Abstract
Numerous surgical techniques have been proposed and described in the treatment of Kienbock's disease. The objective of this systematic review was to assess the current evidence and trends in the management of Lichtman Stages IIIA and IIIB.
We performed a literature search using the Medline, Embase, and Cochrane databases to identify studies evaluating treatment outcomes in Stages IIIA and IIIB of Lichtman's Classification. We included studies between 2008 and 2018, and studies with Sackett levels one to four inclusively. We excluded studies that included skeletally immature patients, non-English papers, other hand diseases, and those without evidence of significance testing. We evaluated the quality of each included study using the Structured Effectiveness Quality Evaluation Scale (SEQES) and our outcomes of interest included Pain, ROM, Grip Strength, and Functionality.
We identified 1489 titles from the various databases. 83 papers remained after the subtraction of duplicates and abstract review. Following full-text review of the remaining 83 papers, 43 more studies were excluded and 40 papers met the criteria for SEQES assessment. There were six low-quality papers and 34 moderate-quality papers. Meta-analysis was not possible due to the variability in how outcomes were reported. A variety of surgical options were presented including decompressions, joint-levelling procedures, revascularization techniques, fusions, arthroplasty and novel combinations of these techniques. These were mainly retrospective and/or cohort studies. Most of these papers had small sample sizes and required further studies. Nonetheless, all of these treatment modalities were shown to offer pain relief and some degree of return of function ranging from minimal improvement to return to normal daily functions.
This systematic review has revealed a significant weakness in the literature and a lack of strong evidence in the treatment of Stages IIIA and IIIB of Kienbock's disease. The unknown etiology of this disease and its rarity make it very difficult to produce randomized controlled trials and appropriately-sized studies. As such, there is currently insufficient data to determine a superior treatment modality from another. Furthermore, the fact that most, if not all, surgical interventions produced positive results may also be a consequence of publication bias.
