EXCISION
OF
THE
LUNATE
H.
Froimi
Train:a
tile
fair results,
results
and
cases
fourteen
and
Unit,
opinions
described
with one poor
one in which
twenty-four
S. GILLESPIE,
Research
There
are different
disease.
Dornan
(1949)
KIENBOCK’S
VANCOUVER,
Department
on the
sixteen
IN
results
cases,
generally
performed
poor
at two
of Surgery,
UniI’ersitI’
of excision
reporting
of the lunate
seven excellent,
results.
large
DISEASE*
CANADA
result.
Marek
(1957)
analysed
four
arthrodesis
of the wrist was required
reported
operations
BONE
This
of British
bone
four
cases in detail,
later.
Stahl
paper
Vancouver
(‘olunibia
will
hospitals
add
in the
in Kienb#{246}ck’s
good and four
with
(1947)
three good
described
a report
years
based
1935
on
to 1958
inclusive.
CLINICAL
Method
of study-Only
witness
and
subsequently
Workmen’s
Compensation
radiological
examination
of the
full palmar
fiexion,
and
General
features-Twenty-two
wrist
was
antero-posterior
patients
used
eleven
patients
and the left in thirteen.
forty years in twenty-one
instances;
in three
instances
the lunate
bone was excised
within
common
indication
the
was
could
by the author
or a reliable
medical
The
group
consisted
of eleven
and nine private
cases.
A uniform
including
lateral
views in full radial
and
were men and two women.
in
this interval
symptoms
MATERIAL
patients
who could
be examined
radiographed
were
included.
Board
cases,
four
military
eight to fourteen
years.
be obtained.
A history
in full
dorsiflexion
full ulnar
deviation.
The right wrist was
The age of the patients
it was between
forty and
two years of the beginning
In four patients
of accident
was
direction
of strain
was dorsiflexion
for operation
was always
pain.
views
and
affected
was between
twenty
and
fifty years.
In seventeen
of symptoms;
in three
no definite
time
noted
in twenty
for the onset
of
men:
the most
of the wrist, but this was quite
variable.
All patients
showed
limitation
of movement
The
of
wrist.
Operation-The
operation
was performed
dorsal
approaches
and three had palmar.
the typical
features
of Kienb#{246}ck’s disease
by different
Histologically,
with avascular
ASSESSMENT
Symptoms-One
patient
stated
that their
wrists
were improved.
patients.
Moderate
to severe
ulnar
deviation
and dorsiflexion.
that
the wrist
OF
was
surgeons.
the lunate
necrosis
Twenty-one
patients
had
bone in all patients
showed
of bone.
RESULTS
worse
after
operation.
The
remainder
Pain-A
minor
ache
on heavy
effort
was
pain was present
in three
cases.
It was most
Ability
to t’ork-One
man is unable
to work.
stated
noted
by most
pronounced
in
Two
patients
returned
to lighter
work.
The remaining
twenty-one
returned
to their
original
work
or to
work of a similar
kind.
Signs-No
patient
presented
increased
warmth
over the wrist or fluid effusion
at the time
of
examination.
Soft-tissue
thickening
was observed
in six patients.
Range
of movement-This
was variable:
average
figures
were dorsiflexion
40 degrees,
palmar
flexion
40 degrees,
radial
deviation
22 degrees
and
ulnar
deviation
19 degrees.
The
diminution
compared
with radial
deviation
was striking.
Crepitus
was noted
most marked
with the wrist in dorsiflexion
and ulnar
deviation.
Radiographic
findings.
Osteoarthritis-Marginal
lipping
of the
dorsal
aspect
in six patients.
This appearance
did not progress
*
VOL.
This
43 B,
paper
NO.
was
2,
delivered
MAY
1961
at the meeting
of the Canadian
Orthopaedic
of ulnar
in thirteen
radius
or
was
regress
Association,
deviation
patients
observed
after
June
as
and
on
was
its
operation.
27-30,
1959.
245
246
H.
1
FIG.
Case
I.
formation.
S. GILLESPIE
Figure
1-Radiograph
Figure
2-Sixteen
2
FIG.
after
operation
years
after excision
and the ulnar
styloid
showing
of the
normal
ulnar
styloid
lunate
bone.
There
are
process,
which
has altered
process
cystic
and
changes
no
evidence
of cyst
in the triquetrum
in shape.
