Treatment of Stages IIIA and IIIB in Kienbock's Disease: A Systematic Review.

Despite numerous proposed surgical interventions, there is a lack of consensus in the optimal treatment of advanced Kienbock's disease.  This study aims to perform a systematic review of the current evidence in the management of Lichtman's stages IIIA and IIIB of the disease.  A literature search was performed using the MEDLINE, EMBASE, and COCHRANE databases to identify studies between 2008 and 2018 evaluating stage-specific outcomes in Lichtman's stages IIIA and IIIB. The quality of each included paper was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Data extracted were stage-specificity, clinical and functional outcomes, and radiographic progression of Lichtman's staging.  A total of 1,489 titles were identified. Eighty-three papers were fully reviewed, and 30 articles met eligibility criteria for inclusion. There were 3 low-quality and 27 moderate-quality papers. Surgical techniques reported included decompression surgeries, joint-levelling, and radial wedge osteotomies, revascularization techniques, intracarpal arthrodesis, proximal row carpectomy, arthroplasty, and balloon kyphoplasty. All treatment modalities offered pain relief and improvement in functional outcomes. Compared with proximal row carpectomy, intracarpal arthrodesis, and arthroplasty, nonsalvage procedures provided similar clinical and functional outcomes in both stages, with joint-levelling and radial wedge osteotomies preserving greater range of motion.  In this systematic review of Kienbock's disease stages IIIA and IIIB, all treatment modalities provided positive outcomes. In stage IIIB, there is evidence to support nonsalvage procedures, as they produced similar clinical outcomes to salvage procedures that have the advantage of not precluding future treatment options if needed and preserving greater range of motion.