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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Objective

To document the activity limitations experienced by patients who had undergone a 4-corner wrist fusion, and the compensatory mechanisms they use in daily life.

Methods

Patients completed 2 copies of the Adelaide Questionnaire, a measure with a standardized section and an individualized section. The test–retest reliability of the questionnaire was evaluated.

Results

Twenty-five patients were recruited to the study, and 21 completed both questionnaires. Excellent test–retest reliability was gained for both the standardized and individualized sections of the Adelaide Questionnaire.

Conclusion

Patients with 4-corner wrist fusions report activity limitations following surgery, particularly with daily tasks that involve hand/forearm rotation and grip strength. Various compensatory mechanisms are used by the majority of patients. The impact of these mechanisms on activity limitations varies between patients, but often decreases impact of the activity limitations on everyday life.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Patients with scapholunate advanced collapse wrist, the most common pattern of degenerative arthritis of the wrist, and scaphoid nonunion advanced collapse wrist often present with chronic wrist pain, limited wrist movement and grip strength, and a reduced ability to perform daily tasks due to radial-sided wrist instability (1). These patients are frequently treated surgically, where the wrist is stabilized using a limited wrist fusion procedure (2). This procedure is considered motion preserving because functional wrist motion is maintained (3). Following surgery, patients should experience very few, if any, difficulties with daily tasks. Thus, these patients should have, at the most, slight activity limitations.

Little research has been undertaken to ascertain the activity limitations following limited wrist fusion. Slight activity limitations have been reported between 15 and 66 months following 4-corner wrist fusion (excision of the scaphoid and midcarpal fusion) (3–7), although a greater magnitude of activity limitation may be experienced at 12 months following surgery (8). These results may be explained by the recovery of wrist function over time since surgery as well as the variable methods used to evaluate activity limitations. These methods include the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Michigan Hand Outcomes Questionnaire, the Wrist Outcome Scale, and the Activity Rating Scale. However, no information has been provided on the specific activities that are most frequently limited following 4-corner wrist fusion. Moreover, when activity limitations are present, compensatory mechanisms are often used to decrease the difficulty associated with performing a task (9). Currently, there is a paucity of information regarding compensatory mechanisms used by individuals with a 4-corner wrist fusion.

Gaining an understanding of the specific activity limitations associated with 4-corner wrist fusion and the compensatory mechanisms that are used to overcome these limitations would provide clinicians with information that could direct patient management. Surgeons could use this information to educate patients on the expectations of their postoperative recovery and to flag potential limitations that may be ongoing. Specific activity limitations may be amenable to hand therapy, which aims to minimize activity limitations, thereby increasing patients' quality of life. Therefore, the aim of this study was to document the activity limitations experienced by patients who had undergone a 4-corner wrist fusion, and the compensatory mechanisms they used in daily life, with the Adelaide Questionnaire. To achieve this aim, the test–retest reliability of the Adelaide Questionnaire was evaluated in patients following 4-corner wrist fusion.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Patients.

Seventy-three patients were invited to participate in this study, of whom 25 returned the first questionnaire. The study group and nonresponders had similar demographic characteristics with respect to sex, side of wrist injury, hand dominance, and time since limited wrist fusion, but differed with respect to age (t = −2.2, P = 0.0034), with the study group being on average 9.1 years older than the nonresponders.

The study group consisted of 21 men and 4 women, with a mean ± SD age of 53.5 ± 18 years (Table 1). All had undergone a 4-corner wrist fusion, by 1 surgeon, a mean ± SD of 4.6 ± 2.9 years previously. They received the same surgical technique and were prescribed the same postoperative rehabilitation (10). The dominant wrist was operated on in 16 (64%) cases, primarily due to radial-sided wrist instability (56%) or nonunion of a scaphoid fracture (36%). All but 2 patients reported that they were satisfied with the outcome of the wrist surgery, and 1 patient reported that he changed his occupation because of his wrist disorder. No patients were receiving treatment for their wrist at the time of this study. Ethical approval for this study was obtained from The University of Melbourne.