V
3
FIG.
Case
2.
Figure
3-Radiograph
of cyst formation.
Figure
eight years after diagnosis.
4-Ten
Note
FIG.
before
years
the large
styloid
4
operation
showing prominent
ulnar styloid process and no evidence
after operation.
Excision of the carpal lunate bone was carried out
radial
process,
exostosis.
which
Cystic
has altered
changes
are
present
in the
ulnar
head
and
in shape.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
EXCISION
One
patient
later
this
showed
was
Carpal
not
with
(Fig. 5).
However,
lunate
flexion.
The
some
flexion
volar
antero-posterior
/ormation-Apparent
The triquetral
Ct’s!
the capitate
usual
no
3.
arthritic
Bone
and
change
in one
in two.
radiographs
formation.
of the
was
There
were
was
Figure
scaphoid
absent
patients,
end
involved
the
of the ulna
and
in one
change
in relationship
a 90
After
degrees
This
led, in the
bone.
in twelve
end
volar
of the
excision
patients
of the
the styloid
patient
millimetres
in dorsiflexion
(Fig. 6).
lower
proximally.
radius
of the scaphoid
or enlarged
year
intercarpal
to four
from
in dorsiflexion
ulna
process
(Figs.
in eight
was
the
three.
FIG.
6
seven years after operation.
There is no carpal bone shift,
6-Lateral
radiographs showing that residual volar inclination
is maintained
in five patients,
no relationship
a slight
recovers
one
or
moved
one
in dorsiflexion.
either appeared
in nine
capitate
from
to the
undergo
foreshortening
In the lower
bones
varying
inclination
involved
case.
two
shift. The
bone
maintained
5
no cyst
reformation-This
marked
was
to
operation;
radiocarpal
relationship
scaphoid
247
before
patients
distances
appeared
the
to 0 degrees
5-Antero-posterior
Figure
bone
wrist
was
patients
FIG.
Case
intimate
to an apparent
bone
bone
site. In four
was
there
other
bone
for
DISEASE
articulation
the
carpal
cyst formation
I to 4).
and
In
minor
inclination
radiographs,
KIENBOCK’S
IN
radio-scaphoid
deviation,
scaphoid
In the normal
in palmar
bone
only
patient
in no
to the capitate.
inclination
was
BONE
altered.
the wrist in ulnar
especially
aIld palmar
of the
had
not
remarkable.
shift-There
bone
LUNATE
THE
narrowing
appearance
narrowing
OF
between
in dorsiflexion.
slight in eleven,
bone
reformation
moderate
and
in three
limitation
and
of wrist
motion.
Ulnar
shortening-Persson
in production
or more
of ulnar
to cyst formation.
had
shortening.
In two
patients
43 B,
of results-The
radiological
changes
NO.
described
ulnar shortening
as the important
etiological
factor
In the author’s
series eleven
patients
had two millimetres
This ulnar shortening
appeared
to show an inverse
relationship
Ten patients
with normal
ulnar
length
The size and shape
of the ulnar styloid
it appeared
to regress in size and in three
cystic changes.
Classification
movement,
VOL.
(1945)
of the Kienb#{246}cklesion.
2,
MAY
1961
and only two with ulnar shortening
process
was altered
in five patients.
to broaden
(Figs.
1 to 4).
results
were assessed
on the basis
of
and the need for a change
of occupation
pain,
grasp,
(Table
I).
range
of
248
H.
In the
group
excellent
there
was
antero-posterior
movement
was
or more,
radiographic
changes
occupation
Three
Two
(Figs.
5 and
of the good
were
In
included
the
between
extensive
fair
S. GILLESPiE
no significant
pain,
grasp
70 degrees
or more,
range
were absent
or minimal
was
of good
power,
range
of lateral
movement
was
and there
had been no
of
30 degrees
change
of
6).
were
placed
mild
patient
pain
had
results
because
of
group
one
the triquetrum
radiographic
in this
category
because
and the ulna.
The other
patient
change
in the radiocarpal
joint.
TABLE
RESULTS
OF EXCISION
OF THE
Good
had
BONE
.
.
movement.
.
.
5 (21
Fair
.
.
.
.
2(8%)
Poor
.
.
.
.
1(4%)
TABLE
TO LENGTH
Length
of follow-up
Excellent
change
of pain
and
of
severe
pain
of
the
CASES)
16 (67%)
.
