The authors' treatment approach is based upon consideration of the natural history of the disease. What is known is that Kienbock's disease exists in diagnosed patients, but the specific natural history in each specific patient is not known. In other words, progression cannot be predicted for an individual patient. Therefore, treatment is predicated on symptom severity and alleviation, with consideration of the stage of disease (Table 2).
Cast treatment can be considered in mildly symptomatic Stage I or II disease, if the patient is willing to undergo temporary immobilization with no guarantee of success. More predictably, wrist arthroscopy can be used in early stage Kienbock's very successfully. Arthroscopy can be used to precisely stage the severity of disease in terms of carpal collapse, cartilage involvement, synovitis, and ligament integrity . The authors have performed arthroscopy on several patients in this stage of disease, based on preoperative symptoms and MRI scans showing changes in lunate signal intensity compared with surrounding carpal bones. The lunates showed mild proximal softening on probe evaluation without loss of cartilage. These patients had synovectomies performed, but no procedures were performed to the bone. Over the next 12 months, symptoms abated, and follow-up MRI scans showed normal lunate signal intensity (Fig. 1).
In more advanced stages of Kienbock's disease, arthroscopy can be used alone or as an adjunct to more traditional open procedures.
With more advanced disease, the efficacy of arthroscopy is less predictable; however, the relative ease of recovery from the procedure, and the possibility of treating patients' symptoms with or without supplemental procedures make this surgical option attractive. In these cases, a synovectomy is performed first, followed by inspection of ligaments, all radiocarpal joints and the triangular fibrocartilage complex (TFCC). TFCC tears can be addressed with standard arthroscopic procedures. In cases with moderate chondroma-lacia, arthroscopic debridement and chondro-plasty can be performed. If osteochondral flap tears exist, they can be debrided with a shaver or arthroscopic hand instruments.
In cases of Lichtman Stage Illb lesions with collapse, arthroscopic evaluation will usually reveal a significantly misshapen and soft proximal lunate. Symptomatic cases are generally best treated by open surgery to excise the lunate, and use of scaphocapitate or scapho-trapezial-trapezoid arthrodesis. Others have advocated radius osteotomy [17,34] and a vascular pedicle procedure  for these and claimed satisfactory results (Fig. 2).
For Stage IV disease, salvage procedures are the rule. Proximal row carpectomy can be used, with proximal capitate excision, or with the addition of interposition material, with good success. Alternatively, intercarpal arthrodesis can be considered if the radiocarpal joint is well preserved. Because of lunate involvement, four-corner fusion is not an option. Total wrist arthrodesis, and increasingly, total wrist arthro-plasty, complete the treatment options available for severe wrist arthritis, with the indications and results undergoing continual updating. Because recent arthroplasty designs have demonstrated good short-term success, the authors believe they will have an increasing role in these and other complex wrist problems.
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