as the basis of pathological
fracture. Subsequent fibrovascular tissue in the fractured area
cannot be transformed into osseous tissue-point of no return.
Separation and osteonecrosis result in bone collapse. Collapse
of the lunate is followed by carpal instability and decreasing
height of the proximal carpal row. The instability is
characterized by proximal migration of the capitate and rotatory
subluxation of the scaphoid (dorsal subluxation, palmer
rotation). The resulting malarticulation leads to osteoarthritis
mainly in the radiocarpal joint compartments (7-9)
SIGNS
AND SYMPTOMS
Patients often present with an insidious history of wrist
pain. 72% of patients give a history of trauma, usually a fall
on the extended hand, although it is often elicited in
retrospect and may be treated as a "sprain" acutely.
Patients present months, even years later with limitation of
motion in the wrist, especially palmar flexion, weakness (grip
can be decreased by 50% as compared to the opposite hand), and
tenderness over the dorsal central aspect of the wrist.
CLASSIFICATION
Staging
classification of Kinnock’s disease on radiological and MRI
criteria. Lichtman (10)
Stage MRI and
conventional radiography
I Normal
radiographic appearance,diagnosis by MRI only
11 Increased
spongiosal sclerosis,initial fracture of the proximal pole
possible
III (a) Lunate
collapse without carpal instability
III (b) Progessive
lunate collapse with carpal instability
IV Progessive
carpal collapse and ostcoarthritis (SLAC wrist)
Lichtman and
coworkers have
proposed a classification in stages III (a) and III (b)
depending on presence of carpal instability. A reliable
criterion of instability in stage III (b) is the so-called 'ring
sip', the orthograde view on the distal pole of palmar tilted
scaphoid. Decreased height of the lunate can be evaluated with
the quotient of deformation i.e. the relation of longitudinal and sagittal diameter
of the lunate (normal 0.53mm). More commonly used is the carpal
index of Youm (11), i.e. the relationship of the
length of the carpus to the length of the third metacarpal bone
(average 0.54 ± 0.03).
In stage IV there
are signs of Perilunar osteoarthritis (decreased width of
interarticular spaces, subchondral sclerosis, manifestation of
osteophytes and
sometimes with articular loose bodies.
CT enables an
earlier and more extensive detection of pseudocystic inclusions
within spongiosal sclerosis (stage II), otherwise Occult or
typically shell- formed avulsion fractures at the proximal pole
(stage III (a)) and signs of perilunar osteoarthritis.
ARTHROSCOPIC
CLASSIFICATION (Gregory I. Bain)
-
Grade
0 All articular surfaces are functional
-
Grade
1 One non-functional articular surface typically the proximal
lunate.
-
Grade
2 Two non-functional articular surfaces.
-
Grade
2A The non functional articular surface of proximal
lunate and the lunate facet of the radius
-
Grade
2B Non Functional proximal articular surface of the lunate, and
distal articular surface of the lunate
-
Grade
3 Three non-functional articular surfaces. The lunate facet of
the radius, proximal and distal articular surfaces of the
lunate, with a preserved capitate
-
Grade
4 All four articular surfaces
DIFFERENTIAL
DIAGNOSIS
Differential
diagnosis includes the rare fractures of the lunate without
consecutive necrosis, the ulnolunar impaction syndrome, Carpel
Instability, Scaphoid injury (Fracture/AVN) , Tenosynovitis of
the extensor compartment, AVN Capitate and intraosseous ganglia
originating from the scapholunar or lunotriquetral ligament.
TREATMENT
Reconstruction of
the natural course of lunate necrosis is difficult because of
incomplete findings, especially in the initial stages. The
necrosis progresses steadily from initial lunate oedema with a
normal X-ray appearance to condensation, fragmentation and
collapse of the lunate within months. The collapse of the whole
carpus means a dramatic deterioration in therapeutic
possibilities not much later. In order to start treatment
successfully in the initial stage, suspicious findings should be
repeatedly followed up by X-ray films and magnetic resonance
imaging. The development of degenerative changes often takes
years.
