Presentation on theme: "Total Wrist Arthroplasty"— Presentation transcript:
1Total Wrist Arthroplasty BHT-meetingCase Report:Total Wrist ArthroplastyIsabel DoomsGood morning,My case report will be about a Total Wrist Arthroplasty.
2Case presentation Male of 56 years old > 3yr wristpain Right: activity-related dorsal wrist painswelling over the radial carpal jointdecreased wrist motionpoor grip strenghtRight-handedWork : warehouseman of a building companyHobby : cycling, gardening, motorcyclingIt concerns a male of 56 years old, who had more than 3 years pain in his right wrist. His symptoms before the operation were:He is right-handed and works as a warehouseman of a building company, this means counting little plugs to carrying bags of cement (he needs a large variation in loading).During his spare time he likes cycling, gardening and motorcycling.
3Medical diagnoses '08 distal radius # R: 6wks splint '11 wrist pain R:GP: 3m rest + NSAIDRheumathologist: RX: no details'12 Orthopedic SurgeonJuly: RX + Echo: aseptic necrosis os lunatumAugust: MRI → aseptic necrosis os lunatum (IV)=> 3m rest + brace + NSAIDOctober: RX: Kienbock disease stage IV + SL-lesion=> arthrodesisIn 2008 he fall during a cycling tour and probably had a distal radius fracture. He went to his general practitioner (no X-ray was taken) and he immobilised his wrist for 6 weeks after which he started working again.In 2011 his wrist pain increased and the general practisioner gave him 3m of rest and painkillers and sended him to a rheumatologist.In july 2012 he went for the first time to the orthopedic surgeon. All the examinations concluded aseptic necrosis of the os lunate, again 3m of rest, brace and painkiller was prescibed. After this 3m and no progression in symptoms the surgeon suggested arthrodesis.
4Medical Diagnosis Dec. '12: second opinion: 1) Objective: Kienbock disease stage IV → TWA type Maestro1) Objective:TWA is an alternative to wrist arthrodesis which offers the benefit of pain relief with preservation of functional motion. (Orthopaedics&Traumatology:Surgery&Research(2011)97S,S31-S36)In dec he went for a second opinion, they suggested a TWA (they used type Maestro from Biomet)A TWA is a good alternative to wrist arthrodesis. It gives an optimal painrelief and preservation of functional motion. This was also the main objective for my patient.
5Medical Diagnosis 2) Why TWA type Maestro (Biomet)? Indications: * early: end-stage RA* recently: end-stage OA; posttraumatic arthritis; KD; SLAC/SNAC; traumaContraindications:* RA: bone loss or carpal subluxation* Infection* use of walking aids* < 50Y* unable to adhere to activity restrictionsJHS2012;37A:Why would the surgeon choose for a Maestro arthroplasty?I'm not going to give a historical overview of all kind of wrist implants but the most recent designs of implants have better conditions:The indications in early days were mainly end-range RA. Recently an expansion of indications took place such as …Contra-indications for TWA in general are infection, use of... Specific contra-indications to RA are...
6Medical Diagnosis flexioncontracture Complications: dislocation of componentsinfectionlooseningMaestro Biomet:* Radial component* Carpale componentJHS2012:37A:Complications can always occure, such as...How thus the TWA type Maestro looklike?It consists of 2 components:1 radial component which consists of a radial stem and - body adjustable to left/right and the size of the radius.1 carpal component which consists of a carpal plate with a capitate stem and 2 scews and a carpal head adjustable respectivaly in size and heights.Both components are coated with hydroxyapatite so fixation occure by ingrow in the bone.
7Medical Diagnosis 3) Surgical technique: (ref. surgical report) longitudinal capsulotomy (↑scaphoid, lunate, triquetrum)carpal and radial trial componentsa trial reduction and motion evaluation (2 to 3 mm distraction gap = ideal)implants are press-fitcarpal component fixation is augmented with screws into MCII and hamatecapsulare repair and extensor retinaculum closureimmobilisation: volar plaster splint in 30 extentionThe surgical technique in short:Dorsal longitudinal capsulotomy, resection of scaphoid-lunate-triquetrum, preparation for carpal and radial trail components. A trial reduction and motion evaluation is performed. The implants are press-fit and the carpal component fixation in capitate is augmented with 2 screws into the second MC and hamate.Ending with capsulare repair and extensor retinaculum closure.
