Kienbock Disease — Surgical Management

Surgical Indications

Indications by Lichtman Stage and Ulnar Variance

The surgical management of Kienböck disease is guided by two independent variables: the Lichtman radiographic stage (which reflects the degree of lunate collapse and carpal instability) and the ulnar variance (which determines which joint-levelling procedure is biomechanically appropriate).

Absolute Indications for Surgery

• Lichtman stage IIA or greater with persistent pain despite 3-6 months of conservative treatment (immobilisation, NSAIDs, activity modification)
• Progressive lunate collapse on serial radiographs
• Loss of carpal height or fixed scaphoid flexion (stage IIIB)
• Pancarpal arthritis (stage IV)

Relative Indications

• Stage I with persistent symptoms greater than 6 months despite immobilisation (some surgeons offer earlier joint levelling in manual labourers)
• Bilateral Kienböck disease (surgical treatment of the more symptomatic side)
• Patient preference for definitive surgical management over prolonged immobilisation

Contraindications to Specific Procedures

Radial shortening osteotomy:

• Ulnar-neutral or positive variance (shortening the radius would worsen the imbalance)
• Pre-existing DRUJ arthritis or instability
• Active infection at the surgical site
• Uncorrected smoking (significantly increases nonunion risk)

Proximal row carpectomy:

• Capitate head chondrosis on MRI (PRC relies on capitate-radius articulation)
• Radiocarpal arthritis (stage IV)
• Active infection

STT or scaphocapitate fusion:

• Midcarpal arthritis beyond the targeted fusion site
• Advanced pancarpal arthritis (stage IV)
• Poor bone quality precluding reliable fixation

Evidence for Conservative Treatment

Immobilisation and Observation

• Stage I and early stage IIA disease may be managed with short-arm thumb spica cast or splint immobilisation for 4-12 weeks to reduce mechanical load on the lunate
• Activity modification and avoidance of repetitive axial loading are recommended regardless of stage
• NSAIDs provide symptomatic pain relief but do not alter disease progression
• Approximately 20-30 percent of stage I patients improve with immobilisation alone; however, many progress to surgical intervention

Core Decompression

• Percutaneous drilling of the lunate to stimulate revascularisation by creating vascular channels
• Suitable for early stages (I-IIA) regardless of ulnar variance
• Limited evidence base — small case series report symptom improvement in 60-80 percent of patients
• Low morbidity; can be combined with other procedures

Evidence for Joint-Levelling Procedures

Radial Shortening Osteotomy

• The most studied surgical procedure for Kienböck disease with the largest evidence base
• Shortens the distal radius by 2-4 mm, effectively converting a ulnar-negative wrist to neutral or slightly positive variance
• Offloads the lunate by redistributing axial load from the radial side of the wrist to the ulnar side
• Multiple long-term series report pain relief in 70-90 percent of patients with Lichtman stages I-IIIA
• Preserves wrist motion — most patients maintain 80-90 percent of preoperative range
• Union rate greater than 95 percent with plate fixation in non-smokers
• Key landmark study: Weiss et al. (1991) reported 94 percent good-to-excellent results with radial shortening in a series of 36 wrists with average 5-year follow-up

Capitate Shortening Osteotomy

• Shortens the capitate by 2-3 mm, achieving the same lunate offloading effect as radial shortening but without altering the DRUJ relationship
• Indicated when ulnar variance is neutral or positive (radial shortening would worsen DRUJ mechanics)
• Fixation with an intramedullary headless compression screw (Acutrak or Herbert-type) or mini-fragment plate
• Almquist (1982) described the original technique; subsequent series report 70-85 percent satisfactory results
• Nonunion rate approximately 5-10 percent — higher than radial shortening because the capitate osteotomy site is smaller

