Kienböck's Disease - A Case Report: Treatment of Two Advanced Cases.

Introduction: Kienböck's disease is a rare and progressive osteonecrotic condition of the lunate that, in the absence of appropriate management, can result in irreversible structural deterioration of the wrist, collapse of the carpal architecture, and secondary osteoarthritis. Despite the existence of multiple therapeutic approaches, a standardized, evidence-based treatment algorithm has yet to be established. Treatment strategies are primarily determined by the salvageability of the lunate, which is classically considered viable when it preserves both its morphological integrity and structural continuity, in conjunction with a maintained carpal alignment. Several classification systems have been proposed that evaluate bone integrity, chondral damage, and lunate vascularity. In this context, Lichtman stage IIIc is defined by the presence of a coronal fracture of the lunate. This is a case report that documents the feasibility and structural healing in two carefully selected Lichtman IIIc Kienböck's cases with preserved carpal alignment, which benefited from a more conservative surgical strategy. Case Report: Two female patients, aged 42 and 47 years, with a history of chronic wrist pain, presented advanced Kienböck's disease - Lichtman IIIc lesions, with acceptable carpal alignment and integrity of the shape of the lunate. Both cases were successfully treated using lunate osteosynthesis combined with medial closing wedge osteotomy of the radius, demonstrating the potential efficacy of this approach in selected patients. Conclusion: In the advanced stages of Kienböck's disease, when the lunate or the carpal architecture is compromised, palliative surgical interventions such as proximal row carpectomy or partial or total wrist arthrodesis are generally preferred. Through the presentation of these two advanced cases, we aim to highlight the possibility of adopting a conservative surgical approach to the lunate, provided that its morphology and the carpal architecture remain preserved. Within the limits of a case report, a lunate-preserving strategy - lunate osteosynthesis combined with medial closing wedge osteotomy of the radius - achieved computed tomography-confirmed union and acceptable early functional recovery in two selected Lichtman IIIc cases. Robust conclusions about durability and comparative benefit over established palliative procedures will require larger, prospective studies with longer follow-up.