Conservative treatment for Kienbock's disease is probably ineffective. Mikkelsen (1987) found that only 6 of 25 patients has no pain after an average of 8 years, and 7 were forced to change occupations.
Person (1945) classically described ulnar lengthening in Kienbock's disease, after Hulten's observation of the ulna-minus variant. Radial shortening is also performed, and has the advantage of not requiring a bone graft.
Both procedures (often referred to as joint leveling procedures) unload the lunate by distributing the force to the ulnar head and triangular fibrocartilage. Success of these procedures is widely documented (Weiss 1991, Sundberg 1984, Kinnard 1983, Rock 1991, Armistead 1982), and relief of pain routinely occurs in approximately 90%, with improvement in range of motion and strength. The primary complication of ulnar lengthening is non-union (15% in Armistead's study). Excessive radial shortening is the primary complication in the radial shortening procedure, according to Nakamura (1990), this occurs if the radius is shortened > 4mm, and results in ulnar wrist pain. All authors warn that in late stages of Kienbock's disease, especially with carpal arthritis, joint leveling procedures may not be effective at relieving pain and a salvage procedure may be more appropriate
Other methods of decompressing the lunate include scaphotrapeziotrapezoidal (STT) fusion, capitohamate fusion, scaphocapitate fusion and capitate recession. Biomechanical studies indicate that decompression is greatest with a joint leveling procedure, and that STT and SC fusions are more effective that capitohammate fusion (Trumble 1986, Horii, 1990). Short (1992) demonstrated that STT fusion is more effective in unloading the lunate if the scaphoid is fused in neutral or slight extension. Watson (1985) and Voche (1992) have both demonstrated good symptomatic relief with STT fusion.
Proximal row carpectomy has been used with limited success in Kienbock's disease (Inoue 1990, Ferlic 1991). Lunate excision is the oldest treatment for Kienbock's disease, and although carpal collapse occurs, the patients have good relief from pain and reasonably good function (Kawai 1988). More recently this void is being filled with a coiled tendon (anchovi) or silicone implant. Results of this procedure are not well established (Kato 1986, Ishiguro 1984).
Radial wedge osteotomy (Nakamura 1991) demonstrated satisfactory results, with good relief of pain and increase in range of motion and strenqth.
Although early success was demonstrated with silicone replacement arthroplasty (SRA) (Lichtman 1977), silicone synovitis and carpal collapse in a high percentage of long term follow-up patients make this choice less appealing (Alexander 1990, Evans 1986, O'Flanagan 1992).
http://www.ccf.org/pc/ortho/kienbock.htm
Lunatomalacia: Neutral variance. Medial closing or lateral opening radial wedge osteotomy is considered; Early disease with a negative ulnar variance, radial shortening or ulnar lengthening is considered. Each of these procedures unloads the lunate fossa and redistributes load to the scaphoid;
Radial Shortening: Indicated in early disease w/ negative ulnar variance; unloads lunate fossa & redistributes load to scaphoid fossa; distance of only 2 mm is optimal length to cause a reduced load across the lunate. Larger changes do not reduce compression but may lead to impingement of distal radioulnar joint or distal ulna w/ carpus
Ulnar Lengthening: Indicated in early disease w/ negative ulnar variance;
Casting: Immobilization relieves symptoms, but the revascularization of lunate does not readily occur in adults, and a decrease in range of motion in wrist and grip strength gradually occurs.
Lunate Excision: Excision of lunate will initially produce good results, but later, the rest of the carpal bones migrate, leading to joint incongruity, limited wrist motion and grip strength, and degenerative osteoarthritis; removal of lunate has been advocated for > 40 years, but it is not currently very popular; migration of capitate into defect, w/ subsequent disarrangement of the remaining carpal bones, is common
STT fusion: This is slightly less effective in reducing the load across the lunate w/ progressive ulnar deviation of the wrist; STT fusion and scaphocapitate fusion unloads the lunate and transfers load to the scaphoid fossa
Capitate-hamate Fusion: Indicated in persons who use their hands for heavy labor, have severe degenerative changes, or fail to improve following other surgical procedures.