Table 1. Amalgamation of the osseous, vascular, and cartilage classification systems for the assessment and treatment of Kienböck disease.

Assessment				Treatment
Osseous (Lichtman)	Vascular (Schmitt)	Cartilage (Bain)	Description	Principle	Procedure
B1: Lunate intact				Lunate protection
0, I, II	A	0	Intact lunate	Unload lunate Venous decompression Revascularization	Immobilize, unloading procedures Lunate decompression Vascularized bone grafta
B2: Lunate compromised				Lunate reconstruction
IIIA	B	1	Proximal lunate collapse	Lunate reconstruction	MFTGa, PRC, (RSL fusion, lunate replacementa)
B3: Lunate unreconstructable				Lunate salvage
IIIC	C	2b	Lunate collapse	Lunate excision	Lunate replacementa, capitate lengthening, PRC
C1–3: Wrist compromised				Wrist reconstruction
IIIA	B	2a	RC joint compromised	Fuse or bypass RL joint	RSL fusiona, SC fusion
IIIA or C	B	3, 4	RC and MC joint compromised	Bypass central column	SC fusion, hemiarthroplastya
IIB	B	2–4	Carpal collapse, (RSA > 60 degrees)	Stabilize radial column	SC fusion
C4: Wrist not reconstructable				Wrist salvage
IV, KDAC	C	4	Pan–OA	Salvage	Wrist fusion, wrist arthroplastya

Abbreviations: KDAC, Kienböck disease advanced collapse; MC, midcarpal; MFTG, medial femoral trochlear graft; Pan–OA, pan carpal osteoarthritis; PRC, proximal row carpectomy; RC, radiocarpal; RL, radiolunate; RSA, radioscaphoid angle; RSL, radioscapholunate; SC, scaphocapitate.

Source: Lichtman et al.⁴³

Notes: Better prognosis: Age < 15 years nonoperative, 16–20 years consider unloading, > 70 years consider synovectomy or unloading procedure. Lunate unloading procedures: Negative ulnar variance: Radial shortening osteotomy; physis intact: Radial epiphysiodesis; neutral or positive ulnar variance: Capitate shortening. Adjunctive procedures: Synovectomy, scaphotrapeziotrapezoid pinning.

^aAlternative procedures: Used in specialist clinics or in selected cases where the patient has failed less-invasive procedures.