- Email: [email protected]
Comparison of Wrist Kinematics and Functional Performance After Midcarpal Arthrodesis and Proximal Row Carpectomy
ASHT 34TH ANNUAL MEETING SCIENTIFIC SESSION ORAL PRESENTATION ABSTRACTS SEPTEMBER 22 - 25, 2011, NASHVILLE, TN FUNCTIONAL OUTCOME FOLLOWING TOTAL DRUJ IMPLANT Holly D. Habeeb1, Ashley Buren Emrich1, Christina L. Kaufman4, Emily Mailhot3,4, Luis R. Scheker2,4, 1Therapy, Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA; 2Surgery, Kleinert, Kutz and Associates, Louisville, KY, USA; 3Surgery, L’enfantJesus Hospital, Quebec City, QC, Canada; 4Research, Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA Purpose: The purpose of this study was to evaluate patients receiving a total DRUJ implant for improvement in function, lifting ability and pain relief. Background: The DRUJ is a weight bearing joint. If the distal ulna is excised, dynamic impingement occurs with the radius falling on top of the stump of the ulna. The DRUJ main functions are transmission of force when lifting and pronation /supination. For prono/supination, the radius must rotate around a fixed ulna. DRUJ stability is provided by the TFC, ulnocarpal ligaments, the interosseous membrane (IOM), the ECU and the pronator quadratus (PQ). Instability of the DRUJ is the result of injury to the triangular fibro cartilage (TFC) or fracture of one or both forearm bones. Other causes are congenital abnormalities, inflammatory and degenerative arthritis or tumors resection of ulnar head. If proper treatment is not performed, the cartilage of the head of the ulna is lost and arthritis ensues. Darrach, Suave-Kapandji, Bowers and Watson procedures are performed to alleviate pain in chronic instability and arthritis of the DRUJ. These procedures do provide pain relief, but do not result in good lifting ability. Patients with a total DRUJ replacement prosthesis have achieved functional strength and lift up to 20# with little or no complaints of pain.
378
JOURNAL OF HAND THERAPY
Methods: A 5-year follow-up study of 37 patients receiving a total DRUJ prosthesis was conducted. 13/37 patients returned for re-evaluation. Data collected included grip strength, DASH, lifting capabilities, ROM and radiographs, initial injury and time frame, preop and postop pain at rest and with activity, previous surgical procedures, complications, and therapy. Therapy regimen postop included e-stim/TENS, MH, ice, fluidotherapy, exercise ROM and strengthening, scar care, desensitization, edema control. Results: The average age was 42 years, range (24e79), 8 female and 5 male. Previous interventions included ulnar shortening, DRUJ ligament reconstruction, cubital and carpal tunnel release, ECU tendon sheath repair, TFC reconstruction, corrective osteotomy. Of the 13 patients included in this study, 9/13 received therapy postop DRUJ prosthesis. Patients’ pre-op and post-op measurements were compared. There was a significant improvement in average pronation from 52 to 81 degrees; p 5 0.002, and Pain score on a scale of 1e10 decreased from 7 to 1 at rest (p 5 0.005), and 8 to 2 upon activity (p 5 0.011). Importantly, Patients in therapy after total DRUJ prosthesis were able to lift up to 20# without pain. On a scale of 1e10 (1 5 lowest), patients reported a satisfaction level of 9.51 (n 5 19). Conclusion: Patients after salvage procedures have acceptable ROM. However, weight lifting is limited by pain due to, dynamic impingement of the ulna stump on the radius. Patients in therapy after total DRUJ prosthesis were able to lift up to 20# without pain.
SUMMARY Statistically significant differences exist between pre-op and post-op mean values of degree of pronation and pain. Supination showed a borderline significant difference. The stability created by the prosthesis prevents impingement of the ulna stump upon the radius during lifting activities. Our patients expressed the
utmost satisfaction with their implants, emphasizing the success of total DRUJ arthroplasty in repairing dysfunctional DRUJs.
