Traditionally, surgical decision-making in patients with Kienbock’s disease (KD) was based on the radiographic classification of Lichtman [1]. This allowed a rational, algorithmic approach to a complex disease of uncertain etiology. Advances in imaging and arthroscopy in the last 40 years have improved our understanding of the disease, however. The senior author published his arthroscopic classification of the disease in 2006 [2], identifying the spectrum of chondral changes that occur in the lunate and wrist with evolution of the disease. Surgical decision-making for KD involves four biological factors: the osseous, vascular, chondral, and ligamentous status of the lunate and wrist. Osseous factors include morphology of the lunate and wrist, fracture types, and extent of lunate collapse and are best evaluated with radiographs and fine-slice computed tomography (CT) scan [3]. Vascular perfusion magnetic resonance imaging (MRI) study with gadolinium contrast allows assessment of the viability within the “zones” of the lunate [4]. Arthroscopy is the gold standard for the assessment of the chondral surfaces and allows evaluation of the perilunate interosseous ligaments and synovium [2, 5–8].