TFCC injury + kienböcks
Dear friends and colleagues,
I have a difficult case I would appreciate your comments on.
20-year old male, right handed. Professional ice hockey player.
Presented to me with ulnar-sided wrist pain after hockey injury. Clinically, completely unstable DRUJ but surprisingly also dorsal arthrosynovitis.
Sent him to x-ray and MRI (images enclosed below).
Complete TFCC rupture and strong suspicion of Kienböcks stage III A.
In April, I did an arthroscopy which confirmed a soft lunate in the ulnar portion, but no visible fragmentation or arthritis. Complete TFCC foveal rupture.
Thinking that this could be a traumatic oedema of the lunate, I performed an open TFCC reinsertion - 6 week postop immobilization followed by splinting and proprioceptive rehab. Left the lunate untouched.
His DRUJ is now stable, with full ROM, but his MRI has shown no change in lunate appearance.
Sadly, he is again getting dorsal wrist pain and I must treat his Kienböck.
What would you advice?
- Lunate excision with pyrocarbon implant?
- Partial wrist arthrodesis?
I feel that revascularization is out of the question due to the appearance of the bone.