The treatment of Kienböck’s disease is difficult at
stage III. The symptomatology at this stage is linked to
rotatory subluxation of the scaphoid . Most authors advocate
surgical treatment in order to avoid further deterioration of
the wrist. Many forms of operative treatments have been
described but it seems that none of them has proved its complete
effectiveness in the long term. Among the most frequently
proposed treatments are the Conservative treatment with cast,
revascularization of the lunate, radial shortening, Ulnar
lengthening and STT arthrodesis, scaphocapitate arthrodesis,
Vascular Bone grafting, lunate resection and vascularized
pisiform / capitate , Proximal row carpectomy , Prosthetic
replacement, and wrist fusion.
Joint
levelling procedures have been advocated for the treatment of
Kienbock’s disease by several authorities (12-14)
with ulnar lengthening and radial shortening or osteotomy. In
the literature, the number of cases managed by these procedures
is small, and most of these series include cases regardless of
the stage. There is an agreement that stage 2 and stage 3a cases
are best managed by joint leveling procedures. It is the stage
3b cases that are subject to much debate, with
scapho-trapezio-trapezoid or scapho-capitate fusion with or
without lunate excision being a treatment modality. Proximal row
carpectomy and vascularised grafting have also been advocated.
Person (1945) (15) classically described ulnar
lengthening in Kienbock's disease, after Hulten's observation of
the ulna-minus variant. According to A.A.Kawoosa, S.A.
Dhar,M.R.Mir (16) the
distraction osteogenesis addresses almost all the problems of
ulnar lengthening encountered in the earlier series, often
raised objections are non-union, graft site morbidity, healing
of the osteotomy at two sites, hardware removal and the exact
control of the lengthening by the Armistead technique (17) . Inherent to this process of distraction
osteogenesis is the attainment of the exact length as planned
preoperatively. This is helpful in avoiding ulnar impingement
and relief of pain routinely occurs in approximately 90%, with
improvement in range of motion and strength. Most of the author
advocate stages 3a are best manage by ulnar lengthening
According to Prommersberger , Sauerbier et al, Trankle et
al. Stage IIIb is
considered the ideal indication for STT (18-20)
.According to S. Van
den Dungena,*, M. Duryb, G. Foucherb, (21) the
conservative treatment seems to be superior compared to STT
arthrodesis. STT
arthrodesis does not improve the hand function as evaluated by
the DASH score. Since the scores are relatively good in the two
groups, it seems that patients generally adapt them selves
progressively to the disease. Nevertheless, operated patients
complain more often of barometric pain. The analysis of the
X-rays progression shows deteriorations in the conservative
treatment group. However, there is little clinical implication
and this deterioration is very slow. Finally, the number of
lunatum fractures and the evolution from stage III to IV among
operated patients raise the question whether STT arthrodesis is
really able to stop or decrease the long term worsening of the
disease. However, even if the two groups are statistically
comparable with regard to the clinical and radiological initial
parameters, the limited number of reviewed patients, the lack of
randomization of the type of treatment and the heterogeneity of
the stages recommend being cautious drawing the conclusions.
Recently,
radial shortening was shown to be a reliable method in the long
term. Radial shortening is also performed, and has the advantage
of not requiring a bone graft. Both procedures (often referred
to as joint leveling procedures) unload the lunate by
distributing the force to the ulnar head and triangular
fibrocartilage. Success of these procedures is widely documented (22, 23). Excessive radial shortening is the primary
complication in the radial shortening procedure, according to
Nakamura (24) this occurs if the radius is shortened
> 4mm, and results in ulnar wrist pain. All authors warn that
in late stages of Kienbock's disease, especially with carpal
arthritis, joint leveling procedures may not be effective at
relieving pain and a salvage procedure may be more appropriate.
Animal studies have confirmed that simultaneous shortening of
both radius and ulna reduce the compression forces in the
radiolunate joint induced by forearm muscle contraction. Shibata (25) performed radial shortenings, with or without
ulnar shortenings in all patients with stage I–III
Kienbock’s disease were investigated at a median of 19 years
after surgery. The clinical outcomes were excellent or good in
six and fair in eight patients. Grip strength did not improve,
possibly because of the shortening of the radius, but it was 87%
of the unaffected side and all the patients were satisfied with
the outcome of surgery.