COMPARISON OF WRIST KINEMATICS AND FUNCTIONAL PERFORMANCE AFTER MIDCARPAL ARTHRODESIS AND PROXIMAL ROW CARPECTOMY Aviva Wolff, Howard Hillstrom, Scott Wolfe, Andrew Kraszewski, Rohit Garg, Sherry Backus, Jocelyn Hafer, Mark Lenhoff, Rehabilitation, Hospital for Special Surgery, New York, NY, USA Purpose: To compare wrist coupling, angular excursion, and functional performance between: healthy subjects, subject’s status post midcarpal arthrodesis (MA) and proximal row carpectomy (PRC) during hammering and dart throwing. Background: Traditional outcome measures have described the wrist in isolated planes of motion (flexionextension, radial-ulnar deviation). While practical and straightforward, these measures do not convey information concerning functional activities of the wrist. Most functional activities employ ‘‘coupled’’ wrist motion, a combination of flexionextension (FE) and radial-ulnar deviation (RUD) [1]. In particular the ‘‘dart throwers motion (DTM)’’, radial-extension to ulnar-flexion, has been implicated as a common path of motion in many activities that require simultaneous force generation and targeted accuracy. There is little information concerning the relationship between functional performance and wrist ‘‘coupling’’, the amount of flexion-extension (FE) per degree of radial-ulnar deviation (RUD). Methods: Twenty-nine males, 10 healthy, 10 who had undergone MA
and 9 who had undergone PRC on their dominant wrist performed 15 trials of dart throwing and hammering. Data was acquired at 200 Hz with a motion capture system. A wrist joint coordinate system was implemented to calculate angles. Performance for dart throwing was measured as distance to the target’s center (mm). Hammering performance was measured as: time taken per nail (sec), total strikes, and percentage of missed strikes. Coupling, was the angle with respect to the positive horizontal axis using arctangent2(y,x). For example, 2458 indicates 1:1 flexion:ulnar-deviat ion and 2908 indicates isolated flexion. Kinematic Path Length was defined as the total angular distance traveled along the kinematic path for each task. Active range of motion (ROM) and grip strength for the dominant hand and Patient Rated Wrist Evaluat ion (PRWE) scores were compared bet ween groups. One-way ANOVA (a 5 0.05) with LSD post-hoc tests was used to test differences. Significance was a , 0.016 for post-hoc tests. Results: Flexion-extension (FE) ROM, radial-ulnar deviation (RUD) ROM, grip strength and PRWE scores were worse for MA and PRC groups compared to healthy. Clinical measures were not different between MA and PRC. Coupling, kinematic path length and performance were reduced for both MA and PRC groups compared to healthy for dart throwing, however no differences existed between the 2 surgical groups. Kinematic path length was significantly reduced for MA compared to PRC and healthy. Hammering performance (time taken and total strikes per nail) was worse in MA compared to PRC and healthy. PRC group showed reduced coupling compared to both MA and healthy and was significantly less than the coupling for healthy subjects. Conclusion: PRC individuals demonstrated improved performance and greater wrist motion compared to MA during hammering. Preserved motion at the midcarpal joint in PRC may be responsible for improved hammering performance. - Altered wrist kinematics and functional performance were found after MA and PRC. - A better understanding of functional outcomes following wrist reconstruction has implications for patient consent, surgical technique selection, implant design and postoperative rehabilitation.
