‘Osteonecrosis of the lunate’- Kienbock’s Disease
As a living Tissue the bone essentially requires:
continuous blood supply to enable functionality. Interruption in the blood supply can make the bone die being referred to as Osteonecrosis. Blood supply can be hindered because of a severe traumatic injury, fracture or dislocation or even without any concrete cause. But if not treated, osteonecrosis can cause the joint to deteriorate and result in severe arthritis.
The wrist is made of a framework :
of eight carpal bones. These carpal bones provide mobility and flexibility to the wrist of a human hand. One among the eight carpal bones is ‘The Lunate’. When blood supply to the lunate gets interrupted it causes clinical death of the bone or avascular necrosis leading to the disease which is known as Kienbock’s disease, a rare and debilitating medical condition resulting in chronic impairment.
Cause of Kienbock’s being unfathomable:
may seem to be just a sprain initially. When pain, numbness, swelling, limited motion ability with decrease in grip strength is visible, then it is relatively diagnosed by various imaging tests and concluded that the patient might be suffering from Kienbock’s disease. The hand specialist Dr. Gupta formulates a treatment plan accordingly to restore the lunate by both surgical or non surgical techniques.
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Rationale:
When lunate, one of the small carpal bones that make up the wrist, loses blood supply, it clinically dies i.e. ceases to function and this condition is referred to as Kienbock’s Disease. Passing through various stages, the lunate dies a gradual and slow processed death causing severe internal damage to associated bones and the functioning of the wrist joint.
Approach Considerations:
When the pain in the wrist becomes persistently intense along with excessive swelling and the wrist becomes unstable then it becomes essential to diagnostically ascertain the cause for the condition. The MRI scan or X-ray will clearly mark the structural difference in ulna and radius bone lengths to be a tentative cause for lunate osteonecrosis. The wrist surgeon then undertakes the technique of joint leveling to reduce the pressure on the lunate that is being caused by the difference in radial and ulnar bone lengths.
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Preoperative Preparation:
The wrist surgeon informs the patient in length about the procedure that shall be undertaken to relieve him of his problematic condition. After the patient agrees to the technique, some general medical tests are run on the patient for assurance that he is medically fit to undergo surgery. Information regarding any other complications that might hinder the surgery is gathered from the patient that includes medical history, allergies or reactions. The day of the surgery is scheduled and the surgeon proceeds with the operation.
Performing the Surgery:
Joint leveling surgery is carried out by either shortening the longer bone i.e. the radius (radial shortening osteotomy) or lengthening the shorter bone i.e. the ulna (ulnar lengthening).
Ulnar lengthening: After appropriate anesthesia, the wrist surgeon makes an incision on the ulnar side of the wrist and makes a cut on the bone in a stair step way to stretch the bones further apart yet do not let them overlapped and connected. The bone is stretched apart till its length does not become equal to the radius. Once the length of radius and ulna become equal, joint leveling is said to have been performed and the two bones are held together by metal plates and screws to enable healing and become stable.
Radial shortening: After appropriate anesthesia, the wrist surgeon makes an incision on the end of the radius. After assessing through x-ray the amount of bone to be shortened, radius is cut into two pieces and the shorter part i.e. near the wrist is removed. The two pieces are then realigned and held together by metal plates and screws until healed.
After the surgery the wrist is covered with a protective bandage.
Postoperative Follow up:
The wrist is placed in a splint for almost 12 weeks or so and regular x-rays are taken to monitor the progress of the bone, by the wrist surgeon. The splint is removed after the surgeon is clinically convinced that the bones have healed.
Postoperative Rehabilitation:
Rehabilitation program is essential basis for restoring function and reducing pain in the wrist. It comprises of physical and occupational therapy for eight to twelve weeks after the surgery under which the patient is taught exercises that enable strengthening and stabilizing of the wrist muscles. Other exercises help to master motor activities and agility of the hand. With occupational therapy the patient learns how to perform activities while avoiding excess pressure on the wrist.
Postoperative Complications:
Getting radius and ulna at the exact length is difficult and may create complications for the surgeon. In some cases the patient may complain of ulnar side wrist pain or stiffness and the surgery may prove to be inadequate in healing the lunate.
Postoperative Benefits:
- The pain decreases substantially
- The wrist restores strength
- Improvement in the mobility
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 surgeons 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.