Evidence for Revascularisation

Vascularised Bone Grafting

• Pedicled or free vascularised bone grafts (most commonly the 4th and 5th extensor compartment artery-based grafts from the distal radius, or the medial femoral condyle free flap) are used to restore blood supply to the lunate
• Most commonly combined with a joint-levelling procedure (radial shortening or capitate shortening) to simultaneously offload and revascularise the lunate
• Indicated in stage IIA-IIIA with a viable (non-collapsed) lunate shape — revascularisation cannot restore a collapsed lunate architecture
• The Iliac crest bone graft based on the vascularised pedicle was described by Hori (1979); more recent work uses the medial femoral condyle free flap with good structural support
• Series report pain relief in 65-85 percent and radiographic evidence of revascularisation (restored MRI signal) in approximately 60-75 percent

Evidence for Motion-Sparing Salvage

Intercarpal Fusion (STT or Scaphocapitate)

• STT fusion (scaphotrapeziotrapezoid) stabilises the proximal carpal row by preventing scaphoid flexion, which is the primary collapse pattern in Kienböck disease
• Indicated at Lichtman stage IIIB when carpal height is reduced and the scaphoid has rotated into fixed flexion but pancarpal arthritis has not yet developed
• Watson and Ryu (1986) described the technique; series report 70-85 percent good-to-excellent results
• Nonunion rate approximately 5-15 percent — the most common complication; requires careful surface preparation and rigid fixation
• Scaphocapitate fusion is an alternative that preserves more radial deviation than STT fusion

Proximal Row Carpectomy

• Removes the entire proximal carpal row (scaphoid, lunate, triquetrum), allowing the capitate to articulate with the lunate fossa of the radius
• Advantages: no nonunion risk (no fusion), simpler procedure, predictable pain relief, faster rehabilitation
• Disadvantages: loss of carpal height, reduced grip strength (approximately 60-70 percent of contralateral), potential for capitate-radius arthritis over time (long-term follow-up shows radiographic arthritis in 15-25 percent of patients at 10 years, though many remain asymptomatic)
• Contraindication: capitate head chondrosis or midcarpal arthritis — preoperative MRI is mandatory
• Culp (2010) reported 85 percent good-to-excellent results in a series of PRCs for Kienböck disease at stage IIIB

Evidence for Total Wrist Salvage

Total Wrist Fusion

• The gold standard salvage for Lichtman stage IV with pancarpal arthritis
• Provides reliable pain relief in greater than 90 percent of patients
• Eliminates wrist motion but restores grip strength to approximately 80-90 percent of the contralateral side
• Plate-and-screw fixation (dorsal wrist fusion plate) is the most common technique
• Union rate greater than 95 percent with modern plating systems

Total Wrist Arthroplasty

• Motion-preserving alternative to fusion for low-demand patients with stage IV disease
• Relatively newer implants (fourth-generation designs) have improved survival but long-term data remain limited
• Contraindicated in high-demand manual labourers, active infection, or poor bone stock
• Revision to fusion is possible but complex — arthroplasty is generally reserved for older or lower-demand patients

Lunate Blood Supply

Vascular Anatomy

The lunate receives its blood supply through dorsal and volar vascular pedicles entering the bone through ligamentous attachments. Understanding this anatomy is essential for revascularisation procedures and explains why certain wrist positions and fracture patterns predispose to avascular necrosis.

Dorsal vessels (primary supply in 70-80 percent of lunates):

• Enter through the dorsal radiocarpal and dorsal intercarpal ligaments
• Arise from the radial artery via dorsal branches and the anterior interosseous artery
• Supply approximately two-thirds to three-quarters of the lunate via dorsal foramina
• Most vulnerable to disruption during dorsal fracture patterns and surgical dissection

Volar vessels (supplemental supply):

• Enter through the radiolunotriquetral ligament and volar radiocarpal ligament
• Arise from the palmar branch of the anterior interosseous artery and the ulnar artery
• Supply the volar pole of the lunate
• May be the sole supply in a minority of lunates (Type I vascular pattern — single volar vessel only)

Clinical significance:

