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The purpose of this prospective study was to evaluate pain levels, range of motion, patient activity and satisfaction after radioscapholunate (RSL) arthrodesis. This was in association with distal scaphoid excision and complete resection of the triquetrum. The non-union rate for radioscapholunate arthrodesis was examined and the results compared with previous studies.

Twenty-three patients (14 males and nine females) with an average age of 47 (range 26–73) years underwent RSL fusion for post-traumatic osteoarthritis, rheumatoid arthritis and Kienböck's disease of the lunate with a mean follow-up of 32 (range 13–70) months. The absolute prerequisite for any of these groups of patients was a functional midcarpal joint which was assessed pre-operatively with radiographs and intra-operatively prior to RSL fusion.

The average flexion to extension motion changed from 66° to 57°. The ulnoradial range of motion also increased to 43° from a pre-operative value of 22°. The patients visual analogue pain scores reduced from an average of 64 to 28 (p = 0.01). Nineteen patients had no restriction in activity and all but one was satisfied with the outcome. All patients remained in full time employment with ten returning to some form of sport.

RSL fusion with excision of the distal pole of the scaphoid and the entire triquetrum led to minimal reduction in the flexion-extension arc of motion and an increase in the ulnoradial arc. There was also good pain relief and maintenance of a patient's function. Memory staples are also an effective method of securing fusion in the wrist obtaining similar results to that seen in forefoot surgery.

Although capitate shortening for Kienbock's disease decompresses the radiolunate joint, the distal carpal row migrates proximally postoperatively and the carpal alignment subsequently collapses. We hypothesised that partial capitate shortening, in which only the lunate facet of the capitate is shortened and the scaphocapitate joint is preserved, could achieve adequate decompression without carpal collapse. Using 11 cadavers, we measured the intra-articular pressure with an axial load on the radioscaphoid, radiolunate and ulnocarpal joints before and after resection. We also investigated whether the decompression effect is related to the presence of the lunohamate articulation. After resection, the radioscaphoid joint mean pressure was significantly increased by an average of 39%, the radiolunate joint mean pressure was significantly decreased by an average of 53% and the ulnocarpal joint mean pressure was unchanged. The radiolunate joint mean pressure significantly decreased irrespective of the lunohamate articulation status.

Simultaneous avascular necrosis of multiple carpal bones is rare. Concomitant avascular necrosis of scaphoid and lunate has been reported only once. We report one more case of this rare condition which can be a cause of wrist pain. Steroid intake is a known risk factor for avascular necrosis but in our case the patient had been taking herbal medicines for joint pain the composition of which was not known. Probably the presence of steroid in these medicines was the cause of avascular necrosis in this case.

Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients’ with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock’s disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.