Hi everyone,

It’s been a long time since I have posted so I thought now is as good of a
time as any. I found out about a year ago now about my KD in my left wrist
after about a year before that of going to doctors, specialists, about 5
x-rays, then finally an MRI. Anyway, Last August 10th 2007 I had my
operation by Dr. Ian Hargreaves from Sydney (he came to Tassie to do it) He
did the bone graft and attached plates to my wrist bones. It was absolutely
excruciating when I came home from hospital and ended up being dosed up on
pandadine forte for a week til it felt a bit better. I was in a half cast
for almost two months then started physio which honestly I didn’t really see
the point of because paying $50 twice every week for someone to move my
wrist up and down to me was silly but I kept going for about another 2months
until I saw my specialist again for the second time after my operation and
he said to discontinue physio so I did and at the moment, 7 months since my
surgery things seem okay (touch wood) I am happy not to have that horrible
aching stinging KD pain anymore but I have quite limited movement in my
wrist, probably ¼ movement compared to the right wrist and occasionally it
can get sore and sometimes I can feel a sort of nervy/stinging pain which I
think is the plates on the bone settling with my muscles and nerves ect.
However, I am always so worried in the back of my mind that I will stuff it
up again and the blood supply to the bone will be cut off again. I am always
conscious and very protective of my wrist but as I work in Administration
and type constantly I have to use it. I read everyone’s posts as they come
into my email and although KD is awful and seems to have so many
complications and different outcomes it is good to have this site to be able
to talk to people and share stories. I wish everyone the best with their KD
procedures. Cheers, Nikki.



   _____

From: KienbockDisease_Australia@yahoogroups.com
[mailto:KienbockDisease_Australia@yahoogroups.com] On Behalf Of
tebcontractors
Sent: Wednesday, 26 March 2008 8:24 PM
To: KienbockDisease_Australia@yahoogroups.com
Subject: [Kienbock Disease Australia] Re: up for another surgery



--- In KienbockDisease_ <mailto:KienbockDisease_Australia%40yahoogroups.com>
Australia@yahoogroups.com, "caritalively"
<island.girl.12@...> wrote:
>
> Hello all,
>
> I wanted to share some ugly news that I found out today. After
> visiting with my lovely doctor today, I found out that this
wonderful
> disease that we all have does not stop..........even when the
doctor
> has removed everything possible to remove. Ok, short version....I
> found out 3 yrs ago I had KD, I was in the 4th stage, we did the
> necessary surgery to fix the problem, well that did not go
> good....went in for a second surgery because of bones
> knocking.....well now almost 3 years later I am told today that due
> to the shifting of all the bones in my hand (mind you I don't have
> any wrist bones any longer with the exception of a relocated bone)
I
> now have 3 bones on the top of my hand that are shifting and its
> going to require a fusion.
>
> Has anyone ever heard of this type of procedure? I have of wrist
> fusions (which I will be up for in a few years) but never a bone
> fusion on the top of your hand.
>
> Any input or info. on that would be greatly appreciated.
>
>
> Well thanks for listening all. Sometimes its hard to complain and
> explain to folks that don't understand this disease. But I
honestly
> thought that after the first surgery it would be done, but I don't
> think it ever will, and unfortunately it will be a life long
thing.
>
> Well I wish you all a great week, without any pain.
>
> Thanks again,
> Carita
>

I really feel for ya, I have just had my first surgery. It was a bone
graft and I dont think it is working because I am in alot of pain.
I know what your going through, I hope that they can sort it out soon.

Take care.

Tom




No virus found in this incoming message.
Checked by AVG.
Version: 7.5.519 / Virus Database: 269.22.0/1341 - Release Date: 24/03/2008
3:03 PM




[Non-text portions of this message have been removed]

--- In KienbockDisease_Australia@yahoogroups.com, "caritalively"
<island.girl.12@...> wrote:
>
> Hello all,
>
> I wanted to share some ugly news that I found out today.  After
> visiting with my lovely doctor today, I found out that this
wonderful
> disease that we all have does not stop..........even when the
doctor
> has removed everything possible to remove.  Ok, short version....I
> found out 3 yrs ago I had KD, I was in the 4th stage, we did the
> necessary surgery to fix the problem, well that did not go
> good....went in for a second surgery because of bones
> knocking.....well now almost 3 years later I am told today that due
> to the shifting of all the bones in my hand (mind you I don't have
> any wrist bones any longer with the exception of a relocated bone)
I
> now have 3 bones on the top of my hand that are shifting and its
> going to require a fusion.
>
> Has anyone ever heard of this type of procedure?  I have of wrist
> fusions (which I will be up for in a few years) but never a bone
> fusion on the top of your hand.
>
> Any input or info. on that would be greatly appreciated.
>
>
> Well thanks for listening all.  Sometimes its hard to complain and
> explain to folks that don't understand this disease.  But I
honestly
> thought that after the first surgery it would be done, but I don't
> think it ever will, and unfortunately it will be a life long
thing.
>
> Well I wish you all a great week, without any pain.
>
> Thanks again,
> Carita
>

I really feel for ya, I have just had my first surgery. It was a bone
graft and I dont think it is working because I am in alot of pain.
I know what your going through, I hope that they can sort it out soon.

Take care.

Tom

Hi, my name is Tom. I have just recently had a bone graft to treat
Kienbocks disease and almost two months on the pain is still there. My
wrist is still in a cast, but I am worried that the operation did not
work.
is it normal to still feel the pain a month after the operation?

