Rationale:

Kienbock’s disease is a condition that occurs because of poor blood supply in one of the eight carpal bones that form the wrist joint. Lunate, one of the smaller carpal bones receives inadequate blood supply and clinically starts to malfunction causing intense pain, swelling, decreased grip strength in the wrist. As it progresses very slowly it is often mistaken for a wrist sprain and is only clinically evident by imaging tests.

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Approach Considerations:

The causes of Kienbock’s disease are still uncertain but when any pressure on the lunate arising out of traumatic injury or sports activities, presence of one blood vessel in the body instead of two, difference in the radial and ulnar bone lengths causes interrupted blood supply to the bone it passes through four stages of progression. Proximal row carpectomy is considered to be an effective technique for treating the disease when the disease is in the third or the last stage of progression i.e. the lunate starts to deteriorate and break into pieces inducing the nearby bones to shift away from their positions or triggering off the collapse of adjoining bones also, causing the wrist to become severely arthritic.

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Preoperative preparations:

After evaluating the condition of the wrist by physical examination and by imaging tests, the wrist surgeon concludes the most effective technique that would be appropriate for the patient depending on the stage of the lunate deterioration. All pros and cons of the treatment are discussed with the patient and on his agreement a few general medical tests are run on him to get a green signal for the surgery. The patient is also requested to provide all information regarding any vile habits of food or alcohol, any allergies or reactions regarding anesthesia or chemical compositions or any other relative information that the patient should disclose to the surgeon.

The Technique:

After appropriate application of anesthesia the wrist surgeon makes an incision on the wrist above the lunate and performs the surgery.

When the lunate collapses and breaks into pieces, the wrist surgeon removes the lunate and two other bones from either side of the lunate by proximal row carpectomy.

After the completion the incision is stitched back and covered with a protective bandage.

Postoperative care:

The wrist is placed in a cast for approximately three weeks or so to avoid instability and pressure on it. After the surgery the wrist surgeon keeps the patient under close monitoring and on medications to subside the post operative pain. When the patient is considered to be in a position to be released, the surgeon releases the patient with a set of instructions regarding activities, rehabilitative program, follow up visit, prescribed medications.

Complications of the technique:

In some cases where the lunate may damage the bone surface of capitate and radius then it does not prove to be effective. It is essential to understand that lunate is the most important bone in the proximal row and has to be effectively and delicately treated else may result in severe and immediate collapse of the carpus i.e. the wrist. Other common complications may be failure of the technique to provide the desired result or infection sustained in the wrist during surgery.

Benefits of the technique:

Benefits of proximal row carpectomy are that it is considered to be a technically simple and easy procedure with successful long term results.  Restoration of strength and mobility is higher in proximal row carpectomy even though partial and patients find a dramatic relief in symptoms of pain.

Rehabilitation program after the surgery:

On an average basis rehabilitative program after proximal row carpectomy is for lesser period of time. The patient cannot ever get back completely motion in the wrist but partial mobility in the wrist is restored with the help of active and passive exercises under the guidance of a skilled physiotherapist and occupational therapist. With physical therapy the patient learns how to exercise and by occupational therapy the patient learns how to perform activities while avoiding excess pressure on the wrist.

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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.