今日の臨床サポート

キーンベック病

著者: 砂川融 広島大学

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/07/14
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
砂川融 : 未申告[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. キーンベック(Kienböck)病は、20~30歳代男性、作業労働従事者に好発する月状骨の無腐性壊死である。まれに10歳代、60歳以上の高齢者に発症することがある。
  1. 原因は不明であるが、解剖学的異常(月状骨の形態や血流動態、尺骨がマイナス変異;単純X線正面像において橈骨関節面の高さに比較し、尺骨遠位端の高さが低い状態)が関連するとされる。
  1. 作業やスポーツ活動などの繰り返しの手関節に対するストレスが原因となる。
  1. 発症は緩徐で、徐々に手関節痛が増強し、握力が低下する。
  1. 早期に治療を行えば症状は軽快し、病変の進行は予防できる。
  1. 進行期であれば解剖学的に正常化することは困難であるが、症状は多くの場合、軽快する。
  1. 放置すると変形性関節症に進行するが、重症度とは相関しない。
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

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文献 

著者: Ryogo Nakamura, Etsuhiro Nakao, Takanobu Nishizuka, Sayako Takahashi, Shukuki Koh
雑誌名: Tech Hand Up Extrem Surg. 2011 Mar;15(1):48-54. doi: 10.1097/BTH.0b013e31820baa36.
Abstract/Text Of various surgical treatments, radial shortening for patients with negative ulnar variance and radial wedge osteotomy (radial closing osteotomy) for patients with 0 or positive ulnar variance are widely accepted for the treatment of Kienböck disease. Long-term follow-up studies have shown more than 10 years lasting satisfactory pain relief, as well as an increase in wrist range of motion and grip strength. As representative surgical procedures, the techniques of radial shortening by transverse osteotomy, using a locking compression plate for internal fixation, and radial wedge osteotomy by step-cut osteotomy, using a small dynamic compression plate or locking compression plate, are described. One important point of radial wedge osteotomy is that resection of simple wedge bone yields a decrease in ulnar variance; therefore, we recommend trapezoidal bone resection with ulnar height of 1 mm for transverse osteotomy at the metaphysis and ulnar height of 2 mm for step-cut osteotomy at the distal fourth of the radius.

PMID 21358526  Tech Hand Up Extrem Surg. 2011 Mar;15(1):48-54. doi: 10・・・
著者: H K Watson, J A Fink, D M Monacelli
雑誌名: Hand Clin. 1993 Aug;9(3):493-9.
Abstract/Text The disability of Kienböck's disease is a manifestation of carpal collapse. Significant loading for any wrist must be taken on the radial side. Triscaphe arthrodesis provides a support mechanism for the collapsed lunate, a solid bone-cartilage mechanism for load transference to the radius, and maintenance of satisfactory motion.

PMID 8408259  Hand Clin. 1993 Aug;9(3):493-9.
著者: O J Moy, C A Peimer
雑誌名: Hand Clin. 1993 Aug;9(3):501-4.
Abstract/Text The primary treatment goal for Kienböck's disease remains decompression of the lunate. Although a number of treatment options are available, scaphocapitate fusion is our first choice in many cases of Kienböck's disease. Scaphocapitate fusion mechanically decompresses the lunate and prevents progressive carpal instability. When compared with STT fusion, it has been shown to result in equal or relatively less loss of wrist motion and thumb basilar joint motion. For disease in earlier stages and with ulnar-minus variance, joint leveling procedures have been shown effective; but ulnar-neutral and ulnar-positive wrists would cause one to favor scaphocapitate fusion to prevent postoperative ulnocarpal abutment.

PMID 8408260  Hand Clin. 1993 Aug;9(3):501-4.
著者: E E Almquist
雑誌名: Hand Clin. 1993 Aug;9(3):505-12.
Abstract/Text The goal of the technically simple procedure of capitate shortening with capitate-hamate fusion is revascularization of the lunate, and on radiographic evaluation, the results have been satisfactory (Figs. 9 through 11). This surgical procedure offers the advantage of direct vision and, therefore, direct staging of the aseptic process. The procedure is designed for patients with early Kienböck's disease who have relatively minor architectural changes in the aseptic lunate, no arthritic changes, and no ulnar-minus variance. When these criteria are met, the clinical results have been encouraging and lasting.

PMID 8408261  Hand Clin. 1993 Aug;9(3):505-12.
著者: Steven L Moran, William P Cooney, Richard A Berger, Allen T Bishop, Alexander Y Shin
雑誌名: J Hand Surg Am. 2005 Jan;30(1):50-8. doi: 10.1016/j.jhsa.2004.10.002.
Abstract/Text PURPOSE: The use of vascularized bone grafts for the treatment of Kienböck's disease may prevent ongoing lunate collapse and provide relief of wrist symptomatology. This study examines our experience with the use of the 4 + 5 extensor compartmental artery (ECA) bone graft for the treatment of Kienböck's disease.
METHODS: A retrospective review was performed of all patients having pedicled vascularized bone grafts for Kienböck's disease between 1991 and 2002. Only those patients who had reconstruction with a 4 + 5 ECA graft were included in the study. Presurgical and postsurgical measurements included range of motion, grip strength, and pain evaluation. Measurements of the radiolunate angle, radioscaphoid angle, Stahl's index, and carpal height ratio were taken from presurgical and final follow-up radiographs. Postsurgical magnetic resonance imaging scans were also examined to verify revascularization of the lunate. Statistical analysis was performed using Student's t test. A chi-square test was used to evaluate the effects of lunate revascularization on radiographic progression of disease. Twenty-six 4 + 5 ECA vascularized bone grafts were performed as treatment for Kienböck's disease. The average patient age was 32 years. At the time of surgery 12 patients were graded as stage II, 10 as IIIA, and 4 as IIIB. Mean follow-up time was 31 months.
RESULTS: At a mean follow-up of 3 months, motion improved from 68% to 71% of the unaffected side, grip strength improved from 50% to 89% of the unaffected side, and 92% of patients had significant improvement in their pain. Satisfactory results were seen in 85% of patients based on the Lichtman outcome score. Seventy-seven percent of patients showed no further collapse on postsurgical radiographs. Sixty-five percent of patients had follow-up magnetic resonance imaging scans at a mean of 20 months after surgery. Seventy-one percent of patients showed evidence of revascularization with improvement in the T2 and/or T1 signal.
CONCLUSIONS: The 4 + 5 ECA bone graft provides a reliable alternative for the treatment of Kienböck's disease and may aid in lunate revascularization.

