Commentary: Terms That Accurately Reflect Current Best Evidence

Abstract

NSTEAD OF BOLSTERING OUR confidence, systematic reviews and meta-analyses often demonstrate the limited scientific basis for many of our treatments. With respect to Kienbock’s disease (idiopathic osteonecrosis of the lunate), the science is poor, largely because the disease is uncommon and therefore difficult to study. The more limited the science, the more likely that our understanding of the disease will change as we perform more experiments. The etiology and pathophysiology of Kienbock’s disease and our ability to modify its course are open to debate. We do not know when or how the disease arrests, but we do know that the natural history is not inevitable progressive collapse and arthritis. With or without treatment, the disease often stops at one of the lower Lichtman stages. In a specific patient, we have no way of knowing when the disease started and whether or not it will progress. We meet patients with currently or previously asymptomatic Kienbock’s, so one should not assume that the disease started at the onset of symptoms. To gauge the importance of these considerations, consider the possibility that we might sometimes perform unnecessary surgery to try to modify the course of Kienbock’s that has already resolved or arrested. Because we currently cannot know the evolution of Kienbock’s disease in specific patients, I think it is time to reconsider the concepts of early and late stages of the illness as used by the authors. 1 I contend that we should judge our treatments according to their goals: to modify the course of mild or moderate disease or to salvage advanced disease. The term early implies that, if the disease does not progress, our intervention should get the credit—an assumption that goes beyond current best evidence. To learn more about Kienbock’s disease, we need to perform experiments that compare the ability of different treatments to modify the course of the disease or to relieve symptoms (palliate)—uncontrolled case series leave us with too many questions. As the authors of this systematic review confirmed, whether considered according to an early/late or disease modifying/salvage paradigm, we have yet to establish that our treatments make a meaningful difference in the course of Kienbock’s disease.