Table 1. Demographic characteristics of the study participants*
Demographic characteristicAll participants (n = 25)Participants in the reliability study (n = 21)
  • *

    Values are the number (percentage) unless otherwise indicated.

  • One of the 12 participants reported that they changed their occupation because of their wrist.

  • None of the participants reported that they changed their occupation because of their wrist.

Age, years  
 Mean ± SD53.5 ± 18.052.9 ± 17.1
 Range17.7–77.917.7–77.9
Sex  
 Male21 (84)17 (81)
 Female4 (16)4 (19)
Dominance of injury  
 Dominant wrist16 (64)13 (52)
 Nondominant wrist9 (36)8 (48)
Preoperative diagnosis  
 Wrist instability14 (56)12 (57)
 Nonunion of scaphoid fracture ± degenerative arthritis9 (36)7 (33)
 Other2 (8)2 (10)
Time since surgery, years  
 Mean ± SD4.6 ± 2.94.2 ± 2.7
 Range0.5–9.40.5–9.3
Current employment status  
 Employed, usual duties7 (28)5 (24)
 Employed, restricted duties2 (8)2 (9)
 Home duties1 (4)1 (5)
 Retired6 (24)6 (28)
 Retired due to ill health4 (16)3 (15)
 Unemployed1 (4)0 (0)
 Student2 (8)2 (9)
 Other2 (8)2 (9)
Change in work due to wrist disorder  
 No13 (52)12 (57)
 Yes12 (48)9 (43)
Lives with a caregiver  
 No5 (20)5 (24)
 Yes20 (80)16 (76)

Outcome measurements.

The Adelaide Questionnaire, a psychometrically sound wrist outcome instrument, was used to evaluate activity limitations and the use of compensatory mechanisms (11–13). This questionnaire was chosen because it assesses the ability to perform activities, prior to and following a wrist disorder, from the wrist-injured individual's perspective. It was developed from qualitative studies where the most difficult and important activities were identified by individuals with a range of musculoskeletal wrist diagnoses, such as osteoarthritis and wrist instability (11). The Adelaide Questionnaire comprises 2 sections: the standardized section and the individualized section.

The standardized section evaluates the activity limitation associated with 25 frequently performed activities. Patients select the response category that most accurately describes their ability to perform each activity during 2 time periods: prior to and following wrist surgery. Response categories include yes (I have difficulty performing the activity), no (I do not have difficulty performing the activity), haven't tried (I have not tried performing this activity), and not applicable (I do not normally perform this activity). The number of yes responses are tallied to produce a summary activity limitation score for 2 points in time (prior to surgery and at the time of assessment). These scores range from 0 (no activity limitation) to 25 (maximum activity limitation associated with the 25 activities) (12). Many comparisons between pre- and postsurgical status can be made with these data, for example, the number of activities that are better, the same, or worse following surgery compared with the preoperative responses. These comparative scores, which are frequencies, range from 0–25.

The individualized section elicits information regarding difficulties associated with up to 5 activities that are perceived by each patient as important at the time of the assessment. This section is optional and is completed when difficulty is experienced with activities that are not contained in the standardized section of the questionnaire. The difficulty and importance of each nominated activity is rated on a 5-point scale (0 = not difficult/not important, 5 = impossible/essential). A total score is calculated by summing the difficulty and importance scores across each of the 5 nominated activities. Thus, the total score represents the magnitude of activity limitation associated with activities that are perceived to be important for each individual. Scores range from 0 (no activity limitation) to 50 (maximum activity limitation) (12). Three additional questions (whether compensatory mechanisms are used, type of compensatory mechanism used, and difficulty associated with the performance of the activity when compensatory mechanisms are used) elicit information on compensatory mechanism use associated with the nominated activities. The responses to these questions are not incorporated into the total score for this section (12).

