BHT-meeting 25-05-2013

Case Report:

Total Wrist Arthroplasty

Isabel Dooms

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

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

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)

Medical Diagnosis2) 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:1580-84

Medical DiagnosisComplications:

flexioncontracture dislocation of components infection loosening

Maestro Biomet:

* Radial component

* Carpale component JHS2012:37A:1580-84

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

Medical Diagnosis

4) Postoperative management:

2,5 wks immobilisation

At 3 wks: start physiotherapy

No resting splint/orthesis necessary

Patients’ aim

Regaining a stable and painfree joint

with a functional ROM

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

Therapeutical assessment

December 2012

ROM Kapanji 10

PDPCD (cm) 2,5

Wrist ext/fl uln/rad pro/sup

-12/2010/-10limited supination

Grip Strength (kgf) NA

VAS 7,5

PRWHE NA

Complications Pain distoradial rad.styloid.

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

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?

Evaluation 6 wks post mobilisation

December 2012 January 2013

ROM Kapanji 10 10

PDPCD (cm) 2,5 0

Wrist ext/fl uln/rad pro/sup

-12/2010/-10limited supination

21/2915/10No limitations

Grip Strength (kgf) NA NA

VAS 7,5 5

PRWHE NA NA

Complications Pain distoradial rad.styloid.

Radial wristpainM.Dequervain?

Mobilisation : 6-12 weeks

Affirmation M. Dequervain!

1) (A)AROM wrist

2) TGE + stretching 1st extensorcompartiment

3) Gradual strenghtening/stabilizing exercise program

4) Functional training/advice : driving, cycling, gardening

CAVE: CMC1!

Evaluation 12 wks post mobilisation

December 2012 January 2013 March 2013

ROM Kapanji 10 10 10 (pain)

PDPCD (cm) 2,5 0 0

Wrist ext/fl uln/rad pro/sup

-12/2010/-10limited supination

21/2915/10No limitations

29/3919/12No limitations

Grip Strength (kgf) NA NA 16 (L:34)

VAS 7,5 5 5 (thumb)

PRWHE NA NA 23,5/100

Complications Pain distoradial rad.styloid.

Radial wristpainM.Dequervain?

Thumb + Radial wrist

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

Endbilan : 4 mo post mobilisation

December 2012 January 2013 March 2013 May 2013

ROM Kapanji 10 10 10 (pain) 10

PDPCD (cm) 2,5 0 0 0

Wrist ext/fl uln/rad pro/sup

-12/2010/-10limited supination

21/2915/10No limitations

29/3919/12No limitations

30/3920/12No limitations

Grip Strength (kgf) NA NA 16 (L:34) 25 (L:49)

VAS 7,5 5 5 (thumb) 1 (thumbs)

PRWHE NA NA 23,5/100 11/100

Complications Pain distoradial rad.styloid.

Radial wristpainM.Dequervain?

Thumb + Radial wrist

CMC1arthrosis

Rehabilitation TWA and literature

Key words in Pubmed:

TWA + exercises (5) ; stabilisation (2); ROM (0); physiotherapy (5)

+ motion (113) → EBM (RA>>none RA)

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

Thoughts for the future

• In literature there is a lack of preoperative data for statistical comparison with none RA-patients (JHS 2012;37A:1580-84)

• Effect of mirror therapy and stabilisation excercises preoperative on the propriocepsis postoperative?