• Viegas (1999) classified lunate vascularity into three types: Type I (single volar or single dorsal vessel, approximately 20 percent of lunates, highest risk for AVN), Type II (two vessels, dorsal dominant, approximately 60 percent), Type III (multiple dorsal and volar vessels, approximately 20 percent, lowest risk)
• A Type I lunate with a single blood supply is the most vulnerable to AVN after injury
• Repetitive loading in an ulnar-negative wrist concentrates force on the radial side of the lunate, microfracturing trabeculae and disrupting the dorsal vessels

Dorsal Approach to the Wrist

Incision and Dissection Layers

The dorsal approach is the workhorse exposure for all surgical procedures on Kienböck disease, including radial osteotomy, intercarpal fusion, PRC, and total wrist fusion.

Skin incision: longitudinal or slightly curved, centred over the Lister tubercle (dorsal radial tubercle), extending from approximately 4 cm proximal to the radiocarpal joint to 3 cm distal

Dorsal retinaculum: divided along the line of the third extensor compartment (EPL), which is elevated with a radial-based flap to expose the second (ECRB, ECRL) and fourth (EDM) compartments

EPL (third compartment): released from its groove at Lister tubercle and retracted radially — this exposes the dorsal wrist capsule

Fourth extensor compartment (EDM): the PIN and posterior interosseous artery lie on the floor of this compartment, directly on the dorsal wrist capsule

Posterior Interosseous Nerve (PIN)

• Branches from the radial nerve in the radial aspect of the fourth extensor compartment (deep branch of the radial nerve)
• Runs with the posterior interosseous artery on the dorsal wrist capsule, deep to the EDM tendons
• Innervates the EDM and EPL (the small intrinsic muscles at the wrist — loss is clinically undetectable as the EDM and EPL are also supplied by the radial nerve proper more proximally)
• Common practice: identify the PIN during the dorsal approach; either protect it with a vessel loop or perform a prophylactic neurectomy at the distal radius level (approximately 1-2 cm proximal to the radiocarpal joint), which provides pain relief without functional deficit

Key Dorsal Landmarks

Distal Radius Anatomy for Osteotomy

Osteotomy Site

• The radial shortening osteotomy is performed 2-3 cm proximal to the radiocarpal joint, at the metaphyseal flare of the distal radius
• This level provides adequate cancellous bone for healing while being distal enough to avoid the radial diaphysis (which would alter radial bow and biomechanics)
• The dorsal cortex is most accessible through the dorsal approach
• The radial nerve (superficial branch) lies on the volar radial aspect of the distal radius and is at risk if the volar cortex is inadvertently breached — avoid extensive volar dissection at the osteotomy site

DRUJ Relationship

• The distal radioulnar joint (DRUJ) is the articulation between the sigmoid notch of the radius and the ulnar head
• Ulnar variance (the relative length of the ulna and radius at the DRUJ) determines load distribution across the wrist
• In an ulnar-negative wrist, the ulna is shorter and a greater proportion of axial load falls on the lunate (through the radius)
• Radial shortening osteotomy corrects this by shortening the radius, equalising load distribution between radius and ulna
• Excessive shortening reverses the imbalance, overloading the ulnar side of the DRUJ and causing impingement and pain

General Positioning and Preparation

Patient position: Supine, arm abducted 90 degrees on hand table, forearm in neutral rotation (important for ulnar variance measurement confirmation on fluoroscopy). A tourniquet is applied to the upper arm and inflated to 250 mmHg before incision.

Anaesthesia: General anaesthesia or regional (brachial plexus block) depending on procedure duration and patient preference. For isolated radial shortening osteotomy, regional is adequate; for combined procedures (osteotomy plus revascularisation), general anaesthesia is preferred.

Preparation: Standard skin prep from mid-forearm to fingertips. Drape to expose the entire dorsal wrist. Administer prophylactic antibiotics (e.g. cefazolin 2 g IV at induction) — the procedure involves bone work and implant placement.

