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Pediatric and Adolescent Kienbock's Disease: A Systematic Review and Meta-Analysis
Christiane How-Volkman, MS
1; Carter D Bernal, MS
1; Kala T. Pham, BS
2; Christine Yin, MD
21California Northstate University, Elk Grove, CA; 2Baylor College of Medicine, Houston, TX
Introduction Kienbock's disease most commonly affects males between the ages of 20 to 40 years, though there have been reports in the pediatric and adolescent population. Given the rarity of this pathology, its natural history and treatment algorithms have been poorly studied. This systematic review aims to pool reported data and analyze Kienbock's disease in the pediatric population, and assess staging, development, and outcomes with regards to surgical and nonsurgical management. Materials & Methods A literature search following the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted on Pubmed, EMBASE, and Scopus databases. Retrospective and prospective studies with a minimum of 5 patients were included. Pediatric patients, defined as individuals aged 21 years and younger, were extracted from these studies. Meta-analysis was performed for homogenous reported end-points. Risk of bias was assessed through the Methodologic Index for Nonrandomized Studies (MINORS) criteria.Results The database search yielded 391 studies, of which 44 met inclusion criteria. This included 173 pediatric patients, corresponding to 178 lunates. The patients were on average 16.81 years (range: 9 to 21 years), and mostly male (65.4%). A total of 166 wrists were categorized by stage on presentation, and Lichtman stage IIIA was most common with 60 wrists (36.1%). Thirteen studies included pre-and operative radiographic staging, demonstrating maintenance of Lichtman stage in majority of cases (70.8%, 34 wrists), while 20.8% demonstrated stage progression (10 wrists), and stage improvement in 8.3% (4 wrists). Lunate silastic arthroplasty and radial shortening osteotomy were the most common surgical options. Meta-analysis revealed scaphocapitate fixation and lunate excision with silastic replacement demonstrated a significant gain in extension (g=3.82, 95% CI [1.66, 5.98], g=.95, 95% CI [.19, 1.71]), compared to other alternatives such as triscaphe arthrodesis, temporary scaphotrapezoidal fixation, and distraction osteogenesis. Furthermore, scaphocapitate fixation additionally demonstrated statistically significant improvement in flexion of the wrist compared to other reviewed options (g= 3.41, 95% CI [1.41, 5.40]). Conclusion Pediatric and adolescent patients diagnosed with Kienbock's disease commonly presented at Lichtman stage IIIA and did not demonstrate stage advancement post-operatively in most cases.
Scaphocapitate fixation significantly increases range of motion in pediatric and adolescent patients with Kienbock's disease. Future direction includes larger prospective studies and development of more comprehensive treatment algorithms.
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