Medscape is available in 5 Language Editions – Choose your Edition here.


Kienbock Disease Treatment & Management

  • Author: Brian J Divelbiss, MD; Chief Editor: Harris Gellman, MD  more...
Updated: Oct 26, 2015

Approach Considerations

The primary indication for operative treatment in Kienböck disease is persistent pain that does not respond to conservative treatment such as nonsteroidal anti-inflammatory drugs (NSAIDs) and immobilization. Most patients with Kienböck disease who have moderate-to-severe symptoms are candidates for operative intervention. The choice of operative technique is based on patient age, disease stage, and the presence or absence of ulnar variance.

The primary contraindication to consider in the operative treatment of Kienböck disease is ulnar-positive or ulnar-neutral variance because in patients with such variance, joint-leveling procedures (radial shortening and ulnar lengthening) cannot be performed.


Medical Therapy

The primary methods of nonoperative treatment are immobilization and anti-inflammatory medications. Because the natural history of Kienböck disease is not well determined, treatment is primarily directed by the level of symptoms. Certainly, a very young patient, though an unusual presentation of Kienböck disease, should be given an adequate trial of immobilization in hopes of allowing revascularization of the lunate and preventing disease progression.


Surgical Therapy

A number of options are available for surgical management of Kienböck disease. The two most important pieces of information are the stage of the disease and the presence or absence of ulnar variance.

Directly comparing the results of different techniques is difficult because most studies have a fairly small number of patients and short follow-up. However, review of the literature reveals that many of the techniques result in very similar rates of good outcomes.

Operative treatment can be classified broadly into six categories, as follows:

  • Lunate excision with or without replacement
  • Joint-leveling procedures
  • Intercarpal fusions
  • Revascularization
  • Salvage procedures
  • Other procedures

Lunate excision with or without replacement

Available approaches include the following:

  • Simple lunate excision
  • Excision with soft-tissue (fascial or palmaris longus tendon graft) replacement
  • Silicone replacement arthroplasty

Joint-leveling procedures

Radial shortening and ulnar lengthening are the two options for leveling the joint. The goal is to produce a wrist with neutral ulnar variance, though correction should probably not exceed 4 mm, because nearly all strain reduction occurs in the first 2 mm of correction. Strains at the lunate can be reduced by 70% with an appropriate radial shortening or ulnar lengthening.

Currently, radial shortening with a volar distal radius locking plate is preferred to ulnar lengthening because there is a lower complication rate with the volar-shortening procedure and because the two procedures have shown similarly good outcomes. In patients with neutral or positive ulnar variance, shortening the radius is contraindicated. In this clinical situation, radial wedge osteotomies designed to decrease the radial inclination have been proposed.[18, 19]

Intercarpal fusions

Various intercarpal fusions for the treatment of Kienböck disease have been reported. The goal is to reduce lunate strain and, in procedures that involve the scaphoid, to correct and maintain proper scaphoid position.

Of the limited intercarpal fusions reported, the greatest experience has been with scaphotrapeziotrapezoid (STT) (triscaphe) fusion. STT arthrodesis does decrease lunate strain but merely by shifting it to the radioscaphoid joint. STT fusion in a cadaver model was found to provide strain reduction similar to that of joint-leveling procedures but with greater loss of motion. The use of STT fusion has waned in recent years because of complications and longer-term follow-up that has revealed decreased success rates.[20]

Several authors have reported scaphocapitate (SC) fusion. Biomechanically, this fusion has been shown to reduce strain at the radiolunate joint by about 10%. Some authors prefer this fusion because it requires only one fusion site and is technically easier to perform.

Finally, capitohamate fusion has been reported in a study with a short follow-up. However, this fusion alone has been shown to be biomechanically ineffective in reducing lunate strain. If this fusion is combined with capitate shortening, significant reductions of load across the radiolunate and SC joints have been noted. This load reduction is offset by large force increases at the ulnotriquetral, triquetrohamate, and scaphotrapezial joints. This method also does not address the scaphoid rotation that occurs with stage IIIb disease.

At present, intercarpal fusions are more likely to be reserved for patients with neutral or positive ulnar variance in whom a joint-leveling procedure is contraindicated.