HI KELLY,
SOUNDS LIKE THAT KD MONSTER WASN'T NICE TO YOU AT ALL.
THE NERVE IN THE PIN ,YOU KNOW THAT WAS A BIG OUCH FOR SURE.THAT WAS SOMETHING
THAT HAPPENED TO ME.BUT I HAD A TENDON INVOLVED ALSO.  IT WASN'T PURTY.BUT I DID
GET OVER IT.TIME AND PATIENCE.I HOPE YOUR SURGERY GOES WELL AND WILL BE THINKING
OF YOU ALL.
HOPE EVERYONE IS BEING PAIN FREE.
JOJO.


[Non-text portions of this message have been removed]

OMG! A nerve in the pin?? I hope it works out for you. Please do not get your
hopes up. The shortening and the hardware are a big pain the arm!! They don't
tell you that the bone flexes thus making the hardware move. Which in turn
causes much pain. Especially if you use it a lot which you do. If I wash my
bathroom walls which takes 2 hours.My hands are no good for at least 2 days.
Hope all goes well.

Michele B.

Kelly Brimhall <kvb1076@...> wrote:                             I had my
first surgery a year ago in April. they did a vascular bone graft. I had pins
holding the graft in place. I was in a cast for 2 months (in sounds much longer
when you say it that way instead of 8 weeks.) I was pain free for about 4-5
months and the pain returned. they did an MRI and found that most of it was
still not getting the blood flow. I am now scheduled to have another surgery
April 22 (almost exactly a year) They are going to do the ulnar shortening. I am
REALLY hoping this will help.  I am a Firefighter, Paramedic and a State Fire
Instructor - all of which involve extensive use of my hands and strength. I
really do not know what I will do if this can't be fixed. I'm trying not to get
my hopes up. I'm also very nervous about having another surgery. The last one
was supposed to be same day, in and out. Well I ended up staying 4 days. I was
in agony. They had me on a morphine drip - that
  did not work. The had me on a demerol drip - that
   did not work. They finally opened my wrist back up and found that the pin had
a nerve twisted in it. They remedied that and I was MUCH better and went home
the next day. Just hoping this one goes much better. I'll let ya know. Here's
wishing for pain free days for all!!!!!
  Thanks for listening,
  Kelly
  Dance like no one's watching....Kelly

  ----- Original Message ----
  From: Michele Barnes <michele_m_barnes@...>
  To: KienbockDisease_Australia@yahoogroups.com
  Sent: Monday, March 24, 2008 11:37:20 AM
  Subject: Re: [Kienbock Disease Australia] Re: aches

  No that is not it either because I have a full fusion on the left and no bones
removed from the right. Just an Ulnar shortening. Unless the tendons and are
just having a heck of a time adjusting?? Could you shift in a full fusion?? Does
anyone know of anyone who has had this problem??

  caritalively <island.girl. 12@hotmail. com> wrote: Hi Michele,

  I am to this day having problems after my 2 surgries. I am up for my
  third here in the next few months (when i have time built up at work)
  my doctor has informed me that due to my last 2 surgries the
  remaining bones that are left in my hand....are now shifting and I am
  up for a top hand fusion. Maybe you should have your doctor check to
  see if maybe that is an issue for you to?

  Hope this helps.

  Wishing you a pain free day.

  --- In KienbockDisease_ Australia@ yahoogroups. com, Michele Barnes
  <michele_m_barnes@ ...> wrote:
  >
  > Does anyone still have aches that are deep thinking you still have
  KD in your wrist after surgery?? I had Ulnar shortening on the right
  wrist and if i use it or sleep on it funny it aches all day. had MRI
  with negative results thank GOD! What the heck is it then?? Had bad
  TFCC tear repair in that wrist to. With the fusion in the left,
  sometimes I can not even pick something up it hurts so bad. Anybody
  have anything for me??
  >
  > Michele
  >
  >
  > ------------ --------- --------- ---
  > Be a better friend, newshound, and know-it-all with Yahoo! Mobile.
  Try it now.
  >
  > [Non-text portions of this message have been removed]
  >

  ------------ --------- --------- ---
  Never miss a thing. Make Yahoo your homepage.

  [Non-text portions of this message have been removed]

  __________________________________________________________
  Never miss a thing.  Make Yahoo your home page.
  http://www.yahoo.com/r/hs

  [Non-text portions of this message have been removed]






---------------------------------
Never miss a thing.   Make Yahoo your homepage.

[Non-text portions of this message have been removed]

I had my first surgery a year ago in April. they did a vascular bone graft. I
had pins holding the graft in place. I was in a cast for 2 months (in sounds
much longer when you say it that way instead of 8 weeks.) I was pain free for
about 4-5 months and the pain returned. they did an MRI and found that most of
it was still not getting the blood flow. I am now scheduled to have another
surgery April 22 (almost exactly a year) They are going to do the ulnar
shortening. I am REALLY hoping this will help.  I am a Firefighter, Paramedic
and a State Fire Instructor - all of which involve extensive use of my hands and
strength. I really do not know what I will do if this can't be fixed. I'm trying
not to get my hopes up. I'm also very nervous about having another surgery. The
last one was supposed to be same day, in and out. Well I ended up staying 4
days. I was in agony. They had me on a morphine drip - that did not work. The
had me on a demerol drip - that
  did not work. They finally opened my wrist back up and found that the pin had a
nerve twisted in it. They remedied that and I was MUCH better and went home the
next day. Just hoping this one goes much better. I'll let ya know. Here's
wishing for pain free days for all!!!!!
Thanks for listening,
Kelly
Dance like no one's watching....Kelly



----- Original Message ----
From: Michele Barnes <michele_m_barnes@...>
To: KienbockDisease_Australia@yahoogroups.com
Sent: Monday, March 24, 2008 11:37:20 AM
Subject: Re: [Kienbock Disease Australia] Re: aches

No that is not it either because I have a full fusion on the left and no bones
removed from the right. Just an Ulnar shortening. Unless the tendons and are
just having a heck of a time adjusting?? Could you shift in a full fusion?? Does
anyone know of anyone who has had this problem??

caritalively <island.girl. 12@hotmail. com> wrote: Hi Michele,

I am to this day having problems after my 2 surgries. I am up for my
third here in the next few months (when i have time built up at work)
my doctor has informed me that due to my last 2 surgries the
remaining bones that are left in my hand....are now shifting and I am
up for a top hand fusion. Maybe you should have your doctor check to
see if maybe that is an issue for you to?

