cmc-thumb-joint-arthroplasty-handout

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Therapy Following Thumb CMC Joint
Arthroplasty
Louise Kelly, M.Sc., OT Reg. (Ont), CHT
Surgical Procedures
• Distraction Arthroplasty. Kuhns, 2003
• Silicone Arthroplasty
• Ligamentous Reconstruction Tendon
Interposition (LRTI)
• Trapeziectomy- hemi or complete
• Trapezio-metacarpal Arthrodesis
Therapy Post CMC Joint Arthroplasty
• Goals of treatment
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Maintain thumb webspace
Maximize thumb ROM
Decrease pain and sensitivity
Strengthen the thumb
Return to usual daily functioning
Literature on Therapy Management
1. Poole and Pellegrini
Journal of Hand Therapy, 2000
2. Roberts, Jabaley and Nick
Journal of Hand Therapy, 2001
3. Brach
Hand Surgery Quarterly, 2003
Post-op Immobilization
TWH protocol:
Forearm based POP, thumb IP joint free,
3-4 weeks.
Variations:
Poole and Pellegrini, thumb IP included,
4 weeks.
Roberts et. al., bivalve, thumb IP free.
Ulnar portion discontinued at 10 days,
radial gutter to 3 weeks
Splint
TWH:
Forearm based thumb spica with IP free.
Start weaning off at 6 weeks.
Variations:
Poole and Pellegrini, splint as above for 3
months.
Brach, as above, thumb in maximum
abduction. Wean off 8-10 weeks.
Exercise
TWH:
Week 3-4, AROM wrist and thumb within
pain limits.
Variations:
Poole and Pellegrini, Week 5-AROM
wrist and thumb MCP and IP. Block basal
joint.
Exercise
Variations:
Roberts et. al., Week 3- AROM wrist and
thumb, 3-4 times daily.
Brach, Week 4- wrist and thumb MCP and
IP AROM. Home program includes
isometrics for thumb abduction and
extension performed in the splint.
Exercise
TWH:
Week 6- PROM wrist and thumb joints.
Variations:
Week 7-8, Poole and Pellegrini,
isometrics for thumb,
thumb setting
opposition
Exercise
Variations:
Brach, Week 5- AROM thumb opposition
and composite flexion.
Strengthening
TWH:
Week 6- grip and pinch strengthening,
therapyputty.
Variations:
Poole and Pellegrini, not till week 9.
Roberts et. al., isometrics and active
resisted.
Brach, gripping at week 8.
Activity Level
TWH:
Light activity started at week 6. Increase within
patient’s tolerance.
Variations:
Roberts et. al., Week 3- light activity initiated.
All:
Unrestricted work and activity permitted 4 to 6
months.
Modalities
TWH:
Scar Management
massage
silicone gel inserts
desensitization, including immersion, contact
and fluidotherapy
Edema Management
coban
isotoner glove
Complications
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Prolonged post-op pain
CRPS
Hypersensitivity of scar
Palmar fasciitis
Outcomes
1. Aggregate grip and pinch strength 20%
improvement at 2 years post surgery with
continued improvement to 6 years.
2. Grip, pinch, self reported ADL and pain
all improved significantly at mean follow
up of 1 year, 11 months. Patients did not
reach maximum improvement until second
year.
Summary of Key Points for Therapy
• Splint should position the thumb in
maximum abduction
• Avoid CMC joint motion in initial weeks of
treatment
• Avoid lateral pinch in first month of
therapy, modify pinch activities later
• Desensitize scar if necessary
• Educate patient regarding time frame for
outcomes
Literature Review for CMC Joint
Arthroplasty
• 14 articles reviewed, 1986 to 2003,
numerous procedures described
• 12 retrospective; 2 prospective ( Hematoma
and Distraction Arthroplasty, Kuhns, 2003;
Swanson vs APL arthroplasty, Tagil &
Kopylov, 2002)
Literature Review (Cont’d)
• Outcomes evaluated
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Pain
ROM
Satisfaction
Grip strength
Tip pinch strength
Key/lateral pinch strength
Radiographic changes
Jebsen
Moberg pick up test
Purdue Peg Board
ADL- self report
AIMS
Literature Review (Cont’d)
• Follow up 12 months to 9 years
• Results
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Complete pain relief 73-97%
Significant post op pain up to 26%
Heavy work painful 50%
ROM similar to non-operated hand
Grip improved more than pinch, equal to nonoperated hand
Results
– Satisfaction related to pain relief
– Self reported ADL better than observed
performance on Jebsen
– Moberg, no difficulties
– Radiographic changes included subsidence,
subluxation
Results
• Complications
– Radial sensory nerve numbness
– Scar tenderness
– RSD
Results
• Better in age 60 and over
• Gains in ROM first
• Continued improvement in pain relief and
strength from 2 to 6 years
• Loss of key pinch after 6 years
Recommendations
• More prospective studies
• Use of standardized functional performance
tests
• Use standardized protocol for measuring
ROM and strength
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