Management of Kienböck's Disease
The management of Kienböck's disease follows a stage-based algorithm: begin with plain wrist radiographs, confirm early disease with non-contrast MRI when radiographs are equivocal, implement activity modification and immobilization for early stages, and progress to surgical intervention based on disease stage and patient age. 1, 2, 3
Diagnostic Approach
Initial imaging must be plain wrist radiographs to assess for lunate sclerosis, collapse, or carpal alignment changes. 1, 2
When radiographs are normal or equivocal but Kienböck's disease is suspected clinically, non-contrast MRI is the gold standard for detecting early osteonecrosis before radiographic changes appear. 1, 2, 3
CT without contrast should be reserved for surgical planning when the degree of collapse or bone fragment size is uncertain from radiographs, particularly when considering osteotomy procedures. 1, 2
Further imaging is usually not necessary once radiographic evidence of Kienböck's disease is confirmed, though CT or MRI may be appropriate in selected circumstances for disease staging. 1
Treatment Algorithm by Disease Stage
Early Stage Disease (Lichtman Stage I-II)
Activity modification to avoid excessive wrist loading is essential for all patients with Kienböck's disease. 2, 3
Rigid immobilization for 12 weeks followed by custom orthotic splinting for an additional 3 months during activities can be effective, particularly in skeletally immature patients who have significant remodeling potential. 4
Conservative treatment in adults generally does not provide good results, and surgery is often needed. 5
Serial radiographs are essential to detect early signs of treatment failure or continued collapse during conservative management. 2
Intermediate Stage Disease (Lichtman Stage II-III with Preserved Architecture)
Surgical decompression osteotomies protect the lunate from collapse by reducing mechanical stress, even though they do not heal the necrosis itself. 5
Patients with negative ulnar variance should undergo radial shortening osteotomy. 6
For patients with positive or neutral ulnar variance, capitate shortening osteotomy is the recommended option. 6
Vascularized bone grafting, particularly a vascularized pedicled scaphoid graft combined with partial radioscaphoid arthrodesis, is one of the most promising procedures for Stage III disease, providing excellent pain management and preventing carpal collapse. 6
Metaphyseal core decompression procedures can reduce intraosseous compartment syndrome pressure. 5, 7
Advanced Stage Disease (Lichtman Stage III with Collapse or Stage IV)
When lunate damage is so severe that bone viability is compromised, lunate replacement becomes necessary. 5
Pyrocarbon lunate implant arthroplasty is an option for young patients in whom vascularized bone grafting has failed but arthritis has not yet developed, allowing preservation of the remainder of the proximal carpal row. 8
In Stage IV disease with established midcarpal arthrosis, salvage procedures including total wrist fusion or total wrist arthroplasty are required. 6
Proximal row carpectomy and complete or partial wrist joint arthrodesis are conventional salvage treatments once radiocarpal joint collapse or midcarpal arthrosis develops. 7
Lunate excision with autologous or synthetic interposition grafts represents a newer salvage option when possible. 7
Post-Treatment Monitoring
Protected weight-bearing and regular radiographic follow-up after any surgical intervention are mandatory to monitor for disease progression. 2
- Serial radiographic evaluation should be performed for at least 3 weeks and at cessation of immobilization to monitor for loss of reduction or continued collapse. 2
Critical Pitfalls to Avoid
Do not rely solely on radiographic features to guide treatment decisions, as they may not correspond directly to initial clinical symptoms and differ among age groups. 6
Extra-articular osteotomies that preserve capsular vascularization and mid-carpal joint anatomy are preferable, as some osteotomies may place excessive pressure on the lunate's ulnar side. 5
In skeletally immature patients, extended conservative management should be attempted before proceeding to surgery, given their significant remodeling potential. 4
Conservative treatment failure in adults is common, so surgical consultation should not be delayed when symptoms persist despite immobilization. 5