Hope this helps.

Wishing you a pain free day.

--- In KienbockDisease_ Australia@ yahoogroups. com, Michele Barnes
<michele_m_barnes@ ...> wrote:
>
> Does anyone still have aches that are deep thinking you still have
KD in your wrist after surgery?? I had Ulnar shortening on the right
wrist and if i use it or sleep on it funny it aches all day. had MRI
with negative results thank GOD! What the heck is it then?? Had bad
TFCC tear repair in that wrist to. With the fusion in the left,
sometimes I can not even pick something up it hurts so bad. Anybody
have anything for me??
>
> Michele
>
>
> ------------ --------- --------- ---
> Be a better friend, newshound, and know-it-all with Yahoo! Mobile.
Try it now.
>
> [Non-text portions of this message have been removed]
>





------------ --------- --------- ---
Never miss a thing. Make Yahoo your homepage.

[Non-text portions of this message have been removed]





      
________________________________________________________________________________\
____
Never miss a thing.  Make Yahoo your home page.
http://www.yahoo.com/r/hs

[Non-text portions of this message have been removed]

No that is not it either because  I have a full fusion on the left and no bones
removed from the right. Just an Ulnar shortening. Unless the tendons and are
just having a heck of a time adjusting?? Could you shift in a full fusion?? Does
anyone know of anyone who has had this problem??

caritalively <island.girl.12@...> wrote:                             Hi
Michele,

  I am to this day having problems after my 2 surgries. I am up for my
  third here in the next few months (when i have time built up at work)
  my doctor has informed me that due to my last 2 surgries the
  remaining bones that are left in my hand....are now shifting and I am
  up for a top hand fusion.  Maybe you should have your doctor check to
  see if maybe that is an issue for you to?

  Hope this helps.

  Wishing you a pain free day.

  --- In KienbockDisease_Australia@yahoogroups.com, Michele Barnes
  <michele_m_barnes@...> wrote:
  >
  > Does anyone still have aches that are deep thinking you still have
  KD in your wrist after surgery?? I had Ulnar shortening on the right
  wrist and if i use it or sleep on it funny it aches all day. had MRI
  with negative results thank GOD! What the heck is it then?? Had bad
  TFCC tear repair in that wrist to. With the fusion in the left,
  sometimes I can not even pick something up it hurts so bad. Anybody
  have anything for me??
  >
  > Michele
  >
  >
  > ---------------------------------
  > Be a better friend, newshound, and know-it-all with Yahoo! Mobile.
  Try it now.
  >
  > [Non-text portions of this message have been removed]
  >






---------------------------------
Never miss a thing.   Make Yahoo your homepage.

[Non-text portions of this message have been removed]

my story.... in 2002 had sudden bad pain in left wrist in Oct. In 2003 Jan
diagnosed with KD stage 3. Had Proximal Row Carpectomy a month later and was
told I would probably need a fusion at 65. I was 34. At age 34 I got a full
fusion of the left wrist. The fusion was causing so much pain that know one knew
why. So I went to Mayo Clinic. They said take the hardware out!! So after a year
I had it taken out. They wanted to wait a full year to make sure the fusion
took. After that was removed more than half of the pain was gone and I could use
my fingers like grabbing etc. You have to be very careful not to hit it or fall.
It could break and they treat it like a broken wrist. I have pain on the inside
of the wrist. Sometimes I can not grab or ring out a wash cloth. All depends on
the day. I can not sleep where it is suspended. It will hurt then to. So if you
are asking if it feels better to have the hardware out the answer is yes. I can
deal with the little aches. As for the
  other wrist I had a TFCC tear repair  and then ulnar shortening and the n the
hardware taken out due to chronic pain from the hardware. They took that out  5
months early! They did not want to but I insisted. I still have the pain in he
wrist like I have KD. I do not know why. Dr.s do not know why either. So I have
had 3 and 3 on both wrists. So I would get the metal out as so as possible.Hope
this helps and keep in touch.

LORI KEMP <hdoink@...> wrote:
  Hi Michelle, I was reading your message to the group and I noticed you have had
a fusion.  Was that a full wrist fusion that you had?  My husband has KD in both
hands.  They tell us that is highly unusual to have it in both wrists.  He has
had two surgeries on each wrist so far.  At this point he is looking at a full
wrist fusion in the left wrist.  He is right handed thank goodness.  I'm just
trying to talk to someone who has had a fusion done already to see what it's
really like.  Any help you can give is much appreciated.  In answer to your
question about the aches after surgery, my husband still is in constant pain in
both hands.  The pain in the right wrist we are told is from the plates used
during a previous surgery.  They could be taken out and in most likelyhood his
pain will go away.  At this point we don't really trust anything we are told in
relation to this disease.  Every surgery he has had we were told the pain would
go away after everything healed.  WRONG!
  Does your pain get worse when you do any kind of activity with your hands?  His
seems to.  But what can you do?  You have to work and live life.

