Rationale:

When one of the small carpal bones, the Lunate, in the wrist joint, gets an interrupted blood supply it results in osteonecrosis of the bone i.e. clinical failure of the bone to function. Passing through four stages of progression, Kienbock’s disease is a gradual condition that usually eludes the patient into believing it to be a wrist sprain. Beginning with just an underlying pain and swelling in the wrist it can end in total arthritis of the wrist bones.

Approach Considerations:

When the condition of the lunate completely deteriorates to cause functional failure in the wrist and progresses to a stage of severe arthritis, the wrist surgeon decides on a procedure in which the nearby bones to the lunate are fused together with it to make it into one solid bone, to relieve pain and sustain partial wrist motion. The wrist surgeon may also fuse the bones with the radius to eliminate mobility but retain forearm motion.

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The fusion technique:

When the lunate becomes non functional and starts to damage the associated bones then the wrist surgeon fuses the bones together to make them functional as a single bone. After holding the bones together, they are stabilized by metal implants such as plate and screws. This technique restores partial mobility and strength back in the wrist joint.

Preparations for the technique:

After the wrist surgeon has conclusively concluded that the lunate has severely damaged and the wrist can only be partially functional after fusion technique, the patient is informed about pros and cons of the technique and mental anxieties of the patient are eased regarding the surgery.

The wrist surgeon also has the patient undergo certain tests to ensure that the patient is medically fit to undergo surgery. The patient is also inquired about past medication history, allergies or reactions to anesthesia or chemical compositions, if any and any habits of the patient that might hinder the surgery.

After completing all relative formalities the surgical technique is performed.

Performance:

After appropriate anesthesia, the patient is put to sleep to go through the surgery painlessly. An incision is made on the wrist over the lunate and the tendons and ligaments are moved aside to get a clear view of the bones that have to be fused with the lunate to enable partial functionality in the wrist. A metal plate is attached to the bones with metal screws to hold the bones together and the wrist surgeons stitches back the incision and places a protective bandage over it.

Follow up after the technique:

After the fusion technique the wrist is placed in a cast or splint for a certain period of time to immobilize the wrist so that the bones can stabilize during the healing process. The patient is asked to visit his surgeon after a week or so to enable the surgeon to monitor the progress of the fused bones. The patient is instructed to keep the wrist straight and avoid activities that can interrupt healing or exert pressure on the wrist.

Complications of the technique:

The most common infections that can occur after fusion technique involve an infection in the incision made to fuse the bones together, an injury to the associated nerve or blood vessels during the surgery or failure in provision of relief after the fusion of the bones.

Benefits of the technique:

It minimizes or eliminates the pain and helps in restoration of partial wrist motion and strength. It is considered to be the most effective technique to salvage the wrist which has been completely damaged by instability and arthritic bones that have been caused by the clinical failure of the lunate bone.

Rehabilitation after the technique:

A personalized rehabilitation program is chalked out for the patient where he is taught exercises and ways to gently bring partial mobility to the wrist or strengthen the muscles. An occupational therapist is essential to teach the patient methods to adapt to activities as fusion technique does not restore mobility to the wrist. Physical therapist with the help of exercises and other protocols restores strength and relaxes the stiff muscles after the surgery.

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More about wrist surgeon:

He is an ingenious professional who passionately believes in deliverance of techniques to relief his patients of each and any debilitation in the hand.  Dr. Vikas Gupta with his compassionate approach and accurate diagnosis is easily one of the most experienced and skillful wrist doctors in the country. His presence at various national and international seminars, his introduction of various international techniques to Indian field of deliverance has received acclamation and he is an influential role model for his peers and interns.

His experience in the field is more than 25 years with more than 6000 surgeries and innumerable cases that have been provided relief by his nonsurgical prescription and combination of techniques. An MBBS and MS in Orthopedics from All India Institute of Medical Sciences, New Delhi and Fellowship from Germany and USA, he has delivered treatment to patients all around the country from various hospitals that include AIIMS as associate professor, Consultant Hand & Upper Extremity Surgery (orthopedics) At Fortis Hospitals, Director, Hand & Upper Extremity Surgery (orthopedics) At Medanta – The Medicity, Gurgaon and at present head of Hand and Shoulder division at Max Healthcare, the super specialty hospital in Delhi- NCR region.