PMID 15680555  J Hand Surg Am. 2005 Jan;30(1):50-8. doi: 10.1016/j.jhs・・・
著者: Takeshi Ogawa, Naoyuki Ochiai, Yasumasa Nishiura, Toshikazu Tanaka, Yuki Hara
雑誌名: J Orthop Sci. 2013 Mar;18(2):230-7. doi: 10.1007/s00776-012-0332-7. Epub 2012 Nov 1.
Abstract/Text BACKGROUND: The purpose of this study was to investigate the midterm clinical and radiographic outcomes of this new treatment for Kienböck's disease.
METHODS: We applied a new method involving drilling, bone marrow transfusion, external fixation, and low-intensity pulsed ultrasound for patients with Kienböck's disease. Between 2000 and 2006, the treatment was performed in 18 patients (10 men and 8 women; 9 right wrists and 9 left wrists). The preoperative Lichtman stages were stage II in 4 cases, stage IIIa in 11 cases, and stage IIIb in 3 cases. The mean age at surgery was 44.9 years (range 16-68 years), and the mean follow-up period was 63 months (range 28-125 months). The overall results were evaluated using the Mayo wrist score and Nakamura scoring system for Kienböck's disease. Magnetic resonance imaging (MRI) was performed for all patients.
RESULTS: Wrist pain improved to no pain in 13 patients, mild pain in 4 patients, and moderate pain in 1 patient. The average wrist flexion-extension arc was 100° and averaged 120 % of the preoperative value. The average grip strength increased from 50 to 85 % relative to the unaffected side. On roentgenograms, the carpal height ratio (change from 0.53 to 0.51) and the Stahl index (change from 0.38 to 0.32) decreased slightly. On MRI, fatty marrow was recovered in 11 patients (61 %) on proton density-weighted images.
CONCLUSIONS: This method can be used as a less-invasive surgical treatment alternative for Kienböck's disease. At an average follow-up period of 6 years, this new treatment has been shown to be a reliable and durable procedure for patients with Lichtman stage II or stage III Kienböck's disease. Caution should be exercised for patients with a fragmented lunate because of the risk of collapse and nonunion of the lunate.

PMID 23114859  J Orthop Sci. 2013 Mar;18(2):230-7. doi: 10.1007/s00776・・・
著者: Y Ueba, K Nosaka, Y Seto, N Ikeda, T Nakamura
雑誌名: J Orthop Sci. 1999;4(3):207-15.
Abstract/Text Excision of the lunate and subsequent replacement with a tendon implant was performed in 22 patients with Kienböck's disease between 1971 and 1985. This procedure was indicated mainly for those with advanced Kienböck's disease, i.e., stage III or IV according to the Lichtman classification. After the collapsed lunate is removed, a tendon-ball implant, made of the palmaris longus and plantaris tendons is placed in the resultant space in the carpus. A forearm distractor is applied during the operation, and distraction is continued for 4 weeks postoperatively. We report the long-term results in 15 patients, whose average follow-up period was 16 years and 3 months. One patient with infection was excluded from the study because the implanted tendon was removed 2 weeks after the operation, and 6 patients were lost to follow-up. All patients were free of pain after the surgery. The flexion-extension range of the wrist increased by 14.2 degrees, on average, after the surgery. The average grip power of the operated hand was 90.2% of that in the non-operated hand. Calcification and ossification were frequent in the implanted tendons a few months postoperatively. The average carpal height ratio (defined as carpal height/length of the third metacarpal) was 0.53 before the operation and 0.49 at the time of follow-up. According to Dornan's classification of clinical results, 9 of the 15 patients were classified as having excellent results and 6 as good.

PMID 10370162  J Orthop Sci. 1999;4(3):207-15.
著者: H H Lin, P J Stern
雑誌名: Hand Clin. 1993 Aug;9(3):521-6.
Abstract/Text In symptomatic stage III Kienböck's disease, proximal row carpectomy may be considered not only as a secondary "salvage," but also a primary reconstructive procedure. The need for concomitant radial styloidectomy is assessed intraoperatively after removal of the proximal row. Distraction resection arthroplasty is an alternative for patients with full-thickness cartilage loss on the capitate head or in the lunate fossa surpassing 3 mm in diameter. For patients with generalized carpal arthrosis (stage IV Kienböck's disease) or unsuccessful previous reconstructive surgeries, total wrist arthrodesis is the most reliable procedure for pain relief. PRC is an acceptable alternative to TWA for stage IV disease if the patient is willing to risk having some residual pain to preserve wrist motion. Transection of the articular branch of the posterior interosseous nerve may be a useful adjunct to these procedures.

PMID 8408264  Hand Clin. 1993 Aug;9(3):521-6.

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