8Medical Diagnosis 4) Postoperative management: 2,5 wks immobilisation At 3 wks: start physiotherapyNo resting splint/orthesis necessaryHis postoperative managment conserned 2,5w immobilisation.After 3w we started with physiotherapy.No resting splint was necessary
9Regaining a stable and painfree joint Patients’ aimRegaining a stable and painfree jointwith a functional ROMThe aim for the patient, as already mensioned in his choice for a wrist implant, is regaining a stable and painfree wrist with a functional ROM.
10Treatment goals 1) Controlling oedema 2) Informing and advising 3) Mobilising hand and wrist (/a/, ass/a/)4) Gradual stabilisation exercise program5) Functional trainingMy treatment goals were following:1) to controle the oedema in the fingers, thumb and hand/wrist2) to inform him for a good wristposition and to advise him in loading managment during the time.3) active, assissted active, passive mobilisations for the hand and wrist will be done4) to work out a gradual stabilisation excersise programme.5) to introduce all the above in functional training.
11Therapeutical assessment December 2012ROM Kapanji10PDPCD (cm)2,5Wrist ext/fluln/radpro/sup-12/2010/-10limited supinationGrip Strength (kgf)NAVAS7,5PRWHEComplicationsPain distoradial rad.styloid.This table gives an overvieuw of the measurments I took on the first day:Kapanji score for the thumb was 10/10.His PulpaDistalPalmarCreaseDistance was 2,5cm.His active ROM for his wrist flexion was 20 degrees, in extension he had a lag of 10 degrees, his ulnare deviation was 10 degrees while his radial deviation had a lag of 10 degrees. He had a limited endrange supination.He gave 7,5/10 on his painlevel.The measurment of his gripstrenght and the Patient Related Wrist Hand Evaluation Questionnaire were not yet applicable at this stage.From the first moment on he complained of pain in the distoradial area around the radial styloideus.
12Early mobilisation : 0-2 weeks 1) Advise: stable wrist + no heavy weight2) Coban + elevation3) Scartherapy4) AROM thumb and fingers5) (A)AROM wrist flexion and extension6) AROM elbow, shoulder and neckNo rotations!CAVE: first extensorcompartimentRemind you in my first clinical assessement that he showed an extension and radial deviation lag. I advised him to regain a neutral wrist position during unloaded simple daily activities and during rest.He used Coban during the night and held his hand elevated as much as possible.Scartherapy in the sense of massage of the scar could he do at home.AROM excersises were given for the thumb (full opposition) and the fingers (lumbrical plus, straight fist, full fist and hook fist) as well as AROM excersises for wrist flexion and extension (the last one assissted extension with the other hand, mirror principle).Keeping the hole upper limb in condition also some mobilisation excersises were given for the elbow, shoulder and neck.No rotation were allowed in sense of turning. Keep in mind he had pain in the area of the first extensorcompartiment from the beginning.
13Mobilisation : 2-6 weeks 1) (A)AROM hand, wrist and forearm 2) Stable wrist during exercises:marblesputty (ultra soft)dumbells (0,25kg and 0,5kg)terraband3) Expanding ADL-activities: writing!CAVE: radial wristpain → M. Dequervain?After the second week until week 6 the active mobility of hand, wrist and forearm will improve.In this fase we started with a gradual exercise programme whereby the wrist had to be held in a stable position.Along with these excersises I asked the patient to practise the stable wrist position during easy activities in daily life. The biggest challenge was writing, for which I gave some writing utensils and excersises for home.Still remember his radial wristpain: compression of the EPB en APL remains painfull, Finckelstein is slidely positive.
14Evaluation 6 wks post mobilisation December 2012January 2013ROM Kapanji10PDPCD (cm)2,5Wrist ext/fluln/radpro/sup-12/2010/-10limited supination21/2915/10No limitationsGrip Strength (kgf)NAVAS7,55PRWHEComplicationsPain distoradial rad.styloid.Radial wristpainM.Dequervain?The clinical assessment at 6 weeks gives us the following results:Normal thumb and finger mobility.Wristflexion improved to 29 degrees and the wristextension became 21 degrees.Also an improvement from the ulnar and radial deviation is seen which means that the his wrist position is more neutral.The rotations are normal and his VAS score decreased to 5/10.Still in this stage gripstrenght and the Patient Rated Wrist Hand Evaluation Questionnaire are not applicable.The question the surgeon was to evaluate the radial wristpain.
