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

Abstract

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.

The prevalence of coexisting Kienböck's and Preiser's diseases is very low and standardized stages of disease and treatments are not established. 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.

Introduction

There are some reports of avascular necrosis of carpal bones. ¹ , ² , ³ , ⁴ Risk factors of avascular necrosis of bones have been reported to include corticosteroid use, smoking, gout, alcoholism, infections, storage disorders, marrow‐infiltrating diseases, coagulation defects, hemoglobinopathies, fat emboli, liver disease, hyperlipidemia types II and III, hemophilia, rheumatoid arthritis, systemic lupus erythematosus, and pancreatitis. ⁵

Kienböck's disease and Preiser's disease comprise avascular necrosis of the lunate and scaphoid, respectively. These diseases are receiving ongoing research on their pathophysiology, classification, and treatment. For Kienböck's disease, Lichtman classification has been used worldwide. A partial treatment method has been established based on stage. For Preiser's disease, Herbert and Lanzetta in 1994 developed a novel classification based on radiographs. In 2003 Kalainov et al. developed a second classification based on MRI findings. Diffuse necrosis or ischemia is classified as type 1 and segmental vascular impairment as type 2. ⁶ , ⁷ The low incidence of Preiser's disease has hindered treatment consensus.

Treatment methods of Kienböck's disease and Preiser's disease are being established, but coexisting avascular necrosis of the scaphoid and lunate is too recently reported to standardize treatment. Coexisting Kienböck's and Preiser's diseases have been reported very rarely and has not been named; coexisting, concomitant, or combined Kienböck's and Preiser's diseases has been used in previous reports. ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² Staging and treatment of the disease have not been established, and associated studies treated patients based on arthritic changes of bones and on their theory of pathophysiology. We report a patient with coexisting avascular necrosis of the scaphoid and lunate without systemic disease or trauma.

Case Report

A 68‐year‐old woman presented with pain in the left wrist that had started 2 years earlier. The patient reported no traumatic wrist event or other medical conditions such as corticosteroid use, smoking, and alcoholism. Physical examination revealed diffuse tenderness of the left wrist and swelling. Range of motion was limited from extension 40° to flexion 10° and grip strength was measured 19 kg. Sclerotic change and collapse of the lunate and scaphoid were observed on plain radiography (Figure 1). Computed tomography (CT) scan revealed fragmentation of the lunate. Magnetic resonance imaging (MRI) showed avascular necrosis of the scaphoid and lunate, suggesting coexisting Kienböck's and Preiser's diseases. Upon MRI analysis, the articular cartilage of the proximal capitate or distal radius lunate fossa seemed to be intact (Figure 2).

Fig. 1.

(A) Preoperative range of motion was measured. Wrist extension and flexion was about 40°/10°. (B) On Plain radiograph, proximal scaphoid and lunate were sclerotic and collapsed.

Fig. 2.

(A) Lunate fragmentation was found on CT scan. (B) Avascular necrosis of proximal scaphoid and lunate were found. Articular cartilage of lunate fossa and proximal capitate seem to be intact.

To prevent arthritis or the possibility of arthritis not being detected on MRI, proximal row carpectomy (PRC) with a distally based capsular inter‐position technique was planned.

During the operation, a dorsal longitudinal skin incision was made on the wrist. The fourth extensor compartment was incised, and a neurectomy was performed on the posterior interosseous nerve terminal branch (Figure 3A). A capsular incision was designed for a distally based capsular flap (Figure 3B–D). The PRC procedure was performed as follows (Figure 3E). The capsular flap was kept safe from damage. A Homan retractor was inserted in the ulna side of the triquetrum for removing the triquetrum. For this, the dorsal lunotriquetral ligament was divided on direct view. The triquetrum was held with a towel clip, and an elevator was inserted to the volar side for blunt detachment from the ligament. This procedure is safer than sharp dissection. A scalpel can be used only when the ligament structure is observed directly. The lunate is removed in a similar fashion. In general, the scaphoid is the most difficult bone to excise. The radioscaphocapitate (RSC) ligament should be saved, but the scaphoid blocks view of the ligament, and the scaphotrapeziumtrapezoid ligament on the distal pole of the scaphoid is strong. Care and patience are needed for blunt dissection. Bone could be fragmented in pieces and removed little by little with a rongeur and osteotome. A scalpel also can be used, but only when ligament structures are visible. The RSC ligament can be tested with ulnar translocation of the carpal bone. If the RSC ligament is intact, the capitate cannot travel over the lunate fossa of the radius. The pisiform is maintained. Excised bones were requested for pathological examination, and the lunate and scaphoid demonstrated avascular necrosis.

Fig. 3.

Intraoperative photos and schematic drawings. (A) The dorsal wrist was exposed through the 4th extensor compartment. (B–D) A distal‐based dorsal capsular flap was prepared. (E) A proximal row carpectomy was performed. (F) Articular cartilage of the proximal capitate and lunate fossa of the distal radius were checked. Little arthritic cartilage erosion of the proximal capitate was found at an asterisk. (G) The prepared dorsal capsular flap was tied to the volar capsule (H‐J) Distal–based dorsal capsular interposition after PRC has been done.

