ISSN 0972-978X 

  About COAA








Resurfacing Capitate Pyrocarbon Implant (Rcpi), An Alternative Treatment For Asseptic Necrosis Of The Lunate Stage Iv Of Litchmann’s Classification- A Case Report

Carlos H Fernandes, João B G Santos, Luis Renato Nakachima,Celso Hirakawa, Flávio Faloppa, Walter Manna Albertoni

Department of Orthopedic Surgery, Universidade Federal de São Paulo. São Paulo (UNIFESP), São Paulo, Brazil.

Address for Correspondence:
Carlos H Fernandes
Rua Borges Lagoa 1065 Cj 68/69
São Paulo, São Paulo, Brazil. CEP 04038-032.

Phone : (55)-(11)-50830145
Fax     :

E-mail :


Aseptic necrosis of the lunate bone in its advanced stage presents a large joint destruction. His treatment consists in total wrist fusion. We report a patient with Kienböck, grade IV of Litchmann’s classification, who underwent proximal row carpectomy and placement of a Resurfacing Capitate Pyrocarbon Implant (RCPI).

J.Orthopaedics 2010;7(3)e10


Kienböck; asseptic necrosis of the lunate proximal carpectomy; RCPI; wrist arthroplasty.


Although it was described more than 150 years ago, the etiology of the Kienböck disease is unknown. Aseptic necrosis of the lunate is studied at the Federal University of São Paulo for over 20 years. The relationship between the incidence and risk factors for the Kienböck disease are difficult to establish, because it is a rare condition. It usually affects adults, being more common among men (1,2).

The optimal treatment has not been established yet and, varies according to the authors. The advanced stages IIIB and IV are characterized by progressive carpal collapse, change of carpal kinematics, fragmentation of the lunate and secondary osteoarthritis. The proposed treatments are controversial and remain a therapeutic challenge. At this stage, the lunate is not amenable to surgery reconstitution; it is only possible salvage surgery. Several surgical techniques have been proposed, like denervation of the wrist, lunate resection and tendon interposition, revascularization of the lunate, shortening osteotomy of the radius, osteotomy for lengthening of the ulna, lowering of the capitate osteotomy, parcial or total wrist fusion, total wrist arthroplasty, carpectomia proximal and, lunate replacement by silicone prosthesis. There is no strong evidence of the superiority of one procedure over another (3,4,5).

The goal of our work was to report a patient with grade IV Kienböck that in lieu of the total wrist arthrodesis, underwent surgery for placement of a capitate head prosthesis made of pyrocarbon (RCPI).

Case Description

JMA, male, 38 years, wall painter, born and raised in São Paulo, Brazil. Patient reported complaint of pain in the left fist, which begun insidiously six months ago. The pain was accompanied by progressive loss of range of active and passive movements (20 ° - 20 ° of flexion-extension).

Examinations of X-rays and MRI have confirmed the necrosis of the lunate (Kienböck) grade IV of Litchmann’s classification (Figure 1).

Figure 1: Image of X-rays and MRI showed the involvement of the radiocarpal and medio-carpal joint.

Surgical Technique

The patient in the supine position was subjected to anesthesia type brachial plexus block.

A dorsal and radial incision in the left wrist was performed, opening between the second and third tunnel extensor.the capsule was opened by the technique in ">" to preserve the ligaments. During resection of the first row of the carpus and radial styloid osteotomy, was possible to observe the articular cartilage lesions of the head of the capitate and lunate fossa on the radio. Then carefully, all articular cartilage of the head of the capitate bone was removed with minimal resection of the proximal part (convex shape) in order to expose the cancellous bone. If possible, the resection should be parallel to the radius distal side. A sharp awl is used to prepare the hole and locate the central aspect of the medullary canal of the capitate. Preparation of the capitate was made, using the broaches (and eventually the impactor/ extractor screwed on their extremity), starting with the smallest size. A guide mark shows the dorsal side on the broach to prepare the capitate with the correct orientation (Figure 2).

Figure 2: Injury in the cartilage surface of the radio. Radioscopy showing the position of the cutter within the capitate. Canal formed in the capitate.

Next we tested the evidence of the prosthesis to check what size was more appropriate. The adequate size and position were confirmed by fluoroscopy. Then, we did the replacement of the trial implant by the corresponding pyrocarbon implant with a plastic tong to prevent any injury to the prosthesis. The procedure of closure was normal and no additional stabilization technique was required. The wrist was splinted for 3 weeks and unrestricted active range of motion was allowed after eight weeks with strengthening started after 12 weeks.

In evaluating the patient in the first year after surgery, he found himself satisfied with the surgery and had returned to his job. He complained of pain in small intensity (intensity in an analog scale of pain) to extreme efforts. Inspection showed a hypertrophic scar on the dorsum of the wrist and the presence of palmar callosities. The presence of callosities demonstrated that the patient had a heavy manual work activity (Figure 3).

Figure 3: Clinical appearance at 1 year of follow-up. Range of active flexion and extension movements of the wrist. Hypertrophic scar. Palmar callosities.