  Hope to hear back from you.
  Lori

  To: KienbockDisease_Australia@...:
michele_m_barnes@...: Fri, 21 Mar 2008 00:49:56 -0700Subject:
[Kienbock Disease Australia] aches

  Does anyone still have aches that are deep thinking you still have KD in your
wrist after surgery?? I had Ulnar shortening on the right wrist and if i use it
or sleep on it funny it aches all day. had MRI with negative results thank GOD!
What the heck is it then?? Had bad TFCC tear repair in that wrist to. With the
fusion in the left, sometimes I can not even pick something up it hurts so bad.
Anybody have anything for me??Michele---------------------------------Be a
better friend, newshound, and know-it-all with Yahoo! Mobile. Try it
now.[Non-text portions of this message have been removed]

  __________________________________________________________
  Test your Star IQ
  http://club.live.com/red_carpet_reveal.aspx?icid=redcarpet_HMTAGMAR

  [Non-text portions of this message have been removed]






---------------------------------
Looking for last minute shopping deals?  Find them fast with Yahoo! Search.

[Non-text portions of this message have been removed]

Hi Michelle, I was reading your message to the group and I noticed you have had
a fusion.  Was that a full wrist fusion that you had?  My husband has KD in both
hands.  They tell us that is highly unusual to have it in both wrists.  He has
had two surgeries on each wrist so far.  At this point he is looking at a full
wrist fusion in the left wrist.  He is right handed thank goodness.  I'm just
trying to talk to someone who has had a fusion done already to see what it's
really like.  Any help you can give is much appreciated.  In answer to your
question about the aches after surgery, my husband still is in constant pain in
both hands.  The pain in the right wrist we are told is from the plates used
during a previous surgery.  They could be taken out and in most likelyhood his
pain will go away.  At this point we don't really trust anything we are told in
relation to this disease.  Every surgery he has had we were told the pain would
go away after everything healed.  WRONG!  Does your pain get worse when you do
any kind of activity with your hands?  His seems to.  But what can you do?  You
have to work and live life.

Hope to hear back from you.
Lori


To: KienbockDisease_Australia@...:
michele_m_barnes@...: Fri, 21 Mar 2008 00:49:56 -0700Subject:
[Kienbock Disease Australia] aches




Does anyone still have aches that are deep thinking you still have KD in your
wrist after surgery?? I had Ulnar shortening on the right wrist and if i use it
or sleep on it funny it aches all day. had MRI with negative results thank GOD!
What the heck is it then?? Had bad TFCC tear repair in that wrist to. With the
fusion in the left, sometimes I can not even pick something up it hurts so bad.
Anybody have anything for me??Michele---------------------------------Be a
better friend, newshound, and know-it-all with Yahoo! Mobile. Try it
now.[Non-text portions of this message have been removed]






_________________________________________________________________
Test your Star IQ
http://club.live.com/red_carpet_reveal.aspx?icid=redcarpet_HMTAGMAR

[Non-text portions of this message have been removed]

Hi Michele,

I am to this day having problems after my 2 surgries. I am up for my
third here in the next few months (when i have time built up at work)
my doctor has informed me that due to my last 2 surgries the
remaining bones that are left in my hand....are now shifting and I am
up for a top hand fusion.  Maybe you should have your doctor check to
see if maybe that is an issue for you to?

Hope this helps.

Wishing you a pain free day.





--- In KienbockDisease_Australia@yahoogroups.com, Michele Barnes
<michele_m_barnes@...> wrote:
>
> Does anyone still have aches that are deep thinking you still have
KD in your wrist after surgery?? I had Ulnar shortening on the right
wrist and if i use it or sleep on it funny it aches all day. had MRI
with negative results thank GOD! What the heck is it then?? Had bad
TFCC tear repair in that wrist to. With the fusion in the left,
sometimes I can not even pick something up it hurts so bad. Anybody
have anything for me??
>
> Michele
>
>
> ---------------------------------
> Be a better friend, newshound, and know-it-all with Yahoo! Mobile.
Try it now.
>
> [Non-text portions of this message have been removed]
>

DEAR COL,
I WILL WISH THE BEST FOR YOU AND JUST REMEMBER IT WILL GET BETTER,PLEASE JUST
REMEMBER WE ARE ALL HERE FOR YOU.KEEPING YOURSELF BUSY IN YOUR BUSINESS RIGHT
NOW COULD BE A GOOD THING.
JUST REMEMBER IF YOU NEED TO TALK OR VENT WE ARE HERE.
JOJO.

[Non-text portions of this message have been removed]

Does anyone still have aches that are deep thinking you still have KD in your
wrist after surgery?? I had Ulnar shortening on the right wrist and if i use it
or sleep on it funny it aches all day. had MRI with negative results thank GOD!
What the heck is it then?? Had bad TFCC tear repair in that wrist to. With the
fusion in the left, sometimes I can not even pick something up it hurts so bad.
Anybody have anything for me??

Michele


---------------------------------
Be a better friend, newshound, and know-it-all with Yahoo! Mobile.  Try it now.

[Non-text portions of this message have been removed]

G'day Col,

Sorry to hear about you and Lisa, I hope that you get over it really
soon. There is always a light at the end of the tunnel.

Wishing you all the best,

Muneera

Hi Col,

   I'm so sorry to hear your news and will be thinking of you at this tough time.
   You must be feeling very low and really hope you come through this and feel
better soon.

   You take care and mail anytime if you want a shoulder.

   Take care

   Fiona

Col <KienbockDisease@...> wrote:
           G'day all,

Sorry haven't posted in a while, but unfortunately Lisa and I have
broken up, she just doesn't love me anymore so I have been very down
lately.

