www.lunatomalacia.com

Welcome to my website!

Here you can find information concerning lunatomalacia (also called  Kienbock Disease)

Own experiences with operations, conversations with doctors, and parts of the unfortunately very less literature which is available, are subject of this representation. As I am afflicted with this illness, but don’t have a medical education, I can’t guarantee for the correctness of my medical information. But I hope I succeed in bringing some light into the darkness of this disease.

Attention: If the left blue frame column and the blue title are missing, please put in the official address  www.lunatomalacia.com                  If you find any other technical faults, please send me an Email.

Thank you very much, and I hope you will be better soon.  

What is lunatomalacia?                            

Lunatomalacia (Kienböck´s disease, avascular necrosis of lunate)  

Definition:

Marked by asepsis (germ-free), rarely complete, most partly existing necrosis (                      ) of wrist os lunatum (lunate bone), caused by reduced blood supply. Further on this causes an increasing osteolysis and a fracture of the lunate bone. The consequence is an arthrosis (joint disease) of the carpal bones.

Synonyms:

Kienböck’s disease

Referring to Robert Kienböck (1871 – 1953), roentgenologist from Wien, who was the first person that documented this disease in 1910.

Symptoms:

Your wrist reacts with spontaneous pain on palpation and compression, painful swelling, loss of strength and motion. These symptoms appear slowly, in the beginning mostly unnoticed, but always increasing, which often happens during a period of several years.

Mainly the dominating hand is afflicted with this disease. But also both wrists can be diseased. An American statistics with 423 participants (compare left hand side) documents 58 persons with a result on both sides

Causes:

There are no safe perceptions concerning the exact causes.

In discussion are:

  -        disproportion of length between ulna and radial bone. This exerts unfavourable conditions of pressure on the lunate bone and increases an              obstruction of blood pressure.

-         permanent microtrauma (for example: persons who work with pneumatic hammers, store-masons, etc.)

-         accidents which cause vascular injuries or occlusions

-         vascular abnormities

-         a combination of several factors mentioned above

People concerned:

rarely young persons, adults mainly in the age of 20 up to 40 years

Diagnosis:

As this disease is very seldom, it is rather improbable that the doctor you consulted will come to an appropriate conclusion immediately after he noticed the first symptoms. Tendinous synovitis, sprain and cancer are possibilities of false estimations. So months and years often go by until after all the correct diagnosis, called lunatomalacia , is found. Then phases I and II of this disease, which have a very less chance to be healed without operation, are unfortunately passed over most of the time. But mainly the disease only then attracts attention when phase III has already shown up. So if you have to suffer from the above mentioned symptoms, point your doctor to the possibility of lunatomalacia. Thereby you probably don’t have to go to a lot of different doctors during the following years. Don’t let them calm you down with the reference to an inconspicuous x-ray picture. You should insist on a MRT (nuclear resonance scanning) even if it doesn’t belong to your doctor’s budget.

Examinational methods:

RADIOLOGICAL:

  -     x-ray picture

-      computerized axial tomography (CT); special x-ray examination. A computer shows three-dimensional sectioned pictures of special parts of your body. Especially qualified for the discovery of bone fractures which can’t be recognised by conventional x-ray.      You will sit comfortably on a chair and just put your hand in the machine. It doesn’t take more than 2 minutes.

-       nuclear magnetic resonance(MRT, MRI, NMR): no strain caused by x-ray beams. Strong magnetic fields produce electromagnetic waves which show results like soft tissue changes and vitality of bones.   You lie prone and get pushed into the so called “pipe”. But don’t be afraid, it’s not dark in there. The pipe is open at head and feet so you can watch the proceedings in the room. Only the keeping still for 15 min is not very convenient. To protect you against the loud noise of the machine, you will get some ear stoppers. First they make a normal “picture”. Then they will inject a contrast medium into the back of your hand vein. Now the second picture follows. It depends on if and how the medium gets concentrated in the lunate bone to find out something about the bones blood supply.

ARTHROSCOPY:

Now and then it may happen that in spite of using highly sensitive examinational technologies like MRT and CT you can’t commit on the exact phase of the disease and the thereby necessary surgical procedure. Then the wrist will be examined by arthroscope (reflected) before the actual wrist operation takes place or even during the operation itself. The patient is in local anaesthesia or in complete narcosis, his arm is bloodless (compare below). Now the hand will be put up and the wrist will be spread. Two or three little cuts in the skin (less than 1 cm) are necessary to insert the arthroscope (small 2 mm long style with palpatory stick and optical magnifying glass at the end) into the problematical area. The palpatory stick can also be replaced by special mechanisms like small forceps or fraises to remove the tissue which is in the way. A connected monitor shows all afflicted parts of the joint and enables an exact result.

