Surgical management of Kienböck's disease with non-negative ulnar variance: A systematic review

Kienböck's disease is a complex disorder characterized by avascular necrosis of the lunate, influenced by variations in vascular anatomy and abnormal carpal loading. Management remains challenging, particularly in patients with neutral or positive ulnar variance, where standard radial shortening is biomechanically inappropriate. The present systematic review evaluates reported surgical strategies for Kienböck's disease in this population, comparing isolated capitate shortening osteotomy with combined intracarpal procedures and exploring the adjunctive role of vascularized bone grafting.

A systematic review was conducted according to PRISMA guidelines. Electronic databases (PubMed, Cochrane Library and Google Scholar) were searched using predefined keywords related to Kienböck's disease and ulnar variance. Owing to heterogeneity of study design and outcome measures, quantitative pooling was not feasible; data were synthesized descriptively. Extracted variables included patient demographics, surgical technique, disease stage, functional and radiological outcomes, and complications.

Thirteen studies involving 293 patients met the inclusion criteria. The majority were Level IV case series reflecting the rarity of this clinical entity. Isolated capitate shortening osteotomy, performed in 125 patients, demonstrated favorable pain relief and functional improvement, with persistent pain and revision rates of 10.4% and 5.6% respectively. Radial wedge osteotomy yielded mixed results, while isolated core decompression provided short-term benefit in limited cases. Combined decompression and revascularization procedures appeared most beneficial in stage IIIA disease, although comparative evidence remains inconsistent.

The evidence base for managing Kienböck's disease in non-ulnar-negative wrists is limited and heterogeneous. Isolated capitate shortening osteotomy appears to offer reliable symptomatic relief in early and mid-stage disease, whereas combined approaches may be considered in selected advanced cases. These conclusions should be interpreted cautiously given the predominance of low-level evidence. Further multicenter prospective studies are needed to clarify optimal surgical strategies and refine stage-specific treatment algorithms.