OF RESULTS
amount
of cases
.
RELATION
a similar
(TWENTY-FOUR
Number
.
wrist
I
LUNATE
Result
Excellent.
of limited
and minimal
radiographic
change.
moderate
pain
and extensive
radiographic
%)
II
OF FOLLOW-UP
(TWENTY-FOUR
Good
CASES)
Fair
Poor
(years)
0-2
2
2-4
-
patient
placed
originating
I
-
-
5
1
-
-
6-8
5
1
-
-
8-10
4
16
in the
from
poor
the
I
-
I
I
-
5
2
-
-
Total
The
-
4-6
OverlO
seemingly
1
category
was
radio-scaphoid
unable
to
work
articulation.
because
Arthrodesis
wrist
is
contemplated.
There
follow-up
was
(Table
Three
the
In one
no
definite
relationship
the
between
quality
of the
result
and
the
period
of
II).
excisions
were carried
out eight
to fourteen
result
was good,
one was fair and the third
years
after
was poor.
the
onset
of symptoms.
DISCUSSION
In normal
in full
ulnar
of
lunate
the
triquetrum
pain
of
wrists
the triquetrum
deviation.
This
bone.
and
Evidence
the
is most common
ulnar
deviation
ulnar
is
styloid
in ulnar
marked,
and
relationship
suggesting
process
deviation
indicating
the lower
was
end
of the ulna
radiographically
that
appeared
there
is an
in the
come
more
abnormal
THE
JOURNAL
close
wrist.
OF
relationship
after
contact
following
and dorsiflexion
of the
a possible
pain-prevention
into
intimate
excision
between
the
observations.
Firstly,
Secondly,
mechanism.
limitation
Thirdly,
BONE
AND
JOINT
SURGERY
EXCISION
cysts
were
commonly
OF
seen
THE
in the
LUNATE
unusual
BONE
sites
IN
KIENBOCK’S
of the triquetrum
249
DISEASE
and
the lower
end
of the
ulna.
Fourthly,
cysts
were
more
common
in the patients
in whom
ulnar
length
was normal
as
compared
with patients
with ulnar
shortening.
Finally,
changes
in the size and shape
of the
ulnar
styloid
process
were observed.
The pain froni
this contact
is usually
not severe.
It is suggested
that in unsatisfactory
cases attention
removal
of the
should
lower
be focused
end of the
on this area.
If the pain appears
ulna might
be considered
in order
to originate
to salvage
at this
a useful
point
wrist.
SUMMARY
I.
Twenty-four
2.
In general,
cent
3.
fair
or
cases
the
of excision
results
have
of the lunate
been
bone
favourable,
in Kienb#{246}ck’s disease
with
88 per
cent
excellent
have
been
or good
reviewed.
and
12 per
poor.
Abnormal
contact
many
cases,
4. Excision
between
but this contact
after prolonged
the
triquetrum
and
the
styloid
process
of the
did not appear
to prejudice
the results.
symptoms
of the disease
gave disappointing
ulna
appeared
results.
The work was supported
Johnson
Ltd., Montreal,
The author wishes
Dr
K.
by funds from the Department
of National
Health and Welfare, and from Johnson &
Canada.
to acknowledge
the advice and encouragement
of Dr F. P. Patterson,
Director,
and
Morton,
Assistant
Director,
of the Trauma
Research
Unit,
and the help of Miss Kay Hoskins
in the
of the illustrations.
S.
preparation
REFERENCES
A.
DORNAN,
31-B,
The
(1949):
Results
MAREK,
F. M.
M.
(1957):
(1945):
Scandinavica,
F. (1947):
Avascular
Pathogenese
in Kienb#{246}ck’sDisease.
Journal
of Bone
43 B,
NO.
2,
Necrosis of the Carpal
und
Supplementum
98, pp.
On
Lunatomalacia
(Kienb#{246}ck’s
MAY
1961
Lunate.
Clinical Orthopaedics,
der Kienb#{246}ckschen Lunatummalazie.
Behandlung
92,
126.
VOL.
of Treatment
and Joint
Surgery,
518.
PERSSON,
STAHL,
in
51 and
10,
96.
Acta
Chirurgica
79.
Disease).
Acta
Chirurgica
Scandinavica,
95, Supplementum