The Management of Kienböck Disease: A Survey of the ASSH Membership

Abstract

Background?The purpose of this study was to determine the current trends and common practices for the treatment of Kienb?ck disease at different stages. Question/Purpose?To determine the current trends and common practices by hand surgeons for the treatment of Kienb?ck disease. Methods?A survey with hypothetical Kienb?ck disease cases stratified by the Lichtman staging system was distributed to the American Society for Surgery of the Hand (ASSH) members. Questions and responses reflected common treatment strategies. Results?Of a total of 375 worldwide respondents, preferred treatments of Kienb?ck disease were as follows: for Stage I disease, an initial trial of splinting was favored (74%), followed by radial shortening osteotomy for continued symptoms. For Stage II disease, 63% of surgeons preferred surgical intervention, particularly radial shortening osteotomy. For Stage IIIa with negative ulnar variance, 69% chose radial shortening osteotomy. Responses were heterogeneous for Stage IIIa Kienb?ck with positive variance, and capitate shortening osteotomy and vascularized bone grafting were preferred. Salvage procedures predominated for Stage IIIb disease, including proximal row carpectomy (PRC; 42%), intracarpal arthrodesis (21%), and total wrist fusion (10.7%). Similarly, Stage IV disease was treated by 87% of respondents by either PRC or wrist fusion. Without regard to stage of disease, 90% of participants reported using the same Lichtman staging to guide treatment and would also alter treatment strategy based upon ulnar variance. Conclusions?Most respondents used Lichtman staging and ulnar variance to guide treatment decisions. Results indicate that the most common surgical treatments were radial shortening osteotomy for early disease and PRC in later stages. Level of Evidence?Level IV, Economic/Decision Analysis

Treatment of Advanced Kienbock's Disease (Lichtman Stage IIIB with Carpal Collapse) by a Shortening Osteotomy of the Radius: 21 Cases

“…25 Finally, any carpal surgery can be added to an eventually failed radial shortening osteotomy. 41 As a conclusion, radial shortening osteotomy should not be contraindicated in advanced Kienbock's disease (without radiocarpal osteoarthritis), as stated, 2,5,15,26 because it achieves long-lasting good clinical results, with very few complications.…”

“…37,38 Radial osteotomies lessen wrist pain and improve wrist mobility, and are probably more effective in increasing grip strength. 38 These are the main reasons to avoid primary aggressive carpal surgery, such as carpal arthrodesis, proximal carpectomy, 15,39 and others, 40 in Kienbock's disease, even in cases with carpal collapse (Lichtman stage IIIB) or lunate fragmentation. 25 Finally, any carpal surgery can be added to an eventually failed radial shortening osteotomy.…”

“…If there is significant synovitis, then the lunate should be excised as well." 2 This became a dogma for most hand surgeons 15 despite the good clinical results published by many authors with radial osteotomies in advanced Kienbock's disease. [16][17][18][19][20][21][22][23]…”

Kienbck's disease mimicing gouty monoarthritis of the wrist

“…The secondary effects of the collapsing lunate are 'compromised' wrists including deformity and collapse of the central column, degeneration of the perilunate articulations, proximal row instability, and degeneration of the radial column [5]. For surgical treatment of stage IIIB, the preferred procedures are proximal row carpectomy with a portion ranging from 42-62%, followed by intercarpal fusions with a portion ranging from 11-19%, total wrist fusion with a portion ranging from 2-16%, radial shortening osteotomy with a portion of 12%, vascularized bone grafting with a portion of 6%, trial of splinting with a portion of 4%, and lunate arthroplasty with a portion of 1% [7,8]. An option for surgical treatment of stage IIIA (lunate collapse without scaphoid rotation) is callotasis lengthening of the capitate bone [9].…”

Radial Shortening Osteotomy for Symptomatic Kienböck's Disease: Complications and Long-Term Patient-Reported Outcome

“…The choice of surgery for symptomatic Kienböck's disease depends mainly on radiographic factors such as disease stage 1 and ulna variance, 2 as well as patient and surgeon preference. 3,4 Radial shortening osteotomy is a widely accepted procedure for Kienböck's disease without secondary changes in carpal alignment or radiocarpal osteoarthritis (e.g., stage 2 and 3A according to the Lichtman classification) and negative or neutral ulna variance. 5 Radial shortening osteotomy levels the distal surfaces of the radius and ulna, redistributes the axial load across the carpus, and subsequently decreases mechanical pressure on the lunate.…”