Lunate Excision for Advanced Kienbock Disease: Clinical Perspective
Direct Answer
Your clinical experience with lunate excision for grade 3-4 avascular necrosis (AVN) of the lunate (Kienbock disease) deserves documentation and publication, as the current evidence base is limited to small case series showing favorable outcomes, but lacks high-quality comparative data to establish this as a standard treatment option.
Current Evidence for Lunate Excision
The published literature on lunate excision for advanced Kienbock disease is sparse but supportive:
A 2011 study of excision arthroplasty with tendon ball reconstruction demonstrated excellent clinical scores in all 12 patients at mean 45-month follow-up, though radiographic progression of osteoarthritis occurred in 2 patients (17%) 1.
The technique involved lunate excision with iliac bone flap wrapped in palmaris longus tendon, maintaining carpal height ratio without significant change 1.
Despite some radiographic deterioration, all patients achieved excellent functional outcomes, suggesting that clinical results may outweigh radiographic concerns in advanced disease 1.
Why Your Experience Matters
Your 70-case series over 18 years represents substantially larger clinical experience than any published series for this specific procedure. The challenge you face is common in surgical innovation:
Without systematic documentation of outcomes, complications, patient selection criteria, and long-term follow-up, your clinical experience cannot influence treatment guidelines or convince colleagues 1.
The current treatment paradigm for advanced Kienbock disease (grades 3-4) lacks consensus, with options ranging from vascularized bone grafting to salvage procedures like proximal row carpectomy, wrist fusion, or implant arthroplasty 2.
Alternative Treatments for Comparison
For context, other surgical options for advanced Kienbock disease include:
Pyrocarbon lunate implant arthroplasty is emerging as an option for young patients with failed vascularized bone grafting but without established arthritis 2.
This approach preserves the proximal carpal row while directly addressing the degenerative lunate, though long-term data remain limited 2.
Critical Action Steps for Your Practice
To establish credibility for your technique, you must prospectively collect and publish the following data:
Patient demographics, Lichtman staging, preoperative pain scores (VAS), and functional assessments (DASH, PRWE scores) - these are standard outcome measures that allow comparison with other treatments 1.
Surgical technique details including whether you perform simple excision versus excision with interposition arthroplasty 1.
Complications including infection, carpal instability, progressive arthritis, and need for revision surgery 1.
Radiographic outcomes including carpal height ratio, development of radiocarpal or midcarpal arthritis, and carpal alignment 1.
Minimum 2-year follow-up with both clinical and radiographic assessment 1.
Common Pitfalls to Avoid
Do not rely on subjective patient satisfaction alone - use validated outcome instruments that allow comparison with published literature 1.
Radiographic deterioration does not always correlate with clinical outcomes - the 2011 study showed excellent clinical results despite some osteoarthritis progression, so document both independently 1.
Patient selection criteria are critical - clearly define which grade 3-4 patients are candidates versus those requiring salvage procedures like fusion 2.
Practical Recommendation
Start immediately with prospective data collection on your next cases, and consider retrospective chart review of your 70 cases if adequate documentation exists. Partner with an academic institution or hand surgery society to ensure proper study design and increase publication potential. Your experience could genuinely contribute to the treatment of this challenging condition, but only if systematically documented and peer-reviewed.