The future of kienböck’s disease: A new algorithm

This book contains extensive descriptions of many of the finer points of Kienböck’s disease, which have evolved over the past 100+ years. The last two decades in particular have seen the introduction of advanced information regarding the etiology, natural history, classification, and treatment options for lunate osteonecrosis. New classification systems have been developed based on advanced imaging, perfusion studies of lunate viability and arthroscopic assessment of the articular cartilage. This chapter brings together the many facets of this book and presents a new treatment algorithm, incorporating the traditional osseous classification system (Lichtman) with the perfusion/viability classification (Schmitt) and the articular cartilage classification (Bain). From this broad base, we have developed a new algorithm to manage Kienböck’s avascular necrosis of the lunate. The new algorithm incorporates the understanding of the diseased lunate and how it affects the wrist. In the earliest stages and in patients with a good prognosis, the “intact lunate” is initially protected utilizing nonoperative measures. With failure to respond, the next step is an appropriate lunate unloading procedure. The “compromised lunate” can be reconstructed with a medial femoral condyle graft or PRC. With further lunate collapse, the wrist will become compromised, and also collapse and develop localized degeneration. This “compromised wrist” still has functional articulations, which enable motion-preserving procedures to be performed to maintain a functional wrist. With more advanced disease (Kienböck’s Disease Advanced Collapse, or KDAC), the wrist is no longer reconstructable, so a salvage procedure is required. In addition to these objective pathoanatomical factors, the final decision must take into account various patient factors that include age, general health, lifestyle, financial constraints, and future demands to be placed on the wrist. Finally, the surgeon’s skill set, equipment, and work environment must be considered.