After the PRC procedure, articular cartilage was assessed for arthritic change. This analysis showed changes in the proximal capitate that were not detected on MRI (Figure 3F). The proximal portion of the distal based capsular flap was tied to the volar capsule (Figure 3G) and distal‐based dorsal capsular interposition after PRC has been done (Figure 3H–J).

As the present case showed, articular cartilage wear can exist even when MRI shows normal cartilage. For this reason, we suggest preparing a capsular flap for interposition with the PRC procedure.

A cock‐up splint was used for 3 weeks. The patient was able to return to work 3 months after surgery, was pain‐free, and returned to all activities. At the last follow‐up 14 months after surgery, no progression of arthritis was seen in the lunar fossa or proximal capitate. The patient's wrist showed a fair range of motion with 30° of flexion, 60° of extension, and a modified Mayo wrist score of 80 (Figure 4). In comparison contralateral extremity, 80% of grip strength was measured (25/31 kg).

Fig. 4.

(A) 1 year after operation, range of motion was measured. Wrist extension and flexion was about 60°/30°. ROM was not significantly improved, but her wrist was pain free. (B) On plain radiograph, arthritis of proximal capitate and lunate fossa were not advanced.

Discussion

Budoff reported favorable results in a case of advanced Kienböck's disease and Preiser's disease with arthritis that was treated with distal‐based capsular interposition with PRC. ⁸ Bhardwaj et al. also reported a case treated with the PRC technique. ⁹ Tomori et al. reported two cases with favorable medium‐term outcomes of closed radial wedge osteotomy (CRWO). In one of them, postoperative MRI was performed 1 year after surgery and showed revascularization of a distal pole of the scaphoid and whole lunate. ¹⁰ CRWO has the advantage of being a joint leveling procedure rather than salvage, and necrotic bone can be revascularized when arthritic changes have not occurred. Park et al. reported a case with radio‐scaphoid and radio‐lunate fusion using a bent distal radius dorsal plate and autologous iliac bone graft. ¹¹ Afshar et al. treated a patient suffering from thalassemia minor hemoglobinopathy with total wrist fusion ¹² (Table 1).

TABLE 1.

Reports published in the literature on the surgical treatment of coexisting Kienböck's and Preiser's disease of the wrist.

No	Author	Sex/Age location	Risk factor	Surgical treatment	Prognosis
1	Budoff et al. (2006)	F/50 Rt. wrist	Smoking Corticosteroid use	Distal‐based capsular interposition with PRC	50% pain reduction
					Nearly full ROM
2	Park et al. (2010)	F/56 Rt. wrist	No risk factor	Radio‐Scaphoid and Radio‐Lunate fusion	Pain disappeared
3	Bhardwaj et al. (2012)	M/20 Rt. wrist	No risk factor	PRC technique	Complete pain relief
					Good range of motion
					Grip strength of 20 kg
4	Tomori et al. (2017)	F/50 Rt. wrist	Smoking	CRWO	No residual pain
					Grip strength of 19 kg
		F/59 Rt. wrist	Smoking		No residual pain
					Grip strength of 23 kg
5	Afshar et al. (2022)	F/39 Rt. wrist	Thalassemia minor hemoglobinopathy	Total wrist fusion	No pain
					Grip strength of 20 kg

Abbreviation: CRWO, closed radial wedge osteotomy; PRC, proximal row carpectomy; ROM, range of motion.

In the present case, the lunate was fragmented and very difficult to save; leveling procedure and revascularization procedure has advantage of restoring normal anatomy, but in case that arthritis occurred or fragmentation of bone cannot be reduced, salvage procedure should be performed. Salvage procedures include total or limited fusion or PRC. Total wrist fusion and limited fusion such as radio‐scaphoid and radio‐lunate fusion could cause limitation of motion with a little weakness of hand. PRC could cause weakness of hand with a little motion limitation. In the present case, it was non‐dominant hand and the patient requested early use of her hand and reduce the possibility of multiple surgeries due to complications such as non‐union. The authors decided to perform PRC based on intact articular surface of the capitate head and distal radius lunate facet. The dorsal capsular interposition technique could be used in patients who do not meet these conditions.

Interposition material could be a meniscal allograft, decellularized dermal allograft, or autologous dorsal capsule. Dorsal capsular interposition can be proximally or distally based. Kwon at el. reported improvement of visual analog scale with distally based capsular interposition after PRC. ¹³ Pros and cons of each method are not yet known. Lee et al. reported significant improvement of disabilities of the arm, shoulder, and hand (DASH) score using decellularized dermal allograft, while Steiner reported improvement of DASH score with meniscal allograft interposition. ¹⁴ , ¹⁵

Conclusion

Standardized treatment of coexisting Kienböck's and Preiser's diseases has not been established, but PRC 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.

Conflict of Interest Statement

All authors have no conflicts of interest to declare.

Author Contributions

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors are in agreement with the manuscript.

Conceptualization, Il‐Jung Park and Soo‐Hwan Kang; Data curation, Hyun Woo Park; Funding acquisition, Il‐Jung Park; Investigation, Hyun Woo Park; Methodology, Dohyung Lim; Supervision, Il‐Jung Park; Writing—original draft, Seungbae Oh; Writing—review and editing, Seungbae Oh and Hyun Woo Park.

Ethics Statement

Ethics committee approval for this study was given by the Institutional Review Board (IRB) of the Catholic University of Korea (IRB No. HC22ZASI0110).