EFFECT OF THE POSITION OF ULNAR THREE DIGITS ON THUMB TO INDEX TIP TO TIP PINCH STRENGTH Wendy McCoy, Jennifer Dekerlegand, Penn Therapy and Fitness, Good Shepherd Penn Partners, Radnor, PA, USA Purpose: The purpose of this study is to assess if differences exist in the amount of tip to tip pinch force generated when the ulnar three digits of the hand are either in a flexed or extended position. Background: Pinch strength is a widely used outcome measure in hand therapy, but no standardized testing position has been documented. Published research utilizing pinch strength testing rarely describes the test position in detail. This lack of standardization results in inconsistencies among clinicians, with the potential error magnified due to the small values of pinch strength force generated. Methods: Volunteers were included in the study if they were without any hand injury or surgery in the past year and provided consent for participation. Pinch strength was assessed using the B&L Engineering pinch gauge and was calibrated by the company prior to the study. Thumb to index tip to tip pinch strength was tested during three trials with the ulnar three digits of the hand in extension and with the ulnar three digits flexed into the palm of the hand. The average of the three trials was utilized for analysis. The flexed and extended testing positions were assessed for both hands. The sequence of test positions was randomized and pinch force was recorded in pounds. Reliability was assessed using an intraclass correlation coefficient and a Student’s t test was used to compare the means between test positions. Statistical significance considered a p value of , 0.05. Results: Seventy-six healthy volunteers (35 males, 41 females) with a mean age of 43.4 6 17.1 years agreed to participate in this study. Eight-nine percent of the sample was right hand dominant and 11% left hand dominant. Reliability was acceptable at
0.98. Right hand pinch force was significantly greater with the ulnar three digits in the flexed position at 13.3 6 4.4 as compared to 10.7 6 3.5 in the extended position (p , 0.001, t 5 9.79, df 5 75). Left hand pinch force was significantly greater with the ulnar three digits in the flexed position as well at 12.1 6 4.2 as compared to 9.9 6 3.5 in the extended position (p , 0.001, t 5 8.49, df 5 75). Conclusion: This study finds the tip to tip pinch strength in a group of healthy volunteers will significantly vary with alterations in positioning of the ulnar three digits of the hand. Based upon these results, we recommend a standardized test position be established and all research and clinical documentation include a description of the testing position utilized to allow for accurate comparisons.
TESTING FOR BICEPS PATHOLOGY: ANALYSIS OF MUSCLE ACTIVATION DURING THE SPEED’S TEST Dexter W. Witt, Nancy Talbott, Nicole Claire, Maggie Sutter, Elizabeth Mulligan, Susan Kotowski, Rehabilitation Sciences, University of Cincinnati, Cincinnati, OH, USA Purpose: The purpose of this study was to investigate the activation patterns of the long head of the biceps and the anterior deltoid during performance of a Speed’s test. Background: The Speed’s Test is recommended as a special test when biceps or labral involvement is suspected. Although performance of the test may vary, it is generally considered positive when an individual, with their shoulder in 908 of flexion and full elbow extension, experiences more anterior shoulder pain during resistance with the forearm supinated than when the forearm is pronated. While the explanation for the positive result is increased biceps activity in the supinated position, there are currently no studies to support this rationale or to demonstrate that the anterior deltoid is not substituting for the biceps. To assist in understanding the mechanism involved in Speed’s test, this study
OctobereDecember 2011 379
378
JOURNAL OF HAND THERAPY
Methods: A 5-year follow-up study of 37 patients receiving a total DRUJ prosthesis was conducted. 13/37 patients returned for re-evaluation. Data collected included grip strength, DASH, lifting capabilities, ROM and radiographs, initial injury and time frame, preop and postop pain at rest and with activity, previous surgical procedures, complications, and therapy. Therapy regimen postop included e-stim/TENS, MH, ice, fluidotherapy, exercise ROM and strengthening, scar care, desensitization, edema control. Results: The average age was 42 years, range (24e79), 8 female and 5 male. Previous interventions included ulnar shortening, DRUJ ligament reconstruction, cubital and carpal tunnel release, ECU tendon sheath repair, TFC reconstruction, corrective osteotomy. Of the 13 patients included in this study, 9/13 received therapy postop DRUJ prosthesis. Patients’ pre-op and post-op measurements were compared. There was a significant improvement in average pronation from 52 to 81 degrees; p 5 0.002, and Pain score on a scale of 1e10 decreased from 7 to 1 at rest (p 5 0.005), and 8 to 2 upon activity (p 5 0.011). Importantly, Patients in therapy after total DRUJ prosthesis were able to lift up to 20# without pain. On a scale of 1e10 (1 5 lowest), patients reported a satisfaction level of 9.51 (n 5 19). Conclusion: Patients after salvage procedures have acceptable ROM. However, weight lifting is limited by pain due to, dynamic impingement of the ulna stump on the radius. Patients in therapy after total DRUJ prosthesis were able to lift up to 20# without pain.
