Stéphane Stahl, MD, of the Department of Plastic, Hand and Reconstructive Surgery at Eberhard-Karl University of Tübingen, in Germany, conducted a prospective case series study in which he analyzed the pattern and extent of osteonecrosis with the duration of symptoms in patients with Kienböck’s disease. Patients were confirmed to have the disease since 2009 using high-resolution 3 Tesla MRI and ultra-thin-section CT scan.
“Short histories of pain were associated with significantly fewer pathognomonic parameters, increasing the risk of false-positive diagnosis in early stages,” Stahl said at the American Society for Surgery of the Hand Annual Meeting. “No specific combination or sequence of radiologic parameters was specific to the natural evolution of the disease. Therefore, we question the validity and prognostic value of current classifications. Kienböck’s disease may progress to fragmentation within only 6 months.”
The causing agent of Kienböck’s disease is not known, and there are no specific symptoms, Stahl said.
“So, the objectives of these studies were to determine the frequency and distribution of radiographic and clinical signs and to determine the correlation of diagnostic parameters with the onset of symptoms,” he said.
Stahl conducted a 5-year prospective study of 26 patients with complete case report forms that included information from a clinical examination, medical record evaluations and self-assessment questionnaires. Radiographs, MRI and CT scans of the patients were evaluated by a board-certified radiologist and hand surgeon.
Some of the diagnostic parameters studied included arthritis, sclerosis of the lunate on CT, deformity of the lunate on radiograph and fractures of the lunate. Eleven of the original 35 patients had arthritis of the lunate without any fractures at the time of examination, according to Stahl.
“We found out that the number of radiologic parameters assessed correlates or increases as the duration of the disease increases,” Stahl said. “We were surprised to see that looking at each individual radiologic parameter, the lapse of time that could be assessed since the beginning of the disease did not significantly differ from one another, except for arthritis of the scaphoid fossa. We were also surprised to see that one-third of the patients had arthritis of the lunate, but no fractures or no sign of carpal collapse.”
To determine the timeline for the evolution of Kienböck’s disease, Stahl performed a retrospective review of data for 106 patients with the disease who were treated at his institution from 1990 to 2014, only reviewing data for patients who had no surgery until fragmentation of the lunate. Of the three patients identified who had a well-documented spontaneous course from an intact lunate morphology until fragmentation, the diseased evolved to fragmentation within 6 months.
“The diagnosis was verified in all cases by clinical examination, X-ray and MRI,” Stahl said.
Stahl concluded the risk of false-positive diagnosis of the disease is particularly high in the early stages, and there is not a specific combination or sequence of radiologic parameters specific to the evolution of Kienböck’s disease. In addition, he said the validity and prognostic value of current classifications are questionable. – by Gina Brockenbrough, MA, and Robert Linnehan
Stahl S. Paper #5. Presented at: American Society for Surgery of the Hand Annual Meeting. Sept. 18-20, 2014; Boston.
Disclosure: Stahl has no relevant financial disclosures.