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BHT-meeting 25-05-2013 Case Report: Total Wrist Arthroplasty Isabel Dooms.

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Presentation on theme: "BHT-meeting 25-05-2013 Case Report: Total Wrist Arthroplasty Isabel Dooms."— Presentation transcript:

1 BHT-meeting Case Report: Total Wrist Arthroplasty Isabel Dooms

2 Case presentation Male of 56 years old > 3yr wristpain Right: activity-related dorsal wrist pain swelling over the radial carpal joint decreased wrist motion poor grip strenght Right-handed Work : warehouseman of a building company Hobby : cycling, gardening, motorcycling

3 Medical diagnoses '08 distal radius # R: 6wks splint '11 wrist pain R: GP: 3m rest + NSAID Rheumathologist: RX: no details '12 Orthopedic Surgeon July: RX + Echo: aseptic necrosis os lunatum August: MRI aseptic necrosis os lunatum (IV) => 3m rest + brace + NSAID October: RX: Kienbock disease stage IV + SL-lesion => arthrodesis

4 Medical Diagnosis Dec. '12: second opinion: Kienbock disease stage IV TWA type Maestro 1) 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)

5 Medical Diagnosis 2) Why TWA type Maestro (Biomet)? Indications: * early: end-stage RA * recently: end-stage OA; posttraumatic arthritis; KD; SLAC/SNAC; trauma Contraindications: * RA: bone loss or carpal subluxation * Infection * use of walking aids * < 50Y * unable to adhere to activity restrictions JHS2012;37A:

6 Medical Diagnosis Complications: flexioncontracture dislocation of components infection loosening Maestro Biomet: * Radial component * Carpale component JHS2012:37A:

7 Medical Diagnosis 3) Surgical technique: (ref. surgical report) longitudinal capsulotomy (scaphoid, lunate, triquetrum) carpal and radial trial components a trial reduction and motion evaluation (2 to 3 mm distraction gap = ideal) implants are press-fit carpal component fixation is augmented with screws into MCII and hamate capsulare repair and extensor retinaculum closure immobilisation: volar plaster splint in 30 extention

8 Medical Diagnosis 4) Postoperative management: 2,5 wks immobilisation At 3 wks: start physiotherapy No resting splint/orthesis necessary

9 Patients aim Regaining a stable and painfree joint with a functional ROM

10 Treatment goals 1) Controlling oedema 2) Informing and advising 3) Mobilising hand and wrist (/a/, ass/a/) 4) Gradual stabilisation exercise program 5) Functional training

11 Therapeutical assessment December 2012 ROM Kapanji10 PDPCD (cm)2,5 Wrist ext/fl uln/rad pro/sup -12/20 10/-10 limited supination Grip Strength (kgf)NA VAS7,5 PRWHENA Complications Pain distoradial rad.styloid.

12 Early mobilisation : 0-2 weeks 1) Advise: stable wrist + no heavy weight 2) Coban + elevation 3) Scartherapy 4) AROM thumb and fingers 5) (A)AROM wrist flexion and extension 6) AROM elbow, shoulder and neck No rotations! CAVE: first extensorcompartiment

13 Mobilisation : 2-6 weeks 1) (A)AROM hand, wrist and forearm 2) Stable wrist during exercises: marbles putty (ultra soft) dumbells (0,25kg and 0,5kg) terraband 3) Expanding ADL-activities: writing! CAVE: radial wristpain M. Dequervain?

14 Evaluation 6 wks post mobilisation December 2012January 2013 ROM Kapanji10 PDPCD (cm)2,50 Wrist ext/fl uln/rad pro/sup -12/20 10/-10 limited supination 21/29 15/10 No limitations Grip Strength (kgf)NA VAS7,55 PRWHENA Complications Pain distoradial rad.styloid. Radial wristpain M.Dequervain?

15 Mobilisation : 6-12 weeks Affirmation M. Dequervain! 1) (A)AROM wrist 2) TGE + stretching 1 st extensorcompartiment 3) Gradual strenghtening/stabilizing exercise program 4) Functional training/advice : driving, cycling, gardening CAVE: CMC1!

16 Evaluation 12 wks post mobilisation December 2012January 2013March 2013 ROM Kapanji10 10 (pain) PDPCD (cm)2,500 Wrist ext/fl uln/rad pro/sup -12/20 10/-10 limited supination 21/29 15/10 No limitations 29/39 19/12 No limitations Grip Strength (kgf)NA 16 (L:34) VAS7,555 (thumb) PRWHENA 23,5/100 Complications Pain distoradial rad.styloid. Radial wristpain M.Dequervain? Thumb + Radial wrist

17 Mobilisation > 12 wks RX: CMC1 arthrosis injection 1) Continuing wrist mobilisation and strenghtening 2) Conservative treatment CMC1: advices: ADL, pincet onloaded ROM exercises wrist position: ulnar deviation

18 Endbilan : 4 mo post mobilisation December 2012January 2013March 2013May 2013 ROM Kapanji10 10 (pain) 10 PDPCD (cm)2,500 0 Wrist ext/fl uln/rad pro/sup -12/20 10/-10 limited supination 21/29 15/10 No limitations 29/39 19/12 No limitations 30/39 20/12 No limitations Grip Strength (kgf)NA 16 (L:34) 25 (L:49) VAS7,555 (thumb) 1 (thumbs) PRWHENA 23,5/100 11/100 Complications Pain distoradial rad.styloid. Radial wristpain M.Dequervain? Thumb + Radial wrist CMC1 arthrosis

19 Rehabilitation TWA and literature Key words in Pubmed: TWA + exercises (5) ; stabilisation (2); ROM (0); physiotherapy (5) + motion (113) EBM (RA>>none RA)

20 Conclusion Good improvement and satisfaction in ROM, strenght, VAS and function TWA = 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 Bunnell

21 Thoughts 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?

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