Anyway I am selling the house and moving on, as soon as I am
re-established in my new home (I am buying another house)I will get
back on the net and have a good chat to all.

Keep in touch guys as i need a lot of support right now, even my
doctor says i am unwell.

For all you folks that have posted lately sorry that i haven't
replied, but when your on a downer like I am, you just don't feel like
doing anything at all. Luckily my business is going good as its the
only thing keeping me going at the moment.

Toni can i ask that you please take over the running of the group for
a while just in case i am off line for a while.

Have a Happy Easter everyone,

talk soon,

Col






---------------------------------
  Rise to the challenge for Sport Relief with Yahoo! for Good

[Non-text portions of this message have been removed]

G'day all,

Sorry haven't posted in a while, but unfortunately Lisa and I have
broken up, she just doesn't love me anymore so I have been very down
lately.

Anyway I am selling the house and moving on, as soon as I am
re-established in my new home (I am buying another house)I will get
back on the net and have a good chat to all.

Keep in touch guys as i need a lot of support right now, even my
doctor says i am unwell.

For all you folks that have posted lately sorry that i haven't
replied, but when your on a downer like I am, you just don't feel like
doing anything at all. Luckily my business is going good as its the
only thing keeping me going at the moment.

Toni can i ask that you please take over the running of the group for
a while just in case i am off line for a while.

Have a Happy Easter everyone,

talk soon,

Col

Ok so with all the failed surgeries 6 tota, I can not find a pain
killer that I am not allergic to or becomes allergic to down the line.
I have major aching in the left fusion and doubly so in the left wrist
that had the tfcc tear repair and the ulnar shortening.So what the
hay!! I am now on Lyrica. Does absolutely nothing. I take it 3 times a
day!! Anyone have any natural remedies other than an ax!! Shoot me an
email. I am about to go insane.
Michele B.

--- In KienbockDisease_Australia@yahoogroups.com, "Heather"
<poopycat@...> wrote:
>
> Hey ya'll - how the #%&?! are ya? Bet you thought my KD had eaten my
> brain and died me! You were right. Look forward to checking back in...
>
> Heather
>

Different predisposed risk factors have been implicated in the development of this Disease. The most commonly cited factors are the interruption of the blood supply to the lunate, negative ulnar variance, and the workplace environment. These factors, as well as how to minimize the risk for developing this disease will be discussed in the following paragraphs

Stahl believed that in a lunate with an already tenuous blood supply, traumatic compression fracture leads to avascular necrosis.

Lee found three vascular patterns in lunates from cadavers: a single vessel, either volar or dorsal, supplying the entire bone; several vessels at both volar and dorsal surfaces of the lunate without central anastomosis; and several vessels at both volar and dorsal surfaces of the lunate with central anastomosis. Therefore according to Lee, patients with the former two patterns are at greater risk for developing Kienbock's Disease.

In fresh specimens, Gelberman and associates also studied the extraossoeus and intraosseous blood supply of the lunate. They found that in intraosseous blood supply consisted from three patterns : Y in 59%, I in 31%, and X in 10%, with dorsal and volar anastomosis just distal to the center of the lunate. Evaluation of the terminal vessels in the lunate allowed Gelberman and associates to conclude that the proximal subchondral bone, adjacent to the radial articular surface, was least vascular. Because of the rich extraeossis blood supply, they discounted the theory held by some that interruption of vessels entering a single pole of lunate caused avascularity. Based on the work, Gelberman and co-workers suggested that it is intraosseous disruption of vascularity, owing to repeated trauma with compression fracture, that cause Kienbock's Disease.

Negative ulnar variance as a risk factor has received considerable attention from the research community. In 1928, Hulton noted that a short ulnar was present in 78% of his patients with Kienbock Disease, where as only 23% of normal patients had a short ulnar. He called this condition ulnar minus variant. Since the condition was first discovered, many authors have confirmed negative ulnar variance in patients with Kienbock's disease.

Theoretically, a short ulnar variance, relative to the distal articular surface of the radius, causes increased shear and compressive loads on the lunate. Elaborate studies by Werner and associates proved that altered load transmission through the radial carpal joint with ulnar minus variance predisposes the radiolunate articulation to increase loads. This is thought to be a contributing factor in the development of Kienbock's Disease.

Until recently, Hulton's findings have been confirmed by many investigators but has been questioned by others. To date, this controversy has not been resolved. To make matters more complicated accurate measurement of ulnar variance is not simple. As pointed out by Epner and Palmer, the apparent variance changes with the position of the arm.

With this in mind, Palmer and associates further standardized the method for determining ulnar variance. They found the position of the distal ulnar, in relation to the distal radial surface changes with varying degrees of forearm rotation and that the change in variance was least with the elbow fixed at 90 degrees, The standard view recommended is a poster anterior wrist radiograph obtained with the patient's shoulder abducted 90 degrees, the elbow flexed 90 degrees, and the forearm in neutral rotation. The importance of accurate measurement of ulnar variance is highlighted by the recent gain in popularity of ulnar lengthening and radial shortening techniques to treat Kienbock's Disease

It appears the effect of aging on ulnar variance supports the theory that negative ulnar variance is a predisposed risk factor in the development of this disease. It has been shown by several researchers that ulnar variance increase with age. The cause of the increase of ulnar variance with aging is unknown, but it might be due to shortening of the radius because the force of the forearm muscle is mainly transferred to the radius to developing Kienbock's Disease.