In the late 1970s, Hori presented his initial work on the use of a vascular pedicle directly implanted into the lunate. Nearly all of his patients showed improvement in their pain at later follow-up. Currently, most revascularizations use vascularized bone pedicles.[21, 22, 23] There are several sources for the pedicles, including the distal radius,[24] pisiform,[25] and pronator quadratus (Braun). Results with the use of pedicled distal radius grafts have shown improved grip strengths and progressive evidence of revascularization on magnetic resonance imaging (MRI) over an 18- to 36-month period.[26]

Revascularization techniques may also be combined with other previously mentioned approaches. Revascularization is especially attractive for the young patient with ulnar-neutral or ulnar-positive variance in whom a radial shortening is not an option and for the patient who wishes to avoid an intercarpal fusion and resultant loss of motion.

Salvage procedures

Salvage procedures are reserved for later stages of disease and for failures of other treatments. Proximal row carpectomy (PRC) has been shown to provide relatively good results for Kienböck disease, as well as for other wrist problems.[27] Wrist arthrodesis is the final option for patients with global wrist degeneration. Arthrodesis can be achieved successfully following a failed PRC. SC arthrodesis has been suggested as an option for wrist salvage in cases of advanced Kienböck disease.[28]

Other procedures

Other possible procedures include the following:

  • Cancellous bone grafting plus external fixation
  • Arthroscopic debridement
  • Wrist denervation
  • Metaphyseal decompression
  • Lunate core decompression [29]

A reasonable approach to determining the surgical treatment of Kienböck disease based on stage is as follows:

  • Stage 0, I, II, or IIIa with ulnar-negative variance – Radial shortening, revascularization, denervation
  • Stage 0, I, II, or IIIa with ulnar-neutral or positive variance – Revascularization, capitohamate (CH) fusion with capitate shortening, distal radius wedge osteotomy, denervation
  • Stage IIIb – SC fusion, radial shortening, denervation
  • Stage IV – PRC, total wrist arthrodesis, denervation
Contributor Information and Disclosures

Brian J Divelbiss, MD Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City

Brian J Divelbiss, MD is a member of the following medical societies: Alpha Omega Alpha, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.


Mark E Baratz, MD Orthopedic Specialists of UPMC

Mark E Baratz, MD is a member of the following medical societies: Orthopaedic Research Society, Pennsylvania Orthopaedic Society, Allegheny County Medical Society, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand

Disclosure: Received royalty from Integra Life Sciences for none; Received consulting fee from Integra Life Sciences for speaking and teaching; Received grant/research funds from Integra Life Sciences for none; Received consulting fee from Elizur for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

A Lee Osterman, MD Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University

Disclosure: Nothing to disclose.

  1. Lutsky K, Beredjiklian PK. Kienböck disease. J Hand Surg Am. 2012 Sep. 37(9):1942-52. [Medline].

  2. Bain GI, Yeo CJ, Morse LP. Kienböck Disease: Recent Advances in the Basic Science, Assessment and Treatment. Hand Surg. 2015 Oct. 20 (3):352-65. [Medline].

  3. Gelberman RH, Bauman TD, Menon J. The vascularity of the lunate bone and Kienbock''s disease. J Hand Surg [Am]. 1980 May. 5(3):272-8. [Medline].

  4. Gelberman RH, Salamon PB, Jurist JM. Ulnar variance in Kienbock''s disease. J Bone Joint Surg Am. 1975 Jul. 57(5):674-6. [Medline].

  5. Stahl S, Stahl AS, Meisner C, Rahmanian-Schwarz A, Schaller HE, Lotter O. A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration. BMC Musculoskelet Disord. 2012 Nov 21. 13:225. [Medline]. [Full Text].

  6. De Smet L. Ulnar variance: facts and fiction review article. Acta Orthop Belg. 1994. 60(1):1-9. [Medline].

  7. Kristensen SS, Thomassen E, Christensen F. Kienbock''s disease--late results by non-surgical treatment. A follow-up study. J Hand Surg [Br]. 1986 Oct. 11(3):422-5. [Medline].

  8. Delaere O, Dury M, Molderez A. Conservative versus operative treatment for Kienbock''s disease. A retrospective study [see comments]. J Hand Surg [Br]. 1998 Feb. 23(1):33-6. [Medline].

  9. Mikkelsen SS, Gelincek J. Poor function after nonoperative treatment of Kienbock's disease. Acta Orthopedica Scandinavia. 1987. 58:241-243.

  10. Lichtman DM, Alexander AH, Mack GR. Kienbock''s disease--update on silicone replacement arthroplasty. J Hand Surg [Am]. 1982 Jul. 7(4):343-7. [Medline].

