Systematic Review of the Treatment of Kienbock's Disease in Its Early and Late Stages

Purpose To perform a systematic review of the treatment of Kienbock's disease to test the hypothesis that none of the reported treatments for Kienbock's disease is superior with respect to outcomes of pain, motion, grip strength, and radiographic measures. Methods We searched PubMed, Medline, and the Cochrane Review for articles published between 1998 and 2008 reporting outcomes of treatment for Kienbock's disease. Patients were grouped by stage of disease. Early stages were defined as Lichtman stage I, II, and IIIa, and 'late' stages as IIIb and IV. The groups were then analyzed on the basis of treatment; procedures performed on subjects in the early group included vascularized bone grafting (VBG), metaphyseal core decompression, and radial osteotomy, whereas the procedures performed on subjects in the late group included VBG, radial osteotomy, partial arthrodesis, proximal row carpectomy, tendon ball arthroplasty, and nonsurgical treatment. Results We found no statistically significant difference between any of the treatment groups for subjective pain outcomes. In terms of objective measures, statistically significant improvement (p<.05) was seen in range of motion after radial osteotomy and VBG in early-stage patients and after all interventions, except partial arthrodesis and nonsurgical treatment, for late-stage patients. Grip strength was significantly improved in early-stage patients after radial osteotomy and VBG and for all late-stage patients, except among those managed nonsurgically. Changes in Stahl and carpal height index scores were not statistically significant regardless of intervention, except after radial osteotomy in the early group, where they statistically worsened. Conclusions Based on retrospective data from uncontrolled studies, no active treatment is superior in the treatment of Kienbock's disease and there are insufficient data to determine whether the outcomes of any intervention are superior to placebo or the natural history of the disease. (J Hand Surg 2010; 35A:713-717. (C) 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)