The active and passive joint range of flexion increased from 20 ° in pre to 60° postoperative and remained in the extension 20°. In the X-ray image, the prosthesis was observed to be in position equal to the intraoperative period. A comparison of the postoperative first week and one year examination, show the latter a halo of bone reabsorption between implant and bone (Figure 4).

Figure 4: X-Ray showing position of the prosthesis with 1 year after the surgery.

Discussion :

In a recent publication, Lumsden et al (2008) showed good results after 15 years following proximal row carpectomy in stages III. Also in 2008, Stern and Croog (2008) showed that the three patients who underwent proximal row carpectomy, required reintervention for total wrist fusion, two patients were grade IV. We believe that to Grade IV would be the best indication to surgical total wrist arthrodesis, but this is not a surgery without complications and has the disadvantage of taking the whole movement of the wrist. The total wrist prosthesis has a very high cost and its surgical technique and instrumental are very sofisticate. The use of the prosthesis seems to us an alternative treatment for pain relief and range of motion, in patients with necrosis of the lunate, grade IV.

Pyrocarbon is being used as a raw material in cardiac prosthesis for more than twenty years (8). Due to its mechanical characteristics, very similar to the bone, its use in orthopedic prosthesis has increased in recent years. The major uses are as casing of prosthesis for elbow, wrist and fingers (9,10,11). The prosthesis is known as RCPI (Resurfacing Capitate Pyrocarbon Implant). The prosthesis has a fairly simple surgical technique and likewise, its instrumental use is equally easy. Recently, Elhassan and Shin described the resurface the proximal capitate using a metacarpal head replacement pyrocarbon implant and debride of the lunate fossa.

The major advantage of using the prosthesis is the preservation of some degree of movement in the joint. The halo of resorption seen in our patient in the first year after surgery was also found in other patients, as described by Saffar (13), and it seems related to a functional outcome.


Preliminary result is very encouraging, at an average 12 months' follow-up, the patient gives a significant improvement of pain and range of motion.


  1. Faloppa F, Albertoni WM, Santarosa ML, Galbiatti JA, Komatsu S. Tratamento da Doenca de Kienböck com prótese de substituição de silicone: avaliação clínica. Revista Brasileira de Ortopedia 1992; 27: 587-592.

  2. Faloppa F, Albertoni WM. Estudo da variação ulnar na Doença de Kienbock. Revista Brasileira de Ortopedia 1989; 24, 305-309.

  3. Graner O, Lopes EI, Caralho BC, Atlas S. Arthrodesis of the carpal bones in the treatment of Kienbock’s disease, painful ununited fractures of the navicular and lunate bones with avascular necrosis, and old fracture dislocations of the carpal bones. J Bone Joint Surg 1966; 48A: 767-74.

  4. Lichtman DM, Mack GR, MacDonald RI, et al. Kienböcks disease: the role of silicone replacement arthroplasty. J Bone Joint Surg 1972; 59A: 899-908.

  5. Rhee SK, Kim HM, Bahk WJ, Kim YW. A comparative study of the surgical procedures to treat advanced Kienböck’s disease. J Korean Med Sci 1996; 11: 171-8.

  6. Lumsden BC, Stone A, Engber WD. Treatment of Advanced-Stage Kienböck's Disease With Proximal Row Carpectomy: An Average 15-Year Follow-Up.  J Hand Surg 2008; 33A: 493 - 502.

  7. Croog AS, Stern PJ. Proximal row carpectomy for advanced Kienböck's disease: average 10-year follow-up. J Hand Surg 2008; 33A: 1122–1130.

  8. Renzulli A, de Luca L, Caruso A, Verde R, Galzerano D, Cotrufo M. Acute thrombosis of prosthetic valves: a multivariate analysis of the risk factors for a lifethreatening event. Eur J Cardiothorac Surg. 1992; 8: 412-20.

  9. Allieu Y, Winter M, Pequignot JP, De Mourgues PH. Radial head replacement with a pyrocarbon head proshesis : preliminary results of a        multicentric prospective study. Eur J Orthopaedic Surg & Trauma 2006; 16: 1-9.

  10. Pequignot JP, Lussiez B, Allieu Y. Chir Main. 2000 Nov;19:276-85. A adaptive proximal scaphoid implant. Chir Main 2000; 19: 276-85.

  11. Skie M, Gove N, Ciocanel D. Intraoperative fracture of a pyrocarbon PIP total joint-a case report. Hand 2007; 2: 90-3.

  12. Elhassan B, Shin AY. Management of Wrist Arthritis Secondary to advanced Kienbock Disease. Techniques in Orthopaedics 2009: 24; 27-31.

  13. Saffar P. Sauvetage des résections de la 1ère rangée des os du carpe en cas d'arthrose radio-capitatum. 2ème congrès Ollier - Arthroplasties : les nouvelles évolutions. Juin 2005. Les Vans, France.

This is a peer reviewed paper 

Please cite as: Carlos H Fernandes: Resurfacing Capitate Pyrocarbon Implant (Rcpi), An Alternative Treatment For Asseptic Necrosis Of The Lunate Stage Iv Of Litchmann’s Classification- A Case Report

J.Orthopaedics 2010;7(3)e10





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.