The recent development of vascularised bone grafts
from the distal radius seems to have excellent early clinical
and radiological success, as described by (26-30).
Vascularised bone grafts have the advantage of immediate
implantation of viable bone. One does not have to wait for
secondary revascularization of a cancellous bone graft and
avoids the temporary weakening of the grafts.
Other methods of decompressing the lunate include
capitohamate fusion, scaphocapitate fusion and capitate
recession. Biomechanical studies indicate that decompression is
greatest with a joint leveling procedure, and that STT and SC
fusions are more effective that capitohammate fusion. STT fusion is more effective in unloading the lunate if
the scaphoid is fused in neutral or slight extension have both
demonstrated good symptomatic relief with STT fusion .(31-35)
Proximal row carpectomy has been used with limited
success in Kienbock's disease (36). The comparison
with limited carpal fusions with proximal row carpectomy and
concluded that the overall results of proximal row carpectomy
are better then any carpal arthrodesis (STT fusion with lunate
excision) though the ideal treatment of advanced Kienbock’s
depends on the patient’s age, sex, job and the stage of
disease. (37) had a mixture of limited carpal fusions
in their series. They concluded that STT fusion with or without
lunate excision and replacement is recommended in selected
patients with advanced disease who have a fragmented lunate.
They also point out that in advanced Kienbock’s disease the
radiolunate fossa is diseased. In proximal row carpectomy the
axial load passes through the artificially created
readiocapitate joint which sits in the lunate fossa. The
proximal row carpectomy would be disadvantageous as the lunate
fossa is diseased and hence the results of the procedure might
be poor. They recommend this procedure for all stages 3 and 4 of
Kienbock’s disease.(38) Even when the head of the
capitate or the lunate fossa shows degeneration on the
pre-operative radiographs in stage 4 cases, a proximal row
carpectomy can be performed and a satisfactory outcome obtained.
Lunate excision is the oldest treatment for Kienbock's
disease, and although carpal collapse occurs, the patients have
good relief from pain and reasonably good function (39).
More recently this void is being filled with a coiled tendon
(anchovi) or silicone implant. Results of this procedure are not
well established (40, 41). Although early success was
demonstrated with silicone replacement arthroplasty (42)
silicone synovitis and carpal collapse in a high percentage of
long term follow-up patients make this choice less appealing (43-45).
Silicone alloarthoplasty of the lunate has been shown to be
deleterious to the wrist because of silicone synovialitis and
inability to stabilize the carpus; however, replacement of the
lunate by biological material such as the transposed
vascularized pisiform (saffars procedure) potentially can stop
carpal collapse Saffar’s procedure (46) is one
option for advanced stages of Kienböck’s disease (stages
IIIa–IV), with a fixed and narrow radiocapitate distance being
its limitation. In approximately half of our patients
progression of carpal collapse was noted in the long term and we
could not identify any predicting factors for it. It is most
probable that deterioration was caused by compromised perfusion
of the pisiform and that magnetic resonance imaging could be
used to assess the reliability of the postoperative blood
supply, a method we did not use routinely at the time of
surgery. Further support for this hypothesis is the inferior
outcome in patients with sclerotic pisiform, which is an
indirect sign of diminished perfusion. On the other hand the
transposed pisiform might not have sustained the increased
pressure, resulting in flattening and sclerosis. It is most
likely that more vascularity of the transferred pisiform was
preserved by a longer immobilization period. Alternatively a
temporary external fixation with moderate traction could have
decreased the initial pressure to the pisiform, possibly
resulting in a decreased number of cases with vascularity loss.
An insufficient refixation of the radiolunate and scapholunate
ligaments to the pisiform also could explain the carpal collapse
in some patients. After an average follow-up period of 10 years
osteoarthritis occurred in 10 of 21 patients and a considerable
percentage suffered from severe carpal degeneration.
