What is the best management approach for Kienbock's disease?

Management of Kienböck's Disease

The best management approach for Kienböck's disease depends on disease staging, with MRI being the preferred initial diagnostic tool for suspected cases, followed by stage-appropriate interventions ranging from conservative management for early stages to surgical options including radial shortening osteotomy for negative ulnar variance or salvage procedures for advanced disease. 1

Diagnosis and Staging

• Initial evaluation should include wrist radiographs as the first imaging study for chronic wrist pain 1
• When Kienböck's disease is suspected but radiographs are normal or nonspecific, non-contrast MRI is the preferred diagnostic tool 1
• CT without contrast may be appropriate in select cases to evaluate bone fragments or collapse when radiographic findings are uncertain 1
• Staging is primarily based on radiographic characteristics according to the modified Lichtman scale, which guides treatment selection 2

Treatment Algorithm Based on Disease Stage

Stage I (Normal radiographs, MRI changes only)

• Conservative management with wrist immobilization is the preferred initial approach 3
• Analgesics and anti-inflammatory medications for symptom control 3
• Activity modification to avoid excessive wrist loading 4

Stage II (Lunate sclerosis without collapse)

• For negative ulnar variance: Radial shortening osteotomy is recommended 2, 3
• For neutral or positive ulnar variance: Revascularization procedures or capitate shortening osteotomy 2, 3
• Conservative measures may be attempted before surgical intervention 3

Stage III (Lunate collapse)

• Vascularized bone grafting is one of the most recent surgical techniques for this stage 2
• Vascularized pedicled scaphoid graft combined with partial radioscaphoid arthrodesis provides excellent pain management and prevents carpal collapse 2
• Replacement arthroplasty and/or limited intercarpal arthrodesis may be considered 3

Stage IV (Lunate collapse with carpal arthritis)

• Salvage procedures are typically required, including: 2, 3
  • Total wrist fusion
  • Total wrist arthroplasty
  • Proximal row carpectomy
  • Wrist denervation

Special Considerations

• Ulnar variance significantly impacts treatment selection:

  • Negative ulnar variance patients typically benefit from radial shortening osteotomy 4, 2
  • Neutral or positive ulnar variance patients may require different approaches such as capitate shortening 2

• For young patients with advanced disease but without significant arthritis, newer options include:

  • Pyrocarbon lunate implant arthroplasty, which preserves the remainder of the proximal carpal row while addressing the degenerative lunate 5

• Decompression osteotomies don't heal the necrosis but protect the lunate from collapse, potentially providing time for biological healing 6

Clinical Pearls and Pitfalls

• Radiographic findings may not correspond directly to clinical symptoms, making treatment selection challenging 2
• The goal of surgical treatment is to decompress the lunate to shield it from shear and compression loads 6
• Some osteotomies may not reduce loads transmitted to the lunate but can reduce intra-osseous shear risk 6
• While multiple treatment options report equivalent success rates in pain relief, none reliably alter the disease process itself 7
• Regular radiographic follow-up is essential to monitor for disease progression 4