15Mobilisation : 6-12 weeks Affirmation M. Dequervain! CAVE: CMC1! 1) (A)AROM wrist2) TGE + stretching 1st extensorcompartiment3) Gradual strenghtening/stabilizing exercise program4) Functional training/advice : driving, cycling, gardeningCAVE: CMC1!Affirmation of Morbus Dequervain by the surgeon.We continued the mobilisation strenghtning programme taking care of the load on the thumb. I also gave some home-excersises for the APL and EPB.After 10 weeks hobby's like cycling and gardening were asked to do again: I advised him to hold his steering wheel on top of it with the thumb next to his index.But doing more and more functional activities the radial wrist pain specified more to pain around the CMC1 joint: for example weeding which askes a loaded pinchgrip became painfull.
16Evaluation 12 wks post mobilisation December 2012January 2013March 2013ROM Kapanji1010 (pain)PDPCD (cm)2,5Wrist ext/fluln/radpro/sup-12/2010/-10limited supination21/2915/10No limitations29/3919/12Grip Strength (kgf)NA16 (L:34)VAS7,555 (thumb)PRWHE23,5/100ComplicationsPain distoradial rad.styloid.Radial wristpainM.Dequervain?Thumb + Radial wristAfter 12 weeks of rehabilitation the clinical assessment was the following:A normal mobility for the thumb and fingers and again an improved in mobility for the wrist.The first gripstrenght was measured: 16 kilograms which means almost 50% of his strenght comparing with his opposite hand.At this stage I asked him to fill in the Patient Rated Wrist Hand Evaluation Questionnaire: his pain score was 12/50 and his function score was 11,5/50, in total 23,5/100 which means limited pain and disability present. The score for the aesthetic question was 5/10 meaning that the appearance of his hand was still very important.
17Mobilisation > 12 wks RX: CMC1 arthrosis → injection 1) Continuing wrist mobilisation and strenghtening2) Conservative treatment CMC1:advices: ADL, pincetonloaded ROM exerciseswrist position: ulnar deviationX-rays revealed CMC1-arthrosis and an injection was given during the consultation by the surgeon.In this stage the most important aspect is to maintain the mobility and to augment the functional use of the hand/wrist during hobby and work taking the limitations of the prothesis into account (no more than 5kilogram of load, no tennis, no stucato activities).In terms of start working again I gave him some advices and home-excersises.
18Endbilan : 4 mo post mobilisation December 2012January 2013March 2013May 2013ROM Kapanji1010 (pain)PDPCD (cm)2,5Wrist ext/fluln/radpro/sup-12/2010/-10limited supination21/2915/10No limitations29/3919/1230/3920/12Grip Strength (kgf)NA16 (L:34)25 (L:49)VAS7,555 (thumb)1 (thumbs)PRWHE23,5/10011/100ComplicationsPain distoradial rad.styloid.Radial wristpainM.Dequervain?Thumb + Radial wristCMC1arthrosisAfter 1 month of start working again, I took this measurments for his endbilan now 3 weeks ago.
19Rehabilitation TWA and literature Key words in Pubmed:TWA + exercises (5) ; stabilisation (2); ROM (0); physiotherapy (5)+ motion (113) → EBM (RA>>none RA)There is no procedure for total wrist arthroplasty known in literature.Trying different key words in combination with Total Wrist Arthroplasty, only the word “motion” gave some results. Remarkable was that all the articles consurnes of surgecal procedures and the orthopaedical treatment of Rheumathoid Arthritis comparing with the few posttraumatic problems.
20“A painless stable wrist is the key to hand function” ConclusionGood improvement and satisfaction in ROM, strenght, VAS and functionTWA = good alternative to wrist athrodesis in end-stage none RA-patients (AmJOrthop.2008;37(8suppl):12-16)“A painless stable wrist is the key to hand function”Sterling BunnellOver all the Total Wrist Arthroplasty gave my patient a good improvement and satisfaction in ROM, strenghts, painrelief and function.Total Wrist Arthroplasty is a good alternative to wrist arthrodesis even so in an end-stage none Rheumatoid Arthritis-patient.As Sterling Bunnell said: A painless stable wrist is the key to hand function
21Thoughts for the future In literature there is a lack of preoperative data for statistical comparison with none RA-patients (JHS 2012;37A: )Effect of mirror therapy and stabilisation excercises preoperative on the propriocepsis postoperative?In literature there is a lack of complete data before the operation for good statistical comparison in the group of none Rheumathoud Arthritis patients.A thought by myself: what can be the effect of mirrortherapy and stabilisation excersises before the operation on the propriocepsis after the operation?