  11. Quenzer DE, Dobyns JH, Linscheid RL. Radial recession osteotomy for Kienbock''s disease. J Hand Surg [Am]. 1997 May. 22(3):386-95. [Medline].

  12. Weiss AP. Radial shortening. Hand Clin. 1993 Aug. 9(3):475-82. [Medline].

  13. Weiss AP, Weiland AJ, Moore JR, Wilgis EF. Radial shortening for Kienböck disease. J Bone Joint Surg Am. 1991 Mar. 73(3):384-91. [Medline].

  14. Watson HK, Monacelli DM, Milford RS. Treatment of Kienbock''s disease with scaphotrapezio-trapezoid arthrodesis. J Hand Surg [Am]. 1996 Jan. 21(1):9-15. [Medline].

  15. Gay AM, Parratte S, Glard Y, Mutaftschiev N, Legre R. Isolated capitate shortening osteotomy for the early stage of Kienböck disease with neutral ulnar variance. Plast Reconstr Surg. 2009 Aug. 124(2):560-6. [Medline].

  16. Zelouf DS, Ruby LK. External fixation and cancellous bone grafting for Kienbock''s disease: a preliminary report. J Hand Surg [Am]. 1996 Sep. 21(5):746-53. [Medline].

  17. Takahara M, Watanabe T, Tsuchida H, Yamahara S, Kikuchi N, Ogino T. Long-term follow-up of radial shortening osteotomy for Kienbock disease. Surgical technique. J Bone Joint Surg Am. 2009 Oct 1. 91 Suppl 2:184-90. [Medline].

  18. Illarramendi AA, De Carli P. Radius decompression for treatment of Kienbock disease. Tech Hand Up Extrem Surg. 2003. 7:110-3. [Medline].

  19. Iwasaki N, Minami A, Ishikawa J, Kato H, Minami M. Radial osteotomies for teenage patients with Kienböck disease. Clin Orthop Relat Res. 2005 Oct. 439:116-22. [Medline].

  20. Lee JS, Park MJ, Kang HJ. Scaphotrapeziotrapezoid arthrodesis and lunate excision for advanced Kienböck disease. J Hand Surg Am. 2012 Nov. 37(11):2226-32. [Medline].

  21. Elhassan BT, Shin AY. Vascularized bone grafting for treatment of Kienböck's disease. J Hand Surg Am. 2009 Jan. 34(1):146-54. [Medline].

  22. Simmons SP, Tobias B, Lichtman DM. Lunate revascularization with artery implantation and bone grafting. J Hand Surg Am. 2009 Jan. 34(1):155-60. [Medline].

  23. Mathoulin C, Wahegaonkar AL. Revascularization of the lunate by a volar vascularized bone graft and an osteotomy of the radius in treatment of the Kienböck's disease. Microsurgery. 2009. 29(5):373-8. [Medline].

  24. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg [Am]. 1995 Nov. 20(6):902-14. [Medline].

  25. Beck E. Os pisiforme transfer. Orthopade. 1986 Apr. 15(2):131-4. [Medline].

  26. Mazur KU, Bishop AT, Berger RA. Vascularized metaphyseal bone grafts from the distal radius in the treatment of Kienbock's disease. Orthopaedic Transactions. 1997. 21:244.

  27. Kremer T, Sauerbier M, Trankle M, Dragu A, Germann G, Baumeister S. Functional results after proximal row carpectomy to salvage a wrist. Scand J Plast Reconstr Surg Hand Surg. 2008. 42(6):308-12. [Medline].

  28. Iorio ML, Kennedy CD, Huang JI. Limited intercarpal fusion as a salvage procedure for advanced Kienbock disease. Hand (N Y). 2015 Sep. 10 (3):472-6. [Medline].

  29. Mehrpour SR, Kamrani RS, Aghamirsalim MR, Sorbi R, Kaya A. Treatment of kienböck disease by lunate core decompression. J Hand Surg Am. 2011 Oct. 36(10):1675-7. [Medline].

  30. Aspenberg P, Wang JS, Jonsson K. Experimental osteonecrosis of the lunate. Revascularization may cause collapse. J Hand Surg [Br]. 1994 Oct. 19(5):565-9. [Medline].