The Adelaide Questionnaire has been psychometrically evaluated, with acceptable validity demonstrated for patients with unilateral wrist disorders such as 4-corner fusions (13).

Procedure.

Patients were sent a letter inviting them to participate in this study. Participation involved completing the Adelaide Questionnaire (which took approximately 5 minutes) and returning it in a reply paid envelope to the researchers. Consent to participate in this study was implied by return of a completed questionnaire. As the test–retest reliability of the Adelaide Questionnaire has not been established in patients with 4-corner wrist fusion, this psychometric property was also evaluated. One week following the receipt of the completed questionnaire, a second, identical Adelaide Questionnaire was mailed to the patients, along with another reply paid envelope for the return of the questionnaire. At this time, patients were also asked to select the category that best described any change in their wrist since they first completed the questionnaire. Response options included much better, slightly better, no change, slightly worse, and much worse.

Statistical analysis.

An a priori sample size calculation was performed for the test–retest reliability component of this study. Based on preliminary psychometric evaluation of the Adelaide Questionnaire (13, 14), 19 patients were required to gain a reliability coefficient of 0.95 with ± 0.1 as the width of the 95% confidence interval (95% CI) around the coefficient. The recruitment of 25 patients allowed for dropouts associated with the second administration of the Adelaide Questionnaire.

All data were entered into and analyzed with the Statistical Package for the Social Sciences, version 12 (SPSS, Chicago, IL). To establish the test–retest reliability of the Adelaide Questionnaire, data from patients who reported that their wrist had not changed since the first administration of the questionnaire were used to calculate the intraclass correlation coefficient (ICC), model 2,1, and 95% CIs for the standardized and individualized sections of the Adelaide Questionnaire (14). The SEM and 95% CIs were calculated to express the expected distribution of error around the sample's mean scores for both sections of the questionnaire (14). The SEM was also expressed as a percentage of the possible range of scores for each section of the Adelaide Questionnaire, and was hypothesized to be lower than 10% (15). For the standardized section of the Adelaide Questionnaire, the number of worse activities was used for these calculations. Worse activities were identified as activities that gained a no response preoperatively and a yes response at the time of assessment. This comparative frequency takes into account pre- and postsurgical responses, as well as the consistency of responses over all of the response categories. Using this score to establish test–retest reliability of the Adelaide Questionnaire eliminated the need to conduct reliability analyses on multiple scores produced from the standardized section of the questionnaire.

A description of the activity limitations and compensatory mechanisms used was based on the responses gained from the first administration of the Adelaide Questionnaire (n = 25). Descriptive statistics were used to summarize both the summary scores of the 2 sections of the Adelaide questionnaire and the responses to each item in the questionnaire; to identify frequently reported activity limitations and the compensatory mechanisms that were frequently used; and to determine the impact of compensatory mechanism use on activity limitation. In order to identify specific activities on the standardized section for which there was a change in activity limitation following surgery, the number of yes responses at the time of assessment was subtracted from the number of yes responses preoperatively. These comparison scores range from −25 to 25, with negative numbers indicating deterioration in function.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Reliability study.

The mean ± SD time between questionnaire administrations was 21.2 ± 16.4 days. Four of the 25 patients did not return their second questionnaire, thus, the reliability estimates were calculated on complete sets of data (n = 21). The demographic characteristics of the patients who completed the questionnaire twice are shown in Table 1. All of these patients reported that there was no change in their wrist between administrations of the questionnaire. Excellent test–retest reliability was gained for both the standardized and individualized sections of the Adelaide Questionnaire (Table 2). This is evidenced by very high ICCs (≥0.95) with narrow confidence intervals, small SEMs (<2 points) with narrow confidence intervals, and small SEM ranges (<4%).

Table 2. Test–retest reliability statistics for the standardized and individualized sections of the Adelaide Questionnaire*
Questionnaire sectionsScore rangeObserved rangeMean ± SDICC (95% CI)SEM95% SEMSEM % range
  • *

    ICC = intraclass correlation coefficient; 95% CI = 95% confidence interval.