Although Kienbock's Disease mostly affects young, active males, usually in the 3rd or 4th decade of life, Yoshida reported that of a 127 cases reviewed, 15 patients were found with aged onset. Among these 15 cases women predominated. This is a striking difference from Kienbock's Disease in young adults. Other findings reported from that study revealed that symptoms in elderly are usually not so severe and conservative treatment is typically effective. It was also shown that the degree of negative ulnar variance was not as great as in the young effected population. Several other researchers have shown that the degree of negative variance is greater in males than in females. This supports the findings that males are more susceptible.

Besides the anatomical and biological factors, the workplace also has been implicated as a contributing factor to the advancement of this disease. Occupations which require the use of pneumatic tools such as a rivet gun and hammers are all at particular risk for the development of Kienbock's Disease. The increased impact loading upon the wrist is thought to be a catalyst for the disruption of the blood supply to the lunate ultimately leading to its demise. The etiology of Kienbock's disease is thought to be either repeated minimal trauma or by a single acute episode. The underlying theme behind the theory of repeated minimal trauma is repetition coupled with force. Both established Cumulative Trauma Disorders (CTD) risk factors have been recognized as potentially harmful elements to the musculoskeletal system. The other proposed etiology, a single acute episode, indicates that force may be of greater importance. In either case, ergonomist must evaluate these factors carefully when designing or redesigning the workplace.

Wrist posture has been indirectly implied as another possible risk factor for the development of Kienbock's Disease. In two separate studies, individuals with cerebral palsy were evaluated because they have a high muscle tone, which is essentially repeated trauma, and the radiocarpul joint is constantly exposed to considerably higher pressure than what is found in normal individuals. Rooker and Goodfellow found five cases of kienbock's Disease in a group of 53 adults with cerebral palsy. An abnormally flexed wrist posture was a common feature in all five cases. This suggested to them that this extreme posture compromised the blood supply to the lunate and was considered a contributing factor to the development of Kienbock's Disease. In a more recent study, Joji reported that there is increased pressure between the radius and lunate due to the dynamics conditions so excessive muscle tone characteristics of cerebral palsy. The resting posture of their subjects was predominantly ulnar flexion with one case of volar flexion. Joji and associates went on to conclude that it was unlikely that volar flexion was the cause of Kienbock's Disease. However, in both studies a resting deviated wrist posture was observed. It is therefore possible that deviated wrist postures, incorporated with other risk factors could lead to the development of Kienbock's Disease.

It appears that the dominant hand of the worker is at the greatest risk for developing Kienbock's Disease. This finding is consistent with the etiology. In fact, the majority of the time Kienbock's Disease is unilateral.

Like many other Cumulative Trauma Disorder's, Kienbock's Disease can be treated by various medical interventions. Many of these interventions will relieve symptoms but if the individual is returned to similar activities it is possible to see a reoccurrence of Kienbock's Disease.

File        : TFCC.mht
Description :

Kienbock' Disease is an isolated disorder of the lunate resulting from vascular compromise to the bone. The symptoms include wrist pain, limited range and motion, and decreased grip strength.

Kienbock's Disease presents in various forms. The changes in the lunate may be very localized or diffuse. With progression, the lunate may fracture into two pieces or crumble into granules or produce an osteochondral fracture from one surface.

The cartilage is not primarily involved in the pathogenesis and remains relatively healthy. Bone death occurs over time. Often, a symptomatic wrist will demonstrate normal X-rays with the diagnosis evident only on MRI. The degree of loading of the wrist appears to be important and changes in the lunate are cumulative.

Additional fault plates may form in other areas of the lunate. This phenomenon is probably present in most of our carpul bones, but time and avoidance of similar overload injuries preclude development of multiple plates. Areas in the lunate reach a critical state in which either a small section or most of the bone becomes relatively walled off by multiple fault plates and further normal injuries can no longer heal effectively because the capillary blood supply is inadequate. Causing the bone to die, providing a significant area further limiting vascular access.

Changing one or more of the aetiological factors can halt progression and the necrosis areas walled off by fault plates can probably heal. Collapsed areas, however, remained deformed.

Most cases of Kienbock's disease develop, then, as a result of a long process of insult which is multifactorial in etiology, producing overload within the substance of the bone. In the susceptible lunate, miniplanes of injury result in relatively avascular fault plates, gradually sectioning off areas in the lunate. Healing in these small areas cannot occur quickly enough if the abnormal loads and demand continue, ultimately resulting in areas of cell death.

In stage IV Kienbock's Disease, good results have been reported with Proximal Row Carpectomy (PRC) and wrist arthrodesis (total fusion).

Choice between the two procedures is determined by the needs and desires of the patient and the integrity of the articular surfaces of the lunate fossa and the capitate.

Proximal row carpectomy should be reserved for those people who desire motion over strength, whereas the wrist fusion is preferable in those people who need strength. Total wrist arthroplasty is generally contraindicated in young active people. Treatment choice must be based on a number of variables, including the experience of the surgeon, the desires and activity level of yourself.

In the early stages, efforts should be made to salvage the lunate and prevent loss of normal architecture. In the later stages, efforts should be made to restore that architecture. In the end stage, normal architecture must be sacrificed to restore function.

PROXIMAL ROW CARPECTOMY:

Excising the proximal carpal row so that the capitate articulates with the lunate fossa on the radius is rarely indicated, as the capitate and radial articulations are almost invariable damaged by the disease process to the lunate. However, the procedure can produce good results in carefully selected cases of wrist arthritis where the two key articular surfaces are considered to be satisfactory on radiographic assessment. The proximal carpul bones are excised through a dorsal approach with dorsal capular repair. The wrist is rested in a cast in neutral flexion/extension for 4-6 weeks and the mobilized. Power and movement are only slowly regained but the patient usually obtains 40-60' of flexion/extension range around the neutral point with moderate grip strength one year after surgery. If the key articular surfaces were in satisfactory condition pre-operatively, reasonable pain relief is obtained.