Fluoroscopy: C-arm positioned from the ulnar side to allow AP and lateral imaging without moving the arm. Confirm PA and lateral wrist views before prepping. Intraoperatively verify ulnar variance, osteotomy position, and implant placement.

Consent: Discuss procedure-specific risks: nonunion (1-5 percent), progressive lunate collapse, DRUJ overload (radial shortening), need for secondary salvage procedure, wrist stiffness, complex regional pain syndrome, and the possibility that the chosen procedure may not fully relieve symptoms (approximately 10-20 percent of patients ultimately require a salvage operation).

Dorsal Approach to the Wrist — Step-by-Step

Step 1: Incision

Make a longitudinal or slightly curved incision centred over the Lister tubercle, extending approximately 4 cm proximal and 3 cm distal to the radiocarpal joint. The incision should follow the axis of the third metacarpal to optimise scar appearance.

Step 2: Dorsal Retinaculum and Extensor Compartments

Incise the dorsal retinaculum along the line of the third extensor compartment (EPL). Create a radial-based flap of the dorsal retinaculum, elevating the second compartment (ECRB, ECRL) radially and the fourth compartment (EDM) ulnarly.

Release the EPL from its groove at Lister tubercle and retract it radially. This exposes the dorsal wrist capsule.

Step 3: Identify the PIN

In the floor of the fourth extensor compartment, identify the posterior interosseous nerve (PIN) running with the posterior interosseous artery on the dorsal wrist capsule.

Step 4: Capsular Exposure

Create a longitudinal capsular incision or a radially-based capsular flap (depending on the planned procedure). For osteotomy procedures, a limited capsulotomy over the radiocarpal joint may suffice. For PRC or fusion procedures, a wider exposure is needed.

Radial Shortening Osteotomy — Step-by-Step

Indication

Lichtman stages I, IIA, or IIIA with negative ulnar variance (greater than 1 mm negative). The patient must have no DRUJ arthritis or symptoms.

Step 1: Plan the Osteotomy

Confirm the ulnar variance on intraoperative fluoroscopy (PA wrist in neutral rotation, compare with contralateral side if available). Calculate the target shortening: aim to achieve a postoperative ulnar variance of 0 to plus 1 mm. The amount of radial shortening = current negative ulnar variance plus the desired postoperative offset.

Mark the planned osteotomy site on the dorsal cortex: 2-3 cm proximal to the radiocarpal joint, at the metaphyseal flare. The osteotomy must be perpendicular to the long axis of the radius.

Step 2: Perform the Osteotomy

Using an oscillating saw under saline irrigation, create a transverse osteotomy through the dorsal cortex at the marked site. Complete the osteotomy carefully through the volar cortex using osteotomes or the saw, protecting the volar soft tissues (especially the superficial branch of the radial nerve on the volar radial aspect).

Remove a measured sliver of cortex to achieve the planned shortening (2-4 mm). Use a calibrated osteotomy template or ruler to confirm the exact gap.

Step 3: Fixation

Apply a 3.5 mm LC-DCP or locking compression plate to the dorsal surface of the radius, centred over the osteotomy site. The plate is contoured to fit the dorsal radial surface. Insert screws in the standard AO technique: load the osteotomy by overbending the plate slightly, then compress across the gap with the plate screws.

Confirm compression across the osteotomy site on fluoroscopy. Verify that the achieved ulnar variance matches the preoperative plan.

Step 4: Wound Closure

Irrigate thoroughly. Close the dorsal retinaculum over the plate if possible (reduces tendon irritation). Close subcutaneous tissue and skin. Apply a below-elbow plaster backslab in neutral rotation.

Capitate Shortening Osteotomy — Step-by-Step

Indication

Lichtman stages I, IIA, or IIIA with neutral or positive ulnar variance. Preserves DRUJ mechanics.

