Arthroscopic Assessment and Management of Kienböck’s Disease

There are three pathological phases of Kienböck’s disease: early vascular, intermediate osseous, and late chondral. The disease ultimately may result in subchondral collapse, an incongruent articular surface, abnormal carpal mechanics, and secondary degenerative osteoarthritis. Traditionally, the disease has been classified using Lichtman’s radiographic staging. The Bain and Begg arthroscopic classification is based on the number of nonfunctional articular surfaces of the lunate and its adjacent articulations. Using arthroscopy these articular surfaces can be inspected, and a more informed decision on management made. The aim of surgical treatment is to maintain functional motion within the remaining normal, functional articulations and to remove the nonfunctional articular surfaces. The articular-based classification directs treatment based on sound surgical principles. If all articular surfaces are intact, then a procedure that does not violate the articular surfaces is indicated (e.g., synovectomy, bone graft, core decompression, or joint leveling procedure). With non-functioning articular surfaces, an articular reconstructive procedure is required to maintain mobility in the carpus (e.g., proximal row carpectomy, radioscapholunate fusion, or hemiarthroplasty). More extensive joint involvement requires a salvage procedure such as a total wrist fusion or arthroplasty.