ARTHRODESIS of the wrist.

Fusion of an osteoarthritic wrist is most commonly obtained by the use of a plate and screws to radius, carpus and third metacarpal, augmented with cancellous bone graft. Slight dorsal angulation potentiates grasp. The dorsal incision extends to the radius, retracting the extensor indicis proprius compartment radially and the extensor compartment ulnarly. The dorsal two thirds of the articular surfaces of the wrist joint are rawed and the cavitates packed with cancellous bone. Modern low profile plates and screws are not unduly prominent, and there is normally no need to remove the metal work unless discomfort is experienced. The stability of the fixation is such that the fingers and the thumb can be mobilized immediately. The dissection can largely avoid direct exposure of the extensor tendons, reducing the risk of tendon adhesions.

DENERVATION of the wrist.

No attempt is made to treat the arthritis, simply the pain that it causes. The nerves that supply the carpus are classified into radial, median and ulnar groups, and a serial nerve blocks will reveal to an extent the likely result of ablation of these various nerves. An extensive long term study has shown it to be useful in reducing pain but retaining movement, apparently without the risk of a Charcot joint. ninety per cent of these series were considered to have gained reasonable pain relief (60% pain free and 30% improved).

OPERATION DETAILS

(44 year old patient0

(P2) Bilateral Wrist Denervation / 3 Incisions on each wrist / 2 Dorsal Incisions / 4th & 5th Compartments / Posterior Interosseous Nerve divided / Branches of Ulnar Nerve divided / Volar Curved Incisions / Radial Nerve and Vessel Branches divided / Anterior Interosseous Nerve and Branches Identified and divided / 20mls Ropivacaine to each wrist / Vicryl Fat / Nylon Skin / Jelenet/Melolin/Wool/Crepe

POST OP COMMENTS - Elevate / Home / Reduce dressing 72 hrs / Out Patients Review 2 weeks

click back to return to KD Info

Kienbocks Disease may be treated by immobilization, revascularization, ulnar lengthening or radial shortening, simple excision, limited intercarpul fusion, or salvage procedures.

Immobilization

Prolonged immobilization of the wrist has been tried in all stages of Kienbock's disease. In some cases it has shown to lead to continued collapse of the lunate. For Stage I, however, immobilization may be indicated in hopes that the vascular insult is kept to a minimum and that the lunate is given a chance to heal. Because diagnosis in this stage is often difficult, a trial period of immobilization may result in characteristic radiographic changes that establish the diagnosis.

Revascularization

In stage II Kienbock's Disease, before the lunate has collapsed, it is possible for the lunate to regain blood supply.

One procedure is which a small piece of volar radial bone, still attached to the pronator quadratus muscle, is grafted to the avascular lunate. This procedure is done through the volar approach with division of the palmer and transverse carpul ligaments in order to mobilize the median nerve. After the volar wrist is entered the lunate is burred with a high speed drill in preparation to receive a 1 to 1.5 cm piece of radial bone still attached to the pronator quadratus muscle. This is secured with pull out wires or clips.

A similar revascularization procedure uses the pisiform. Pisiform transfer on its vascular pedicle. Has found uniformly good results

Another is described as direct transplanting of a vascular bundle into the vascular lunate, with successful results.

It must be remembered, however, that none of the revascularization procedures are likely to work in the face of severe collapse (stage III), for even if they are successful in re-establishing blood supply, lunate height and normal carpul kinematics will not be restored.

Ulna Lengthening and Radial Shortening

On the basis of the theory that ulnar minus variance is a significant etiologic factor in Kienbock's Disease, some have advocated equalization of the distal articular surfaces by either ulnar lengthening or radial shortening. Both procedures have had good results reported. However, it seems unlikely that leveling of the distal articular surfaces of the lunate can restore an already collapsed lunate. These procedures remain questionable in advanced stage III.

Both radial shortening and ulnar lengthening require osteotomy. A segment of bone is removed when radial shortening is done and a segment of bone graft inserted when ulnar lengthening is done. After either, fixation is usually accomplished with a compression plate. It is generally recommended that the ulnar variance be changed to 1 to 2 ml positive variance by placing an appropriate sized interpositional graft during ulnar lengthening.

Radial shortening may be preferable to some because it does not require a second surgical incision to harvest bone graft.

Excision of the Lunate

Lunate excision was one of the first surgical procedures for Kienbock's Disease. The rational of this procedure is to remove sequested bone that is provoking painful synovitis. Some have reported good results from simple excision others critize the procedure predicting late proximal migration of the capitate.

Limited Intercarpul fusion

Its most important advantage is that radiocarpul motion is maintained, unlike with complete wrist arthrodesis.

Patients with severe fragmentation of the lunate undergo resection of the necrotic bone, osteotomy of the capitate in its mid portion, and proximal displacement of the proximal capitate fragment, which is secured to the scaphoid and triquetrum with bone pegs. Essentially, the space vacated by excision of the lunate is filled by the proximal half of the capitate fragment, and the space left by osteotomy of the capitate is filled by autogenus bone graft. The procedure is then completed by performing arthrodesis of contiguous surfaces of the hamate, capitate, scaphoid and triquetrum by first denuding articular surfaces and securing the bone with small cortical bone pegs. When the lunate remains suitably intact, osteotomy of the capitate is omitted, as is lunate excision, and the contiguous surface of the lunate, scaphoid, triquetrum, hamate and capitate are arthrodesed.