Steps

1. Dorsal approach as described above, with capsular exposure extended to the midcarpal joint
2. Identify the capitate body; expose the waist of the capitate through the dorsal capsulotomy
3. Create a transverse osteotomy at the capitate waist (the narrowest point of the capitate, distal to the capitate head)
4. Remove a 2-3 mm sliver of bone
5. Fix with an intramedullary headless compression screw (Acutrak or Herbert-type) directed from proximal to distal along the capitate axis
6. Confirm screw position and achieved shortening on fluoroscopy
7. Close capsule and wound in layers; short-arm thumb spica splint

STT Fusion — Step-by-Step

Indication

Lichtman stage IIIB with carpal collapse, fixed scaphoid flexion, and no pancarpal arthritis.

Steps

1. Dorsal wrist approach with wide capsular exposure
2. Identify the STT joint (scaphoid-trapezium-trapezoid articulation on the radial side of the carpus)
3. Denude the articular cartilage from the scaphoid distal pole, the trapezium, and the trapezoid using curettes and a burr
4. Decorticate the subchondral bone to expose bleeding cancellous surfaces
5. Correct the scaphoid flexion by manually dorsiflexing the distal pole of the scaphoid
6. Fix with K-wires or headless compression screws across the fusion surfaces (scaphoid-to-trapezium and scaphoid-to-trapezoid)
7. Pack the fusion bed with autologous cancellous bone graft harvested from the distal radius or iliac crest
8. Confirm fixation and carpal alignment on fluoroscopy — check scapholunate angle (should be less than 60 degrees post-correction)
9. Close capsule and wound; below-elbow plaster splint in neutral rotation

Proximal Row Carpectomy — Step-by-Step

Indication

Lichtman stage IIIB (or stage III with midcarpal arthritis) when capitate head cartilage is intact. PRC is simpler than intercarpal fusion and avoids nonunion risk.

Step 1: Confirm Capitate Cartilage

Before proceeding with carpal row excision, inspect the capitate head articular surface directly (or by arthroscopy). If the cartilage is intact (smooth, no fibrillation, no exposed bone), proceed. If chondrosis is present, abandon PRC and proceed to total wrist fusion or arthroplasty.

Step 2: Excise the Proximal Row

Remove the lunate first (central, easiest access), then the triquetrum (ulnar), then the scaphoid (radial). Use rongeurs and osteotomes to excise each bone piecemeal through the dorsal capsulotomy.

Step 3: Confirm Reduction and Motion

After excision, the capitate should settle proximally into the lunate fossa of the radius. Manually flex and extend the wrist to confirm a smooth arc of motion without crepitus or impingement.

Step 4: Wound Closure

Irrigate the carpal bed. Close the dorsal capsule. Close retinaculum, subcutaneous tissue, and skin. Apply a below-elbow plaster backslab in neutral to slight extension. Begin early mobilisation at 2-3 weeks postoperative.

Total Wrist Fusion — Step-by-Step

Indication

Lichtman stage IV with pancarpal arthritis when pain is the dominant symptom and the patient accepts loss of wrist motion.

Steps

1. Dorsal approach with wide exposure of the radiocarpal and midcarpal joints
2. Excise the proximal carpal row (or denude articular surfaces depending on technique)
3. Position the wrist in slight extension (approximately 10-15 degrees) — this is the most functional position for activities of daily living
4. Apply a dorsal wrist fusion plate from the distal radius to the third metacarpal
5. Pack all denuded joint surfaces with autologous cancellous bone graft
6. Fix the plate with locking screws into the distal radius (3-4 screws) and the third metacarpal (2-3 screws)
7. Confirm position, plate placement, and fusion alignment on fluoroscopy
8. Close in layers; long-arm plaster with the elbow at 90 degrees and the wrist in extension

Post-operative Protocol — General Principles

Immediate Phase (Day 0-7)