SUMMARY Statistically significant differences exist between pre-op and post-op mean values of degree of pronation and pain. Supination showed a borderline significant difference. The stability created by the prosthesis prevents impingement of the ulna stump upon the radius during lifting activities. Our patients expressed the
utmost satisfaction with their implants, emphasizing the success of total DRUJ arthroplasty in repairing dysfunctional DRUJs.
COMPARISON OF WRIST KINEMATICS AND FUNCTIONAL PERFORMANCE AFTER MIDCARPAL ARTHRODESIS AND PROXIMAL ROW CARPECTOMY Aviva Wolff, Howard Hillstrom, Scott Wolfe, Andrew Kraszewski, Rohit Garg, Sherry Backus, Jocelyn Hafer, Mark Lenhoff, Rehabilitation, Hospital for Special Surgery, New York, NY, USA Purpose: To compare wrist coupling, angular excursion, and functional performance between: healthy subjects, subject’s status post midcarpal arthrodesis (MA) and proximal row carpectomy (PRC) during hammering and dart throwing. Background: Traditional outcome measures have described the wrist in isolated planes of motion (flexionextension, radial-ulnar deviation). While practical and straightforward, these measures do not convey information concerning functional activities of the wrist. Most functional activities employ ‘‘coupled’’ wrist motion, a combination of flexionextension (FE) and radial-ulnar deviation (RUD) [1]. In particular the ‘‘dart throwers motion (DTM)’’, radial-extension to ulnar-flexion, has been implicated as a common path of motion in many activities that require simultaneous force generation and targeted accuracy. There is little information concerning the relationship between functional performance and wrist ‘‘coupling’’, the amount of flexion-extension (FE) per degree of radial-ulnar deviation (RUD). Methods: Twenty-nine males, 10 healthy, 10 who had undergone MA
and 9 who had undergone PRC on their dominant wrist performed 15 trials of dart throwing and hammering. Data was acquired at 200 Hz with a motion capture system. A wrist joint coordinate system was implemented to calculate angles. Performance for dart throwing was measured as distance to the target’s center (mm). Hammering performance was measured as: time taken per nail (sec), total strikes, and percentage of missed strikes. Coupling, was the angle with respect to the positive horizontal axis using arctangent2(y,x). For example, 2458 indicates 1:1 flexion:ulnar-deviat ion and 2908 indicates isolated flexion. Kinematic Path Length was defined as the total angular distance traveled along the kinematic path for each task. Active range of motion (ROM) and grip strength for the dominant hand and Patient Rated Wrist Evaluat ion (PRWE) scores were compared bet ween groups. One-way ANOVA (a 5 0.05) with LSD post-hoc tests was used to test differences. Significance was a , 0.016 for post-hoc tests. Results: Flexion-extension (FE) ROM, radial-ulnar deviation (RUD) ROM, grip strength and PRWE scores were worse for MA and PRC groups compared to healthy. Clinical measures were not different between MA and PRC. Coupling, kinematic path length and performance were reduced for both MA and PRC groups compared to healthy for dart throwing, however no differences existed between the 2 surgical groups. Kinematic path length was significantly reduced for MA compared to PRC and healthy. Hammering performance (time taken and total strikes per nail) was worse in MA compared to PRC and healthy. PRC group showed reduced coupling compared to both MA and healthy and was significantly less than the coupling for healthy subjects. Conclusion: PRC individuals demonstrated improved performance and greater wrist motion compared to MA during hammering. Preserved motion at the midcarpal joint in PRC may be responsible for improved hammering performance. - Altered wrist kinematics and functional performance were found after MA and PRC. - A better understanding of functional outcomes following wrist reconstruction has implications for patient consent, surgical technique selection, implant design and postoperative rehabilitation.