File        : Ulna Variance.mht
Description : Ulna Variance

Kienbock's Disease follows a specific progressive pattern which is formed into stages.

Initially, in the early phases of Kienbock's Disease, the changes are localized to the lunate. In these phases, radiographs reveal increased density, which progresses to lunate collapse. In the later phases, the pathology involves the mechanical structure and kinematics of the wrist, not just the lunate. In the more severe disease, the proximal widens, and rotatory instability of the scaphoid and diffuses degenerative changes occur.

Stage I

In this Stage, radiographs are normal except for the possibility of a linear or compression fracture that may be shown on tomography. In this phase, bone scan usually is abnormal, and magnetic resonance imaging (MRI) is currently diagnostic.

It should be noted that MRI was not available for the diagnosis of this disorder when this classification was devised. Many have suggested that Stage 0 should be added for those cases in which MRI changes are the only diagnostic clues. It should be clearly understood that these cases fit into Stage I.

Stage I was a stage awaiting a diagnostic tool. In fact, Litchman states in his paper that "radionucleide scanning in stage I may be abnormal, and refinements in current techniques may soon permit reliable early diagnosis.

Stage II

Disease in this Stage is still localized to the lunate. The size, shape, anatomic relationship, and kinematics of the carpal bones are not significally altered. The lunate has a definite increased density relative to the other carpal bones. Late in this Stage, some bone height may be lost on the radial side of the lunate fracture that may be shown on tomography. In this phase, bone scan usually is abnormal, and MRI is currently diagnostic.

Stage III

This Stage is the transitional one in which the disease begins to affect the carpal structure and kinematics. At this point, the lunate has collapsed in the frontal plane and elongated in the sagittal plane. The capitate begins to migrate proximally. Foreshortening of the scaphoid (the ring sign), scapholunate dissocation, and ulnar deviation of the triquetrum may or may not be present radiographically. Measurements of the carpal height ratios, or the lunar perimeter and lunate area indices, help determine the degree of carpal collapse.

This transitional Stage is divided into Stages IIIA and IIIB. In Stage IIIA, lunate collapse occurs without fixed scaphoid rotation and other secondary derangements.

Stage IV

All the findings of Stage III are present as well as generalized degenerative changes in the carpus. The surface of the adjoining bones affected resulting in generalized inter-carpal arthritis in the wrist.

"The Disease you never hear off or you have never heard off, until you get it".......( Col Pickering )

Avascular Necrosis of the Lunate

n: osteochondrosis affecting the lunate bone - called also lunatomalacia.

Basically, the blood supply to the lunate bone shuts off, which causes the bone to die, with eventual collapse of the lunate bone.

As this is a RARE DISEASE little is known about its causes.

KIENBOCK ROBERT ( 1871-1953 ) Austrian Radiologist.

Kienbock pioneered in Radiology. From 1910-1911 he published descriptions "Concerning Traumatic Malacia of the lunate and its Consequences : Degeneration and Compression Fractures", descriptions of dislocations of the hand and a slowly progressive Chronic Osteoitis involving the Lunate Bone.

Kienbock described the process of Lunatomalacia both the Radiographic changes seen with the disease, and the clinical symptomatology that accompanied it.

Radiographically, Kienbock described various changes in the lunate with the vast majority of cases beginning the disease in the proximal portion, preserving the distal portion articulating with the capitate. In some radiographs, the shape of the lunate was preserved and only the internal structure was altered, with radiographs demonstrating areas of increased intensity. In most radiographs, however, with the progression of the disease, the shape of the lunate was significantly affected with the destruction of the proximal portion and loss in height of the bone.

Kienbock noted that the disease usually occurred in men in their thirty's and forty's who were heavy labourers. Frequently they would have an antecedent trauma with negative radiographs and were diagnosed with a sprain. Overtime, the clinical course would progress with pain, swelling and restricted motion of the wrist. Percussion of the third metacarpal ( the hand held in a fist ) produced pain in the lunate region and when comparing hands shortening of the carpus might be evident.

Radiographs demonstrated radiographic changes in the lunate and loosening of the radiocarpul joint, which Kienbock thought promoted mechanical damage. This loosening probably referred to the increased radiocarpul space due to synovitis, proceeding radiocarpul arthrosis.

Kienbock favoured the view that the condition was due to a disturbance in the nutrition of the lunate, caused by a rupture of the ligaments from a sprain or sublixation. Leading to, rather than being a result of compression fractures.

Kienbock believed that recovery from this disturbed nutrition only occurred in acute cases, and in late cases, it could be treated only by removal of the lunate.

Usually at surgery or on a post mortem examination, the lunate was found in two fragments, as previously described by anatomist's, one volar and one dorsal.

Now known to be 'Kienbock's Disease'

Click on back to return to KD Info

Kienbock's Disease is diagnosed radiographically. The characteristic changes of the lunate include increased density, fracture lines, fragmentation, and progressive collapse of the lunate.

It should be distinguished from other causes of wrist pain and swelling particularly in the early stages.

Disorders to rule out include rheumatoid arthritis, post traumatic arthritis, synoval based disease, acute fracture, carpul instability, and ulnar abutment syndromes. The radiographic hallmark of increased density seen typically in Kienbock's disease should be distinguished from transient vascular compromise.

Once the Diagnosis of Kienbock's Disease is established, the degree of involvement should be determined in order to assist you through the many treatment options. Casting for 2 to 3 weeks in uncertain cases will usually reveal the diagnosis by relative disuse osteoporosis of the adjacent carpul bones.

click back to return to KD information