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BHT-meeting 25-05-2013

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

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BHT-meeting 25-05-2013

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  1. BHT-meeting 25-05-2013 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:1580-84

  6. Medical Diagnosis • Complications: • flexioncontracture • dislocation of components • infection • loosening Maestro Biomet: * Radial component * Carpale component • JHS2012:37A:1580-84

  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

  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

  15. 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!

  16. Evaluation 12 wks post mobilisation

  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

  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:1580-84) • Effect of mirror therapy and stabilisation excercises preoperative on the propriocepsis postoperative?

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