Phases of the disease (by Decolux/Lichtmann)

Therapy:

Conservative (phase I and II)

Fixation of wrist with a cuff for at least 6 weeks. This method hasn’t reached any satisfying results up to now.

Operative (phase III and IV)

If an operation is unavoidable , don’ fall into panic. Take your time and look for a qualified hand surgeon. This operation is very complicated and will change your life. That’s why you really should consult a specialist. Contact other people concerned. Pick out two or three addresses of hospitals or surgeries which seem to be of interest for you and ask for an appointment to get all the information you need. Then make your decision. Don’t be scared of a long approach, you have only two hands, they are worth it in any case. I have put up with 200 km for one way and I did never regret it. Sometimes the choice of a qualified operation address will also depend on how you want to be attended. There are several possibilities:

in-patient basis: about 1 week in hospital

or

ambulatory: 

Discharge a couple of hours after operation. I think that it is a good idea to offer the ambulant way of operation in spite of the complexibility of this surgery. Of course this only works if you can be sure to have permanent company and help from a closely connected person. The day of operation and the second day are definitely hard. On the third day at the latest, when you feel better again, you will be happy to be at home. Why staying in hospital for some additional days, getting bored and having a lot of supplementary costs? But in the meantime there shall also exist hospitals which let their patients go home on the fourth day at least. This would probably be a compromise. If you have to stay over night at another place than at home, because you live too far away, (arrival the day before and departure the day after the operation) you should definitely book a hotel without full board and which is not very expensive. You will either be interested in an exclusive hotel nor in extraordinary food! This money you can save.

ANAESTHETIC PROCEDURES:

Your operating surgeon will try to convince you of a general anaesthesia, which is understandable in his situation. He can work in calmness and doesn’t have to take care of a totally nervous and frightened patient. Nevertheless I insisted on a local anaesthetic. This was a luck, because during the operation my lunate bone was found to be in a surprisingly good condition, in spite of being in phase III – IV. So my doctor and I could talk to each other and we decided not to perform the originally planned partly artificial ankylosis but to carry out a revascularisation. Up to now we achieved an exceptional healing process.

General anaesthesia: so called incubative anaesthesia

ADVANTAGE: patient doesn’t notice anything during op.; fast and safe;

DISADVANTAGE: communication between doctor and patient during op. is not possible; immediately after awakening you will be in severe pain

Local anaesthesia: so called brachial plexus anaesthesia

You will get an injection into your arm pit which narcotises your arm completely. The patient will possibly get a light sleeping medicine to lower the excitement

ADVANTAGE: the patient can be talked to at any time;  use a Discman with your favourite CD. This calms down your nerves. Your doctor will support this idea, if you ask him. The brachial plexus anaesthesia will possibly last some hours longer than the general anaesthesia. This is a pleasant feeling, because you will be in great pain after a bone surgery.

DISADVANTAGE: you can hear any kind of noise: hammering, sawing, drilling, ......

Attention: on your way to the operation room you should hold your arm closely, because it will be completely numb and seems to be a dead piece of meat which doesn’t belong to yourself! Really horrible! You will run the risk to catch an injury of your shoulder, if your arm falls down, because the weight is really considerable.

BlOODLESSNESS: before the surgeon makes the first cut, your whole arm must be bloodless. Thus a good sight on the part to be operated shall be guaranteed and the danger to unintentionally injure surrounding parts can be decreased. The whole performance of the operation is so to speak depending on millimetres. To make the arm bloodless they fix a pneumatic cuff around the brachial arm. Then the arm gets wrapped tight by using an elastic, so that the blood will be pressed into the direction of your shoulder. When the blood has passed the cuff, the tourniquet will be blown up so that the blood can’t flow back into your hand. This bloodless state may take up to two hours, so that the surgeon has to be done with those activities which require an optimal view.

  The actual operation: Purpose of each operation is to relieve the injured lunate bone of pressure to enable a pain-free exertion of the patient’s wrist later on. The following operation examples are not finally presented, they can also be changed and combined among each other depending on the standard of science and an individual arrangement between doctor and patient.

  1.      Verkürzungsosteotomie  ( transsection of a bone by chisel/saw):

  -     elongation of ulna or

-      shortening of radial bone: thereby both bones shall be brought to an equal level (Null Variante). There are different starting points:

      overlength of ulna compared with radial bone (Ulna-Plusvariante) and

      underlength of ulna compared with radial bone (Ulna-Minusvariante).

