Journal of Chalmeda Anand Rao Institute of Medical Sciences Vol 7 Issue 1 January - June 2014 1Journal of Chalmeda Anand Rao Institute of Medical Sciences Vol 8 Issue 2 July - December 2014 ISSN (Print) : 2278-5310 108

Vascular Pedicle Pisiform Bone Grafting for

Kienbocks Disease : A Case Report

Nagamuneendrudu K1, Valya B2, Vishnu Vardhan M3

1Associate ProfessorDepartment of OrthopaedicsOsmania Medical College2 Professor of OrthopaedicsGandhi Medical College3 Postgraduate StudentDept of OrthopedicsGandhi Medical CollegeSecunderabad, India.

CORRESPONDENCE :

1Dr.K.NagamuneendruduMS (Ortho)Associate ProfessorDepartment of OrthopaedicsOsmania Medical CollegeHyderabad, India.India.E-mail: knagmuni60@gmail.com

Case Report

INTRODUCTION

Kienböck disease is a painful disorder of the wrist ofunknown cause in which radiographs eventually showosteonecrosis of the carpal lunate. It occurs morefrequently between the ages of 15 and 40 years. [1]

Untreated, the disease usually results in fragmentationof the lunate, collapse with shortening of the carpus, andsecondary arthritic changes throughout the proximalcarpal area. Symptoms can develop 18 months beforeradiographs show evidence of the disease. [2]

CASE REPORT

25 years female patient presented with right wrist pain

ABSTRACT

25 years old female patient presented with pain in the right wrist of 3 years duration, withmild restriction of movements, the case is diagnosed as Kienbock’s disease, the case treatedwith vascular pedicle pisiform bone grafting.

Keywords: Kienbock’s disease, pisiform bone, vascular pedicle bone grafting.

for the past 3 year. It is Insidious in onset and pricking innature, gradually progressing and increased since 6months, no constitutional symptoms aggravated bytwisting, relieved by rest, no radiation.

On examination, there is tenderness over the volar aspectof the wrist, in the centre of the proximal row of carpals.Movements are painful in the terminal range ofmovements, flexion and radial deviation are minimallydecreased. Patient is investigated routine bloodinvestigations are normal, X-ray of the wrist showedcollapsed lunate, the carpal height is decreased, CT scan,showed the collapsed lunate.

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Figure 1: Right wrist dorsiflexion decreased Figure 2: Right wrist palmar flexion decreased

Figure 3: Right wrist radial deviation decreased Figure 4: Wrist ulnar deviation equal

Figure 5: Collapsed lunate

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Figure 8: Collapsed Lunate

Figure 6: Collapsed and deformed lunate

Normal Right wrist

Figure 7: Carpal height collapse

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Figure 9: Vascular Pedicled Pisiform bone grafting Figure 10: Other vascularized bone graft donor sites

MANAGEMENT

The patent is operated under general anaesthesia, undertourniquet control without exsanguinating the limb, tofacilitate vessel identification. Haemostasis was doneprogressively. An 8-cm antero-medial zigzag incision wasmade extending from the forearm to the palm, just lateralto the flexor carpi ulnaris tendon and directed towardsthe fourth ray in order to avoid the palmar cutaneousnerves. The vessels on the lateral border of the pisiformwere cut and electrocauterised.

The pisiform was freed from its muscular attachments(flexor carpi ulnaris) and from the pisohamate ligament,preserving the lateral distal insertions of flexor carpiulnaris. When the capsule was incised, the pisiform wasonly attached to the blood vessels on its medial border.

The latter, in addition to the dorsal carpal branch of theulnar artery and accompanying veins were contained ina cellulo-adipose bundle easily identifiable by tractionon the pisiform. The dorsal carpal branch was dividedand ligated at the level of the triquetrum near the originof the deep palmar branch. This bundle was dissectedfrom distal to proximal. Dissection is easier in relation tothe flexor carpi ulnaris than to the dorsal branch of theulnar nerve situated just behind the artery.

The tourniquet could be deflated temporarily todifferentiate vascular and nervous structures. The vesselswere passed behind the flexor carpi ulnaris and werefreed up to the ulnar artery. The pedicle obtained was atleast 4 cm long. The pisiform and its pedicle were slippedbehind the flexor carpi ulnaris and placed lateral to theulnar neurovascular bundle. The flexor carpi ulnaristendon remaining in continuity with the pisohamateligament and the abductor digiti minimi forms a

fibromuscular septum protecting the ulnar neurovascularpedicle. The flexor retinaculum was incised longitudinallyon its medial side to open the carpal tunnel. The flexortendons and the median nerve were retracted laterallyand volarly. The pisiform was completely detached fromthe pisotriquetral capsule and its articular cartilage wasabraded.