Gregory I. Bain (47) reviewed the Arthroscopic
assessment of Kienbock disease, the principles of treatment are
to perform a synovectomy as part of the arthroscopic procedure.
A reconstructive procedure is then performed, depending upon the
arthroscopic findings. They adopt the principle that the chosen
reconstructive procedure will address the non-functional
articular surface and will utilize remaining functional
articular surfaces. Grade 0: an extra-articular procedure is
recommended. An extra-articular unloading procedure may be
indicated. If there is negative ulnar variance then a radial
shortening osteotomy is indicated. For neutral or positive ulnar
variance a capitate shortening procedure can be performed. A
revascularization procedure could be indicated in this group.
Grade 1: Proximal row carpectomy or a radioscapholunate fusion
can be performed. Grade 2: Two non-functional articular
surfaces. Grade 2A: The radioscapholunate fusion will remove
both non- functional. Grade 2B: This typically occurs when there
is a coronal fracture in the lunate. This is best managed with a
proximal row carpectomy. Grade 3: Usually there will be only a
functional capitate articular surface. Theoretically this could
be managed with a hemiarthroplasty. Alternatively, a salvage
procedure such as a total wrist fusion or arthroplasty is
indicated. Grade 4: Total wrist fusion or arthroplasty is
indicated.
COMPLICATIONS
Spontaneous
extensor tendon rupture has been reported to be associated
commonly with displaced or nondisplaced distal radius fractures
or inflammatory diseases, such as rheumatoid arthritis. Although
several flexor tendon ruptures caused by the volar displacement
of a lunate fragment in Kienböck’s disease have been
reported, (48) and Kienböck’s disease can cause
multiple extensor tendon ruptures by chronic attrition from a
dorsally displaced fragment of the lunate. The spontaneous wrist
fusion in literature secondary to kienbock disease in 18 years
old male reported. (49)
SUMMARY
Kienbock’s
disease remains a difficult entity to treat. Until the etiology
and natural history of the disease are understood, treatment
will continue to be based on attempts to decrease load across
the lunate or bring a blood supply to it. There is no single
procedure that could be used to treat patient with advanced
Kienbock’s disease. The best procedure will depend on patient
age, patient expectations, occupation of patient and findings
seen after extensive arthroscopic evaluation.
Reference :
-
Yoshida T, Tada
K, Yamamoto K et al. Aged-onset Kienbock's disease. Archives
of Orthopaedic and Trauma Surg, 1990; 109(5):241-6
-
Nakamura R,
Imaeda T, Suzuki K et al. Sports-related Kienbock's disease.
American J Sports Medicine. 1991;19(1):88-91
-
Schmitt
R,
Fellner
F,
Obletter
N. Diagnosis and staging of lunate necrosis. A
current review. Handchir
Mikrochir Plast Chir. May 1998; 30(3):142-50
-
Gelberman RH,
Bauman TD, Menon J et al. The vascularity of the lunate bone
and Kienbock's disease. J Hand Surq. 1980; 5(3):272-8
-
Panagis
JS, Gelberman RH, Taleisnik J et al. The arterial anatomy of
the human carpus. Part II: the intraosseous vascularity. J
Hand Surg. 1983; 8A:375,
-
Hulten O .Ober
anatomische Variationen des Handgelenkknochen. Acta Radiol.
1928;9:155–168
-
Beckenbaugh RD
, Shives TC, Dobyns
JH et al . Kienböck’s disease: the natural history
of Kienböck’s disease and consideration of lunate
fracture. Clin Orthop. 1980;149:98–106
-
Kristensen
SS, Thomassen E, Christensen F. Kienböck’s
disease-late results by non-surgical treatment: a follow-up
study. J Hand Surg [Br] 1986;11:422–5
-
Keith
PP, Nuttal D, Trail I. Long-term outcome of
nonsurgically managed Kienböck’s disease. J Hand Surg
[Am] 2004;29:63–7
-
Lichtman
DM, Alexander AH, Mack GR et al. Kienböck’s
disease: update on silicone replacement arthroplasty. J
Hand Surg [Am] 1982;7:343–7
-
Youm Y,
McMurtry R, Flatt A, et al .Kinematics of the wrist. An
experimental study of radial-ulnar deviation and
.exion–extension. J Bone
Joint Surg, 1978; 60-A : 423–431.
