Revascularizing the Lunate: Modern Perspectives on Vascularized Bone Grafting in Kienböck's Disease

Kienböck's disease is a progressive condition characterized by avascular necrosis of the lunate, leading to carpal collapse, chronic pain, and functional impairment if left untreated. Management remains challenging due to variability in disease presentation and the absence of standardized treatment algorithms, particularly regarding surgical options. Among these, vascularized bone grafts (VBGs) have gained increasing attention for their ability to restore blood supply, promote osteogenesis, and preserve carpal architecture. This review provides a comprehensive synthesis of the anatomical basis, indications, surgical techniques, and clinical outcomes of pedicled versus free VBGs in the management of Kienböck's disease. Pedicled grafts, commonly harvested from the distal radius or adjacent carpal structures, maintain their native vascular supply and offer a technically less demanding option with lower morbidity, making them suitable for early to mid-stage disease (Lichtman II-IIIA). In contrast, free vascularized grafts, such as those from the iliac crest or lateral femoral condyle, require microsurgical anastomosis but provide greater structural support and flexibility, particularly in advanced stages or revision cases. Clinical evidence from predominantly retrospective studies suggests that both techniques yield significant improvements in pain, grip strength, and functional outcomes, with variable radiographic progression. However, the literature is limited by small sample sizes, heterogeneity in study design, and lack of direct comparative trials. As a result, no clear consensus exists regarding the superiority of one technique over the other. Current decision-making is largely guided by disease stage, anatomical considerations, and surgical expertise. Further high-quality, prospective comparative studies are needed to establish evidence-based guidelines and optimize treatment strategies for patients with Kienböck's disease.