The radiolunotriquetal ligament was incised to exposethe lunate. Necrotic bone fragments were removed fromthe lunate to allow graft placement. Traction is appliedto the wrist and a percutaneous scaphotrapezial K-wireis inserted. The pisiform is inserted into the lunate withcare to orient the pedicle as anteriorly and distally aspossible to prevent it from being crushed during forcedpalmar flexion of the wrist. The transplant is fixed with alunotriquetral K-wire.

After tourniquet release, the incision in theradiolunotriquetral ligament is closed taking care not tocompress the vascular pedicle. Skin is closed and plasterimmobilization is applied.

DISCUSSION

The natural course of Kienböck disease is unpredictable,the treatment of established Kienböck disease cannot berigidly prescribed, but an attempt is made to stage thedisease and suggest the treatment procedures byLichtman et al. The following staging classification ofKienböck disease:Stage-I there is a linear or compression fracture butotherwise normal architecture and density.Stage-II density is abnormal, without lunate or carpalcollapse.

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Figure 11: Incision Figure 12: Pisiform bone isolated from Flexor carpi ulnaris

Figure 13: Pisiform vascularized graft Figure 14: Pisiform graft in situ in the collapsed lunate

Figure 15: Fixation of the graft in the lunate by traqutro-lunate

pinning.

Figure 16: The Final X-ray.

Surgery Steps

Stage-III Lunate collapse is presentStage-IIIA without carpal collapse (i.e., carpal height isnormal, radioscaphoid angle is less than 600

Stage IIIB, with carpal collapse (diminished carpal height,radioscaphoid angle greater than 600). Stage IV, extensive osteoarthritic changes are presentase,proposed, is useful when planning treatment.

Numerous surgical procedures have been described forKienböck disease. Joint “Leveling” procedures, includeulnar lengthening and radial shortening usually areindicated for Lichtman Stage I through Iiia Kienböckdisease, with an ulnar-minus variation and withoutdegenerative changes in the radiolunate or capitolunatejoints. Wedge osteotomies have been used to decreasethe load on the lunate by decreasing the radioulnarinclination of the distal radius. [2]

Lunate revascularization using a variety of pedicled bonegrafts has been effective in preserving the lunatearchitecture. These revascularization procedures usuallyrequire protection of the lunate with pinning of thescaphocapitate or scapho-trapeziotrapezoid joint or withan external fixator. Excision of the lunate can give short-term relief.

Prosthetic lunate replacement also may provide relief.Limited intercarpal fusions can prevent proximal carpalmigration after lunate excision and can help decreasepressure on lunate prostheses. When secondary arthriticchanges have developed throughout the wrist (Stage IV),treatment usually is proximal carpal row resection orwrist arthrodesis. In the present case there is no fixedration of scaphoid, There is no ulna minus, So therevasculrization is done with vascularized pisiform bone,the size of the bone is nearly matching the size of lunate.

The scapho trapezoid pinning with K wire prevents theproximal collapse of the carpus and prevents the loadingon the lunate, So first the scapho-trapezoid pinning is

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done after applying longitudinal traction, then, thepisiform is isolated with pedicle. The cartilage over thepisiform is removed placed into the lunate, fixed withlunate- traquitral pinning. This case needs follow up forthe outcome.

CONCLUSION

1. Kienbock’s disease the condition of lunate due toloss of blood supply of unknown aetiology, resultingIn avacular necrosis and collapse with consequentialcarpal collapse and secondary arthosis withcompromised function of the wrist.

2. The natural history how the disease progress isunpredictable

3. Lichtman’s classification is the presently availablestaging of Kienbock’s disease

4. Many procedures are advocated for themanagement of the Kienbock’s disease of whichrevascularization with vascularized bone graftingof which the vascularized pisiform grafting isdescribed.

5. This condition requires careful planning and choiceof treatment.

6. It needs long term follow up for the outcome.

CONFLECT OF INTEREST

The authors have no conflicts of interest to disclose.

FUNDING : None

REFERENCES

1. Norbert Kuhlmann J, Cedric Kron, Andre Boabighi, Serge Baux,Maurice Mimou. Vascularized pisiform bone graft indications,technique, and long term results. Acta Orthopædica Belgica. 2003;69: 311-316.

2. Canalc ST, Beaty JH. Campbells operative orthopaedics: 4-VolumeSet (Expert Consult Premium Edition - Enhanced Online Featuresand Print), 12edn., Mosby: 2012.