-
Lichtman DM,
Mack GR,
MacDonald
RI
et al.
Kienbock's Disease: the role of silicone replacement
arthroplasty. J Bone Joint Surg (Am). 1982; 59(7): 899-908.
-
Axelsson R,
Moberg E The treatment of Kienbo¨ ck’s disease and the
role of joint levelling operations. In: Razemon JP, Fisk GR
(Eds) The wrist.
Edinburg
and
New York
: Churchill Livingstone.1988; 194–201.
-
Nakamura R,
Imaeda T, Miura T Radial shortening for Kienbo¨ ck’s
disease: factors affecting the operative result. J Hand
Surg. 1990; 15B: 40–45
-
Persson,
Mauritz. Pathogenese und Behandlung der KienböckschenLunatummalazie:
Der Frakturtheorie im Lichte der Erfolge operativer
Radiusverkürzung (Hulten) und einer neuen
Operationsmethode-Ulnaverlängerung.Acta Chir.
Scandinavica, Supplementum 98, 1945.
-
A. A. Kawoosa ,
S. A. Dhar , M. R. Mir . Butt. Distraction osteogenesis for
ulnar lengthening in Kienbock’s
disease.International orthopaedics (SICOT) 2007,31:339-344
-
Armistead RB,
Linscheid RL, Dobyns JH .Ulnar lengthening in the treatment
of Kienbock’s disease. JBJS (Am). ,1982; 64(2):170–178
-
Prommersberger
KJ, Krimmer H, Hausser D .STT arthrodesis as therapy of
lunate necrosis in an advanced stage. Handchirurgie
Mikrochirurgie Plastische Chirurgie, 1998; 30: 181–187.
-
Sauerbier M,
TrankleM, Erdmann D . Functional outcome with
scaphotrapeziotrapezoidarthrod esis in the treatment of
Kienbock’s disease stage III. Annals of Plastic Surgery,
2000; 44: 618–625
-
Trankle M,
Sauerbier M, Linsner G et al .STT arthrodesis for treatment
of stage III semilunar bone necrosis: functional outcome.
Handchirurgie Mikrochirurgie Plastische Chirurgie, 2000;32:
419–423
-
S.Van den
Dungena, M. Duryb et al. Conservative treatment versus
scaphotrapeziotrapezoid arthrodesis for Kienbock’s
disease. A retrospective study.chirurgie de la main.25,2006;
141-145
-
Weiss AP,
Weiland AJ, Moore JR et al: Radial shortening for Kienböck
disease. J Bone Joint Surg, 1991; 73A:384–391
-
Rock MG, Roth
JH, Martin L: Radial shortening osteotomy for treatment of
Kienböck’s disease. J Hand Surg, 1991;16A:454–460
-
Nakamura R,
Imaeda T, Miura T: Radial shortening for Kienböck’s
disease: Factors affecting the operative result. J Hand
Surg. 1990;15B:40–45
-
Shibata M
.Clinical and experimental study of shortening osteotomy of
forearm bone(s) in Kienbo¨ ck’s disease.
Nippon
Seikeigeka Gakkai Zasshi, 1989; 63: 245–261
-
Morgan RF,
McCue FC. Bilateral Kienbock's disease. Journal of Hand
Surgery, 1983; 8(6):928-32.
-
Hori Y, Tamai
S, Okuda H et al. Blood vessel transplantion to bone. J Hand
Surg 1979; 4A: 23–33.
-
Bochud
RC, Buchler U. Kienbock’s disease, early stage 3—height
reconstruction and core revascularization of the lunate. J
Hand Surg 1994; 19B:466–478.
-
Kakinoki R,
Matsumoto T, Suzuki T et al . Lunate plasty for Kienbock’s
disease: use of a pedicled vascularized radial bone graft
combined with shortening of the capitate and radius. Hand
Surg 2001; 6:145–156
-
Gabl M,
Reinhart CI, Zimmermann R et al . Stage 3 Kienbock’s
disease: reconstruction of the fractures lunate using a free
vascularized iliac bone graft and external fixation. J Hand
Surg 2002; 27B:369 –373.
