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AVN Lunate: Review Of Literature

 Pankaj Kumar *

* Assistant Professor, Department of Orthopedics, B.P.Koirala Institute of Health Sciences, Dharan, Nepal

Address for Correspondence:
Dr Pankaj Kumar
C/o Ramnandan Mandal
Campus chowk-4, Janakpurdham, ( Nepal )
Ph. No: 00977-9842052282
E-mail: ,


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

AVN, Lunate , approach


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.


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)


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.


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.


  • 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 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.


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.


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)


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.

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This is a peer reviewed paper 

Please cite as : Pankaj Kumar : AVN Lunate: Review Of Literature

J.Orthopaedics 2008;5(1)e4





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