  • Number of worse activities, identified as activities that gained a no response preoperatively and a yes response at the time of assessment.

Standardized section       
 10–250–204.9 ± 6.70.98 (0.95–0.99)0.981.923.8
 2 0–245.2 ± 7.1    
Individualized section       
 10–506–4022.7 ± 8.30.95 (0.87–0.98)1.823.573.6
 2 6–3922.3 ± 8.0    

Activity limitation and compensatory mechanism use.

The summary activity limitation scores ± SD for the standardized section of the Adelaide Questionnaire were 5 ± 2 preoperatively and 6 ± 3 at the time of assessment, from a maximum of 25. Preoperatively, 10 (40%) patients reported difficulty with various activities. Activity limitations were most frequently reported with undoing a screw-top lid of a jar, turning on a tap, lifting up a saucepan full of food, and taking weight through the wrist (Table 3). Postoperatively, 18 (72%) patients reported difficulty with activities; activity limitations were most frequently associated with opening a door with the operated extremity, opening a screw-top lid, lifting, turning on a tap with the operated extremity, pulling an electric plug out of a wall with the operated extremity, doing up buttons, and putting weight through the operated wrist (Table 3). When comparisons were made between pre- and postsurgical status, there was, on average, a deterioration in activity limitation (mean ± SD comparison score −1 ± 2, range −3 to 2). Patients reported deterioration in their ability to wash their body, use eating utensils, do up buttons, open a door, pull an electric plug out of a socket, and lift. However, some patients improved their ability to put on underwear, pull up trousers, wash the dishes, lift up a saucepan full of food, dust, and care for children (Table 3). The haven't tried responses detailed in Table 3 demonstrate that some patients avoided the performance of usual activities, such as lifting a saucepan full of food, dusting, caring for children, and craft activities.

Table 3. Pre- and postoperative responses to the standardized section of the Adelaide Questionnaire for 4-corner wrist fusion patients*
Daily activityPreoperative responsesPostoperative responsesComparison AL score§
YesNoNAHTYesNoNA
  • *

    AL = activity limitation; NA = not applicable; HT = haven't tried.

  • Total mean ± SD score 5 ± 2, range 2–9.

  • Total mean ± SD score 6 ± 3, range 2–12.

  • §

    Total score: mean ± SD −1 ± 2, range −3 to 2. A negative score corresponds to a deterioration in activity limitation compared with preoperative status.

Wash the body421-0718-−3
Washing hair322-0421-−1
Doing hair322-0223-1
Putting on underwear322-0223-1
Pulling up trousers520-0520-0
Tying shoe laces421-1519-−1
Using eating utensils421-0718-−3
Doing up a zip421-1519-−1
Doing up buttons619-1915-−3
Handling money421-0520-−1
Undoing a screw-top lid916-41110-−2
Opening a door916-01213-−3
Turning on a tap817-01015-−2
Accessing a vehicle223-0223-0
Pulling an electric plug out of a socket619-2914-−3
Washing the dishes3193321701
Lifting a saucepan9160681101
Sweeping4183421632
Gardening518236142−1
Dusting or polishing3175521351
Lifting activities8170211120−3
Craft activities3157531070
Caring for/playing with children3202621521
Steering the car5200241901
Taking weight through the wrist9160391300

