Treatment of Kienböck's disease: a major unsolved problem

In this multi-author manuscript, we discuss the many aspects of etiology, natural history, assessment, classification and treatment of Kienbock's disease. We now have a better appreciation of the osseous, vascular, and articular aspects of Kienbock’s disease. New imaging modalities, provide a better understanding of pathoanatomy, including dynamic scans of lunate perfusion, how the lunate fractures creates collapsed and the associated carpal instabilities. The basic science forms the fundamentals of the Amalgamated Classification System, which focuses our attention to the patient’s age, the state of the lunate and state of the wrist. Then the Precise Treatment Algorithm provides a structured and clear management pathway, which directs the treatment to non-operative, unloading osteotomy, revascularisation, motion preserving or a salvage procedure. With this framework we can look towards a multimodal treatment approach, utilising minimally invasive techniques including arthroscopy and single cut unloading osteotomies.