      The last one predominates.

      shortening of capitatum

  2.    Revascularization (reanimation of blood flow):

-     so called spongiosa-plasty: filling up the necrotic lunate bone with bone tissue of your own body, for example taken out of your iliac crest, which is the biggest reservoir with the best bone forming (osteogenous) potency. Also spongiosa of the pea shaped wrist bone (os pisiforme, no. 8 of picture above) or other wrist bones are used.

-        insertion of a blood conveying artery into the lunate bone.

  3.      Arthrodesis (joint stiffness)

  -         partly arthrodesis

Different kinds of wrist bones are connected with screws to achieve a pain-free exertion, for example STT-arthrodesis (the first letters of the related bones are used). Also other wrist bone connections are thinkable. If necessary, the lunate bone will be removed, too. After that limited bendings and turnings of the wrist are still possible. The fingers are completely movable.

  -         complete arthrodesis

Last solution, if nothing else helps. Complete stiffing of the wrist. Bending of wrist not possible any more. Turning of wrist still possible. Fingers completely movable.

  4.      Implant as substitute for lunate bone:

The lunate bone is removed and replaced by an implant (titanium, plastics or unnecessary muscle tendons of your hand). Often noticed displacements (luxations) and/or damages of the implants pointed out that this method does not correspond with the knowledge of science any more.

  5.      Excision (removal) of the proximal wrist bones (in direction to the trunk):

To achieve decompression, several wrist bones are removed and the rest of them will be screwed with each other. Mobility is possible compared to the partly arthrodesis mentioned above.

  6.      Pain relief by enervation:

In all phases of lunatomalacia a partly or complete enervation of the wrist can be carried out. Also just one of these methods or enervation as an additional operation are possible. Thus different nerve branches, which are sensitively supplying the wrist, will be cut. By this they want to achieve that patients won’t be in great pain any more in future.  Attention: This has nothing to do with the mobility of your fingers, which is further on 100% guaranteed, as the muscle tendons are not concerned!!!

  Aftercare

  -  directly after the operation the fixation of your forearm with a plaster bandage will follow. Referring to the operation method you will have to wear this for about 10 days up to 8 weeks.  The fingers are free. If you want to or if you have to, you can start writing, drawing or using a keyboard after a couple of days. It seems to be a little awkward, but it works.

  -   2 weeks after op. you will get rid of your threads, they probably will change your plaster bandage or even take it off. Permanent control through radiological examinations (x-ray, MRT) will be carried out, to see if the therapy is successful. Those checks will take place in intervals of (appointments can depend on your doctor or the operation method):

  -         1 month after op. 1. x-ray control

-           2 months after op. 2. x-ray control

-           3 months after op. 3. x-ray control

-           6 months after op. 4. x-ray control

-         12 months after op. 5. x-ray control

-         24 months after op. 6. x-ray control

Motion therapy with a physical therapist who has experience (very important) with hand operations!

  Personal tips (I will thank you for some more):

  - The plastered hand must always be held up higher than your heart, so that it won’t swell! Also at night! You should build up special constructions with pillows. PC-keyboard or writing pad must be put in an oblique position – helpful for this is a board, used as inclined plane.

- If you are in pain after exertion (of course only if you got rid of the plaster and the threads), I recommend you to take short baths in ice-cold water which you should fill in a tall pot. (Fill the water in there and put it into the deep-freeze chest!)

Prognosis

This disease is unfortunately not curable.

Any operation which is necessary within phase III can, if being successful, reduce or take away pain. But also a successful operation and a healing process over years, which is almost free of afflictions, won’t guarantee that there won’t show up a worsening of your wrist, which probably makes another op. necessary. The rather less statistics of illness which exist are showing the whole spectrum of possible healing processes, beginning with very bad up to very good. Therefore no predictions can be ensured. With regard to the reduction of pain, power, maintenance of mobility and the quality of life after operation, the achieved results are mostly at least satisfactory!!!

Personal remarks

It will be a shock, if you are holding the depressing diagnosis of lunatomalacia in your hands, that’s for sure. Life will change a lot in most cases: different sportive activities and hobbies have to be cancelled from one day to the other. Special wishes concerning your profession suddenly can’t be realised any more. Many concerned people can’t go on practicing their profession, they have to retrain or get unemployed.

Nevertheless:

My doctor told me:

“The worst you can do now is to be sorry for yourself and carry your ill hand around like a dead part of your body which doesn’t belong to you.

He is right!

Keep all your courage and power! Have patience --- and take your fate tightly in both of your hands (yes, it works!!!)

GOOD LUCK!!!  

For further informations please visit www.kienbock.com and

http://darkerblue.kienbock.com !!!