Nineteen (76%) patients completed the individualized section of the questionnaire. The mean ± SD individualized total score was 25 ± 9 (range 4–40) from a maximum score of 50. Nominated difficult and important activities were similar to those listed in the standardized section of the Adelaide Questionnaire, but there were important differences. Sports (63%) and work activities (47%) were frequently nominated as problematic activities, and 4 (21%) patients reported difficulty with intimate moments (Table 4). Sixteen (84%) patients used compensatory mechanisms, but these mechanisms were not used for some activities, such as caring for family members, sleeping, and intimate moments (Table 4). However, when compensatory mechanisms were used, they included avoiding the task, requiring assistance, and altering the way in which the task was performed. Compensatory mechanisms tended to decrease the difficulty associated with the nominated task by 0–52% (mean ± SD 15 ± 18%) per patient; often this was associated with a reduction of 1 category on the difficulty scale. The most frequently reported compensatory mechanisms were taking longer to perform the task (25%), altering the type of grip used (19%), using 2 hands (15%), and using the contralateral hand (13%), although the type of compensatory mechanism used tended to be dependent on the type of activity performed (Table 5). Table 5 shows that patients reported the use of more than 1 compensatory mechanism for activities that tended to be more complex in nature (such as sports, work, and outside tasks), and that a small proportion of these patients reported using a wrist brace when performing these tasks.

Table 4. Summary of responses from the individualized section of the Adelaide Questionnaire: number of patients reporting specific activity limitation, activity difficulty and importance, and compensatory mechanism (CM) use
Activity limitationNo. of patientsDifficultyImportanceCM use, no. (%)
NoMildModerateSevereImpossibleNotMinimalModerateVeryEssentialNoYes
Sports1222404143313 (25)9 (75)
Work903321102424 (44)5 (56)
Outside tasks701510013301 (14)6 (86)
Hygiene612112022210 (0)7 (100)
Dressing604110022201 (17)5 (83)
Intimate moments402200011114 (100)0 (0)
Cleaning303010011110 (0)4 (100)
Washing210010000201 (50)1 (50)
Caring for family210001000112 (100)0 (0)
Writing100010000100 (0)1 (100)
Cooking100100001000 (0)1 (100)
Eating101000001000 (0)1 (100)
Sleep100010000101 (100)0 (0)
Transport101000010000 (0)1 (100)
Table 5. Type of compensatory mechanisms (CMs) used for nominated difficult and important daily tasks
Activity limitationNo. of patientsNo. of CMsType of CM
AvoidAssistanceBraceEquipmentAlter gripUse 1 handUse 2 handsUse shoulder and elbowTakes longerUses rest breaksNot stated
  • *

    Pay to get outside jobs done.

  • Electric shaver.

  • Buttons.

  • §

    Computer.

Sports91320305000210
Work51001103210200
Outside tasks691*1100121101
Hygiene7700012400000
Dressing5610000020300
Cleaning4400000020200
Washing1100000000100
Writing110001§0000000
Cooking1100000000100
Eating1100000000100
Transport1100000010000

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

The results of this study show that activity limitations occur following 4-corner wrist fusion. This concurs with previous reports and also adds to the body of knowledge on the effect of a limited wrist fusion on individuals (Table 6). This study identified frequently reported activity limitations prior to and following 4-corner wrist fusion. Patients also continued to experience difficulty with a variety of activities following surgery. Compensatory mechanisms are frequently used by these patients, and these mechanisms have the capacity to reduce the impact of activity limitations on everyday life. Moreover, the results of this study highlight that standardized outcome measures may underestimate the magnitude of activity limitation and do not consider the relationship between compensatory mechanism use and activity limitation.

Table 6. Comparison of study results with published literature*
Author (ref.)No. in sampleAverage followup time, monthsActivity limitation outcome measure usedActivity limitations reported
  • *

    AQ = Adelaide Questionnaire; SS = standardized section; IS = individualized section; MHQ = Michigan Hand Outcomes Questionnaire (range 0–100); ADL = activities of daily living; WOS = Wrist Outcome Scale; DASH = Disabilities of the Arm, Shoulder, and Hand scale (range 0–100); ARS = Activity Rating Scale (range 0–100); P = plate; T = traditional fixation (Kirschner wires, staples, or screws).

  • Values are the mean ± SD or the mean (range) unless otherwise indicated.

  • Converted from a 0–25 scale to a 0–100 scale.

  • §

    Converted from a 0–50 scale to a 0–100 scale.

  • Converted from a 0–5 scale to a 0–100 scale.

