What is the recommended treatment for a patient with Kienbock's disease in the left wrist?

Treatment of Kienböck's Disease in the Left Wrist

For Kienböck's disease, treatment depends critically on disease stage: early-stage disease (Stage I-II) should begin with activity modification and immobilization, while more advanced stages (Stage III-IV) typically require surgical intervention with procedures ranging from revascularization and unloading osteotomies to salvage procedures. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis and stage:

• Obtain wrist radiographs as the essential first imaging study to assess lunate morphology, collapse, and carpal alignment 2, 1
• If radiographs are normal or equivocal but clinical suspicion remains high, MRI without IV contrast is the preferred diagnostic tool to detect early bone marrow edema and avascular changes 2, 1
• CT without contrast may be used selectively to evaluate bone fragments or the degree of collapse when radiographic findings are uncertain 2, 1
• Stage the disease using the Lichtman classification, as this directly guides treatment selection 3, 4

Stage-Specific Treatment Algorithm

Stage I (Normal Radiographs, MRI Shows Edema)

• Implement rigid immobilization for 3-4 months as the primary treatment 3, 5
• Prescribe activity modification to avoid excessive wrist loading 1
• Consider transitioning to a custom orthotic splint for an additional 3 months during activities after the initial immobilization period 5
• Provide analgesics and anti-inflammatory medications for symptom control 3
• Obtain repeat MRI at 6 months to assess for resolution of lunate edema 5

Critical pitfall: Conservative treatment in adults often fails to provide good long-term results, so close monitoring for disease progression is essential 6. Younger patients with high remodeling potential may respond better to conservative management 5.

Stage II (Lunate Sclerosis, Early Compression Fracture)

If conservative management fails after 3-4 months or the patient presents with Stage II disease:

• Perform revascularization procedures (vascularized bone grafting from distal radius) to directly restore blood supply to the lunate 3, 4
• Alternatively, implement unloading procedures to indirectly revascularize by reducing mechanical stress 3, 4:
  • Radial shortening osteotomy if negative ulnar variance is present 3, 4
  • Ulnar lengthening as an alternative unloading procedure for negative ulnar variance 3
  • Capitate shortening or radial-wedge osteotomy if neutral or positive ulnar variance exists 4
• These procedures can be performed alone or combined with vascularized bone grafting 4

Key principle: The goal is to decompress the lunate and shield it from shear and compression loads, providing time for biological healing even though the osteotomies do not directly heal the necrosis 6.

Stage IIIA (Severe Lunate Collapse, Carpus Still Aligned)

• Continue with unloading osteotomies (radial shortening, capitate shortening, or radial-wedge osteotomy) combined with vascularized bone grafting 3, 4
• Consider silicone replacement arthroplasty or autogenous tendon replacement arthroplasty as alternative options 3
• Limited intercarpal arthrodesis may be performed to stabilize the carpus 3

Stage IIIB (Carpal Collapse with Scaphoid Rotation)

• Perform scaphotrapeziotrapezoid (STT) or scaphocapitate arthrodesis to correct scaphoid hyperflexion and address carpal collapse 4
• This addresses the secondary carpal malalignment that develops as the disease progresses 4

Stage IV (Degenerative Changes Present)

Salvage procedures are indicated when radiocarpal or midcarpal degenerative changes are established:

• Proximal-row carpectomy for patients requiring motion preservation 3, 4
• Wrist arthrodesis for definitive pain relief when function is severely compromised 3, 4
• Wrist denervation as a less invasive salvage option 3

Ongoing Monitoring and Follow-Up

• Obtain regular radiographic follow-up every 3-6 months to monitor for disease progression, particularly in patients managed conservatively 1
• Assess for development of carpal collapse, scaphoid rotation, or degenerative changes that would necessitate escalation of treatment 4
• Monitor grip strength, range of motion, and pain levels as functional outcome measures 3

Critical Clinical Pitfalls

• Do not rely solely on conservative treatment in adults, as the majority will require surgical intervention due to unresolved symptoms or progressive disease 6, 5
• Recognize that decompression osteotomies do not heal the necrosis but protect the lunate from collapse, buying time for potential biological healing 6
• Avoid assuming all osteotomies equally reduce lunate loading—some procedures may not reduce transmitted loads or may even place excessive pressure on the ulnar side of the lunate 6
• Do not delay surgical intervention in Stage II-IIIA disease, as early intervention before carpal collapse offers the best chance of preserving wrist function 4
• Be aware that even with appropriate surgical treatment, progression to end-stage disease can occur, though patients may remain pain-free with acceptable function 7