• Elevation above heart level for 48 hours to minimise swelling
• Interim splint or cast immobilisation (below-elbow plaster for osteotomy and fusion procedures; sugar-tong or short-arm thumb spica for capitate shortening)
• Analgesia: paracetamol and NSAIDs; consider short course of opioids for the first 48-72 hours
• Finger flexion-extension exercises from day 1 to prevent digital stiffness (regardless of wrist immobilisation)
• Monitor wound at 5-7 days for signs of infection

Immobilisation Phase (Weeks 1-6)

Rehabilitation Phase (Weeks 6-12)

• Progressive wrist range of motion exercises under hand therapy supervision
• Avoid heavy lifting and repetitive loading for 8-12 weeks post-osteotomy, 12-16 weeks post-fusion
• Grip strengthening with therapy putty and graduated resistance exercises once bony healing is confirmed
• Wrist extension splinting at night if flexion contracture develops
• Functional use of the hand encouraged — activities of daily living are permitted within the guidance of the therapist

Return to Function

• Office work: 2-4 weeks (osteotomy), 2-3 weeks (PRC), 6-8 weeks (fusion)
• Manual work: 8-12 weeks (osteotomy and PRC), 12-16 weeks (fusion); heavy manual labour may not be possible after fusion
• Driving: when confident grip and steering control (typically 4-6 weeks for osteotomy/PRC, 8-12 weeks for fusion)
• Sport: 12-16 weeks (osteotomy and PRC); fusion patients may need to modify or change sport

Special Case: Revascularisation with Vascularised Bone Graft

Indications

• Lichtman stage I-IIIA with a viable (non-collapsed) lunate
• Young patients (less than 35 years) where preserving the lunate architecture is a priority
• Often combined with a joint-levelling osteotomy to simultaneously offload and revascularise

Technique (Fourth-Fifth Extensor Compartment-Based Graft)

1. Dorsal approach with extended exposure of the distal radius
2. Identify the fourth and fifth extensor compartment arteries (branches of the anterior interosseous artery) running on the dorsal surface of the distal radius
3. Raise a pedicled corticocancellous bone graft from the dorsal distal radius (approximately 1 x 0.5 x 0.5 cm) based on these vessels
4. Create a dorsal cortical window in the lunate and curette necrotic bone
5. Insert the vascularised graft into the lunate, maintaining the vascular pedicle
6. Secure the graft with a K-wire if needed
7. Optionally combine with radial or capitate shortening osteotomy through the same approach

Post-operative

• Short-arm thumb spica cast for 4-6 weeks
• Serial MRI at 3-6 months to assess revascularisation (return of normal signal on T1-weighted sequences)
• If revascularisation fails (persistent low signal on MRI with progressive collapse), escalate to motion-sparing salvage

Special Case: Bilateral Kienböck Disease

Epidemiology and Implications

• Bilateral involvement occurs in approximately 2-5 percent of patients
• More common in patients with systemic risk factors (steroid use, sickle cell disease, systemic lupus erythematosus)
• Management requires staged treatment: address the more symptomatic side first, then the contralateral side after recovery

Staged Approach

• First side: definitive surgical management as per Lichtman stage and ulnar variance
• Second side: delay at least 8-12 weeks; assess each side independently as staging may differ between wrists
• Total wrist fusion on one side and PRC on the other is an acceptable strategy — this preserves some motion in at least one wrist

Special Case: Failed Joint-Levelling Procedure

Recognition

• Persistent or worsening pain greater than 6 months after osteotomy with radiographic union
• Progressive carpal height loss, increasing scapholunate angle, or lunate fragmentation on serial radiographs

Management Algorithm

1. Confirm osteotomy union on CT (exclude nonunion as a cause of pain)
2. Assess current Lichtman stage — if the patient has progressed from IIIA to IIIB or IV
3. If IIIA or early IIIB: consider intercarpal fusion (STT) or PRC
4. If IIIB with capitate chondrosis or stage IV: total wrist fusion
5. Discuss expectations — salvage procedures have lower functional outcomes than primary procedures