-
Horii E,
Garcia-Elias M, Bishop AT et al. Effect on force
transmission across the carpus in procedures used to treat
Kienbock's disease. J Hand Surg, 1990;15(3):393-400.
-
Short WH,
Werner FW, Fortino MD et al . Distribution of pressures and
forces on the wrist after simulated intercarpal fusion and
Kienbock's disease. J Hand Surg, 1992;17(3):443-9,
-
Trumble TE,
Irving J. Histologic and magnetic resonance imaging
correlations in Kienbock's disease. J Hand Surg,
1990;15(6):879-84
-
Watson HK, Ryu
J, DiBella A. An approach to Kienbock's disease: triscaphe
arthrodesis. J Hand Surg. 1985; 10(2):197-87.
-
Voche P, Bour
C, Merle M. Scapho-trapezio-trapizoid arthrosis in the
treatment of Keinbock's disease. A study of 16 cases. J Hand
Surg. 1992;17(1): 5-11
-
Inoue G, Miura
T. Proximal row carpectomy in perilunate dislocations and
lunatomalacia. Acta Orthopaedica Scandinavica, 1990;
61(5):449-52
-
Nakamura R,
Horii E, Watanabe K et al .Proximal row carpectomy versus
limited wrist arthrodesis for advanced Kienbock’s disease.
J Hand
Surg.1998; 23B: 741–745.
-
De smet, Ph
Robijns , I. Degreef. Proximal row carpectomy in advanced
kienbock’s disease .J hand surg ( british and europian
vol. 2005;30b:6:585-587
-
Kawai H,
Yamamoto K, Yamamoto T et al. Excision of the lunate in
Kienbock's disease. Results after long-term follow-up. J
Bone Joint Surg
(Br), 1988;70(2):287-92,
-
Kato H, Usui M,
Minami A. Long-term results of Kienbock's disease treated by
excisional arthroplasty with a silicone implant or coiled
palmaris longus tendon. J Hand Surg, 1986;11(5):645-53.
-
Ishiguro T.
Experimental and clinical studies of Kienbock's disease.
Excision of the lunate followed by packing of the free
tendon. J Japanese Orthop association, 1984;58(5):509-22.
-
Lichtman DM,
Mack GR, MacDonald R et al. Kienbock's disease: the role of
silicone replacement arthroplasty. J Bone
Joint Surg (Am) 1977 59(7):899-908
-
Alexander AH,
Turner MA, Alexander CE et al. DM. Lunate silicone
replacement arthroplasty in Kienbock's disease: a long-term
follow-up. J Hand Surg, 1990 ;15(3):401-7
-
Evans G, Burke
FD, Barton NJ. A Comparision of conservative treatment and
silicone replacement arthroplasty in Kienbock's disease. J
Hand Surg.1986; 11(1):98-102
-
O'Flanagan SJ,
Curtin J. Lunate silastic arthroplasty in Kienbock's
disease. J
Royal
College
of Surgeons of Edinbourgh, 1992; 37(1):52-6
-
Saffar P.
Replacement of the semilunar bone by the pisiform.
Description of a new technique for the treatment of
Kienboeck’s disease. Ann Chir Main 1982; 1:276 –279.
-
Gregory I.
Bain, Malcolm Begg. Arthroscopic Assessment and
Classification of Kienbock’s Disease. Technique in Hand
and upper Exremity Surg. 1006;10(1),18-13
-
Jong
Woong
Park
, Sung Kon Kim, Jung
Ho Park. Multiple Extensor Tendon Ruptures With Advanced
Kienböck’s Disease The Journal of hand Surg. 2007;vol 32A
-
Jeffrey
E. Budoff,
Houston
,
TX
et al.
Spontaneous Wrist Fusion: An Unusual Complication of Kienböck’s Disease. The Journal of hand
Surg . 2005;vol
30A,
|