EFFECT OF THE POSITION OF ULNAR THREE DIGITS ON THUMB TO INDEX TIP TO TIP PINCH STRENGTH Wendy McCoy, Jennifer Dekerlegand, Penn Therapy and Fitness, Good Shepherd Penn Partners, Radnor, PA, USA Purpose: The purpose of this study is to assess if differences exist in the amount of tip to tip pinch force generated when the ulnar three digits of the hand are either in a flexed or extended position. Background: Pinch strength is a widely used outcome measure in hand therapy, but no standardized testing position has been documented. Published research utilizing pinch strength testing rarely describes the test position in detail. This lack of standardization results in inconsistencies among clinicians, with the potential error magnified due to the small values of pinch strength force generated. Methods: Volunteers were included in the study if they were without any hand injury or surgery in the past year and provided consent for participation. Pinch strength was assessed using the B&L Engineering pinch gauge and was calibrated by the company prior to the study. Thumb to index tip to tip pinch strength was tested during three trials with the ulnar three digits of the hand in extension and with the ulnar three digits flexed into the palm of the hand. The average of the three trials was utilized for analysis. The flexed and extended testing positions were assessed for both hands. The sequence of test positions was randomized and pinch force was recorded in pounds. Reliability was assessed using an intraclass correlation coefficient and a Student’s t test was used to compare the means between test positions. Statistical significance considered a p value of , 0.05. Results: Seventy-six healthy volunteers (35 males, 41 females) with a mean age of 43.4 6 17.1 years agreed to participate in this study. Eight-nine percent of the sample was right hand dominant and 11% left hand dominant. Reliability was acceptable at
0.98. Right hand pinch force was significantly greater with the ulnar three digits in the flexed position at 13.3 6 4.4 as compared to 10.7 6 3.5 in the extended position (p , 0.001, t 5 9.79, df 5 75). Left hand pinch force was significantly greater with the ulnar three digits in the flexed position as well at 12.1 6 4.2 as compared to 9.9 6 3.5 in the extended position (p , 0.001, t 5 8.49, df 5 75). Conclusion: This study finds the tip to tip pinch strength in a group of healthy volunteers will significantly vary with alterations in positioning of the ulnar three digits of the hand. Based upon these results, we recommend a standardized test position be established and all research and clinical documentation include a description of the testing position utilized to allow for accurate comparisons.
TESTING FOR BICEPS PATHOLOGY: ANALYSIS OF MUSCLE ACTIVATION DURING THE SPEED’S TEST Dexter W. Witt, Nancy Talbott, Nicole Claire, Maggie Sutter, Elizabeth Mulligan, Susan Kotowski, Rehabilitation Sciences, University of Cincinnati, Cincinnati, OH, USA Purpose: The purpose of this study was to investigate the activation patterns of the long head of the biceps and the anterior deltoid during performance of a Speed’s test. Background: The Speed’s Test is recommended as a special test when biceps or labral involvement is suspected. Although performance of the test may vary, it is generally considered positive when an individual, with their shoulder in 908 of flexion and full elbow extension, experiences more anterior shoulder pain during resistance with the forearm supinated than when the forearm is pronated. While the explanation for the positive result is increased biceps activity in the supinated position, there are currently no studies to support this rationale or to demonstrate that the anterior deltoid is not substituting for the biceps. To assist in understanding the mechanism involved in Speed’s test, this study
OctobereDecember 2011 379