No Surgical Treatment Best for Kienbock's DiseaseKienbock's disease is a disease that prevents the blood flow to a small bone in the hand, the lunate. Kienbock's disease was identified in 1910, but doctors and researchers don't understand yet what actually causes the disease, although there are suggestions that it is the result of trauma or of systemic causes. Because the cause of Kienbock's disease isn't understood, treatment isn't always effective and no-one treatment seems to be better than another. Presently, treatment is aimed at reducing pain, improving function in the hand, and limiting the disease progression.
Usually, conservative, or nonsurgical, treatment is tried first, when a patient develops the disease. This could mean immobilizing the wrist with a brace for up to three months. However, a surgical procedure called vascularized bone grafting has been developed to fix the actual area injured by the disease, which doctors may feel is a better option. Other surgeries include joint-leveling, partial wrist athrodesis (fusing the bone), proximal row carpectomy (removal of some of the bone), and total wrist athrodesis, although the last two procedures are reserved for late-stage Kienbock's disease. The authors of this study compared pain, motion, grip strength, and x-rays after various treatments for Kienbock's disease to see validate the theory that there is no one treatment that is better than another.
Researchers reviewed studies that had been done testing the various types of treatments and available procedures. They were able to find 37 articles that fit their criteria of patient-reported subjective outcomes and follow-up of at least 12 months. Sixteen studies followed patients who had early-stage disease and the remaining 25 for late-stage disease.They add up to more than 37, because some articles included both early and late stages.
The articles identified the stages of Kienbock's disease as Lichtman stage I, II, and IIIa. These were the early stages. The later stages were identified as Lichtman stage IIIb and IV.
Surgical procedures used in the studies for early-stage included:
- vascularized bone grafting
- metaphyseal core decompression
- radial osteotomy.
For later-stage, surgical procedures included those just listed plus:
- partial arthrodesis
- proximal row carpectomy
- tendon or muscle ball arthroplasty (replacement)
Some late-stage patients were also treated non-surgically, but this was not so in the early-stage group.
The various studies measured patient-reported outcomes differently. The ultimate goal is to find out the patients' response to pain, range of motion, grip strength, and carpal height index.
When the researchers interpreted the data, they found there was no significant differences in how the patients in all studies felt after their procedures when reporting pain levels. Objectively, when the patients were seen by their individual study researchers, the reports say that the patients had significant improvements in their range of motion and grip strength if they had undergone a radial osteotomy or a vascularized bone grafting (for early-stage disease) and in all procedures except for partial arthrodesis and non-surgical patients for the late-stage groups. For the late-stage disease, only patients who had non-surgical treatments did not increase in grip strength.
Once the data were analyzed, the researchers came to the conclusion and agreed with the thought that there is no superior surgical procedure to treat either early-stage or late-stage Kienbock's disease.
Lindsay Innes, BS, and Robert J. Scrauch, MD. Systematic Review of the Treatment of KienbÃ¶ckâs Disease in Its Early and Late Stages. In The Journal of Hand Surgery. May 2010. Vol. 35. No. 5. Pp. 713-718.
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