This evidence-based medicine review examines three clinical questions in Kienböck's disease: how reliably can we stage it, should we operate, and which operation works best? It critically appraises the available literature and finds the evidence base is limited to uncontrolled case series for all surgical interventions. No RCTs exist comparing surgical to nonsurgical treatment or comparing surgical techniques to each other.
When a young patient presents with wrist pain and lunate sclerosis, the Lichtman stage drives every treatment decision — but the 3A/3B distinction is only reliable if you measure the radioscaphoid angle. A value above 60° is required to call it stage 3B; without applying this criterion, interobserver agreement is poor.
For stage 2 and 3A disease, initial immobilization for 6 weeks is reasonable before committing to surgery. If symptoms persist, surgical choice depends on ulnar variance: radial shortening for ulnar-negative or neutral patients, vascularized bone graft with offloading for ulnar-positive patients.
Stage 3B and 4 disease are generally addressed with salvage procedures (proximal row carpectomy or wrist fusion), though some surgeons apply disease-modifying techniques even at stage 3B.
The honest caveat from this review: every surgical recommendation rests on uncontrolled case series. Observed improvements may reflect natural disease course or placebo effect. When counseling patients, acknowledge that the evidence for any specific operation over another. Or over prolonged immobilization. Simply does not yet exist.
This evidence-based medicine review examines three clinical questions in Kienböck's disease: how reliably can we stage it, should we operate, and which operation works best? It critically appraises the available literature and finds the evidence base is limited to uncontrolled case series for all surgical interventions. No RCTs exist comparing surgical to nonsurgical treatment or comparing surgical techniques to each other.
When a young patient presents with wrist pain and lunate sclerosis, the Lichtman stage drives every treatment decision — but the 3A/3B distinction is only reliable if you measure the radioscaphoid angle. A value above 60° is required to call it stage 3B; without applying this criterion, interobserver agreement is poor.
For stage 2 and 3A disease, initial immobilization for 6 weeks is reasonable before committing to surgery. If symptoms persist, surgical choice depends on ulnar variance: radial shortening for ulnar-negative or neutral patients, vascularized bone graft with offloading for ulnar-positive patients.
Stage 3B and 4 disease are generally addressed with salvage procedures (proximal row carpectomy or wrist fusion), though some surgeons apply disease-modifying techniques even at stage 3B.
The honest caveat from this review: every surgical recommendation rests on uncontrolled case series. Observed improvements may reflect natural disease course or placebo effect. When counseling patients, acknowledge that the evidence for any specific operation over another. Or over prolonged immobilization. Simply does not yet exist.