  31. Begley BW, Engber WD. Proximal row carpectomy in advanced Kienbock''s disease. J Hand Surg [Am]. 1994 Nov. 19(6):1016-8. [Medline].

  32. Bochud RC, Buchler U. Kienbock''s disease, early stage 3--height reconstruction and core revascularization of the lunate. J Hand Surg [Br]. 1994 Aug. 19(4):466-78. [Medline].

  33. Bonzar M, Firrell JC, Hainer M. Kienbock disease and negative ulnar variance [see comments]. J Bone Joint Surg Am. 1998 Aug. 80(8):1154-7. [Medline].

  34. Condit DP, Idler RS, Fischer TJ. Preoperative factors and outcome after lunate decompression for Kienbock''s disease. J Hand Surg [Am]. 1993 Jul. 18(4):691-6. [Medline].

  35. Hashizume H, Asahara H, Nishida K. Histopathology of Kienbock''s disease. Correlation with magnetic resonance and other imaging techniques. J Hand Surg [Br]. 1996 Feb. 21(1):89-93. [Medline].

  36. Jensen CH, Thomsen K, Holst-Nielsen F. Radiographic staging of Kienbock''s disease. Poor reproducibility of Stahl''s and Lichtman''s staging systems. Acta Orthop Scand. 1996 Jun. 67(3):274-6. [Medline].

  37. Menth-Chiari WA, Poehling GG, Wiesler ER. Arthroscopic debridement for the treatment of Kienbock''s disease. Arthroscopy. 1999 Jan-Feb. 15(1):12-9. [Medline].

  38. Miura H, Sugioka Y. Radial closing wedge osteotomy for Kienbock''s disease. J Hand Surg [Am]. 1996 Nov. 21(6):1029-34. [Medline].

  39. Nakamura R, Horii E, Watanabe K. Proximal row carpectomy versus limited wrist arthrodesis for advanced Kienbock''s disease. J Hand Surg [Br]. 1998 Dec. 23(6):741-5. [Medline].

  40. Nakamura R, Watanabe K, Tsunoda K. Radial osteotomy for Kienbock''s disease evaluated by magnetic resonance imaging. 24 cases followed for 1-3 years. Acta Orthop Scand. 1993 Apr. 64(2):207-11. [Medline].

  41. Quenzer DE, Linscheid RL, Vidal MA. Trispiral tomographic staging of Kienbock''s disease. J Hand Surg [Am]. 1997 May. 22(3):396-403. [Medline].

  42. Sakai A, Toba N, Oshige T, Menuki K, Hirasawa H, Nakamura T. Kienböck disease treated by excisional arthroplasty with a palmaris longus tendon ball: a comparative study of cases with or without bone core. Hand Surg. 2004 Dec. 9(2):145-9. [Medline].

  43. Salmon J, Stanley JK, Trail IA. Kienböck's disease: conservative management versus radial shortening. J Bone Joint Surg Br. 2000 Aug. 82(6):820-3. [Medline].

  44. Sennwald GR, Ufenast H. Scaphocapitate arthrodesis for the treatment of Kienbock''s disease. J Hand Surg [Am]. 1995 May. 20(3):506-10. [Medline].

  45. Takase K, Imakiire A. Lunate excision, capitate osteotomy, and intercarpal arthrodesis for advanced Kienböck disease. Long-term follow-up. J Bone Joint Surg Am. 2001 Feb. 83-A(2):177-83. [Medline].

  46. Thienpont E, Mulier T, Rega F, De Smet L. Radiographic analysis of anatomical risk factors for Kienbock's disease. Acta Orthop Belg. 5/2004. 70:406-9. [Medline].

  47. Trail IA, Linscheid RL, Quenzer DE. Ulnar lengthening and radial recession procedures for Kienbock''s disease. Long-term clinical and radiographic follow-up. J Hand Surg [Br]. 1996 Apr. 21(2):169-76. [Medline].

  48. Trumble T, Glisson RR, Seaber AV. A biomechanical comparison of the methods for treating Kienbock''s disease. J Hand Surg [Am]. 1986 Jan. 11(1):88-93. [Medline].

  49. Watanabe K, Nakamura R, Imaeda T. Arthroscopic assessment of Kienbock''s disease. Arthroscopy. 1995 Jun. 11(3):257-62. [Medline].

  50. Watson HK, Guidera PM. Aetiology of Kienbock''s disease. J Hand Surg [Br]. 1997 Feb. 22(1):5-7. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.