Staging and its use in the determination of treatment modalities for Kienböck's disease.

For more than 80 years, surgeons have staged an unsuccessful search for a universally acceptable treatment for Kienböck's disease. It is our contention that no single treatment will be universally successful. Treatment choice must be based on a number of variables, including the experience of the surgeon, the desires and activity level of the patient, the anatomic variation of the ulna, and most importantly, on the stage of the disease. In the early stages, efforts should be made to salvage the lunate and prevent loss of normal architecture. In the later stages, efforts should be made to restore that architecture. In end stage, normal architecture must be sacrificed to restore function. Currently we recommend immobilization with possible equalization procedures for patients with ulnar-minus variance and stage I disease. In a patient with stage I disease and ulnar-positive variance, we recommend immobilization with consideration for a revascularization procedure. For stages II or IIIA disease with ulnar-minus variance, we attempt an equalization procedure. For stages II or IIIA disease with ulnar-positive variance, we recommend revascularization as performed by Hori. In stage IIIB disease, we prefer a triscaphe fusion to restore carpal stability and prevent further degeneration. In stage IV disease, proximal row carpectomy or wrist arthrodesis is indicated.