Bialocerkowski (current study)2555AQSS 24 (8–48)
    IS 50 (12–80)§
Chung et al (8)1112MHQFunction 56.5 ± 22.5
    ADL 70.8 ± 25.1
    Work 64.0 ± 36.6
Cohen et al (3)1928WOS18 ± 12
Dacho et al (4)4947DASH29 (21–43)
Sauerbier et al (5)3625DASH28 (18–51)
Tomaino et al (6)766ARS26
Vance et al (7)P 21P 15DASHP 27 (3–81)
 T 31T 59 T 8 (1–24)

The Adelaide Questionnaire consists of 2 sections. The standardized section requires patients to identify limited activities from a list of empirically derived activities, whereas the individualized section requires patients to nominate limited activities that are specific to their circumstances. This approach to outcome measurement captures salient activity limitations at both group and individual levels (16). A strength of the standardized section of the Adelaide Questionnaire is that it uses a baseline measure as a comparator for current status. This puts into context the change that has taken place in activity limitation after surgery. Although there has been much debate regarding the most appropriate baseline measure (17), evidence suggests that patients accurately recall significant impediments to function (18). However, in this study group the average period of time between surgery and the administration of the Adelaide Questionnaire was >4 years. Therefore, more meaningful activity limitation information may be gained from interpreting the summary score at the time of assessment (the number of yes responses) rather than the comparative score. The comparative score may be more useful in situations with shorter recall periods (19), such as for patients following distal radius fracture. Potentially there may be only a few months between the time of assessment and a point in time prior to fracture.

Analysis of the most frequently reported activity limitations at the time of assessment (the number of yes responses) suggests that significant impairments may be present with respect to forearm/hand rotation and grip strength. Opening a door, unscrewing a lid of a jar, and turning on a tap all involve the transfer of rotator torque from the forearm to the hand. Without the scaphoid, torque transfer in patients with 4-corner wrist fusions may be less efficient because it occurs via the lunate (20). Moreover, stiffness associated with immobilization of the radiocarpal joint may contribute to inefficient transfer of rotation torque. Adequate grip strength is also required to perform these activities. Grip strength was not evaluated in this study, but may have been limited in our study group. Further research is warranted to identify the impairments that contribute to these frequently reported activity limitations so that they can be addressed during the postoperative rehabilitation period.

The Adelaide Questionnaire also elicits activity limitations that are specific to each patient's role and circumstance. Potentially, activity limitations may be underestimated if aspects of dysfunction that are unique to each patient are not identified. This is illustrated in Table 6, where the magnitude of activity limitation gained on the individualized section of the Adelaide Questionnaire was substantially greater than the results gained by other authors who used other, standardized outcome measures such as the DASH, the Wrist Outcome Scale, and the Activity Rating Scale. Table 6 also shows that the group studied by Chung et al (8) had greater activity limitations compared with groups from other studies. This may have resulted from differences in the demographic characteristics of the study groups, variations in surgical technique, and differences in items contained in the outcome measures used. Further research is therefore warranted to compare the results of different outcome measures in the same study group in order to ascertain the most appropriate measure for activity limitation following 4-corner wrist fusion.

In the individualized section of the Adelaide Questionnaire, almost two-thirds of the study group reported difficulty with sports. The importance that patients place on sport participation varies (demonstrated by the range of importance scores in Table 4), as does the way in which patients deal with this activity limitation. For example, 4 patients reported that sports participation was impossible as a result of their wrist. Two of these patients reported that they continued to play sports without any modifications, whereas the remaining 2 patients reported that they no longer played sports. The importance that patients place on participation in sporting activities and their subsequent ability to participate may have an impact on their perceived quality of life. Work tasks were also frequently reported to be difficult, and compensatory mechanisms were used by just over half of these patients. However, few patients reported that they changed their occupation because of their wrist, and only 2 patients reported that they were undertaking restricted work duties at the time of this study (Table 1). Therefore, compensatory mechanism use may allow patients to perform otherwise difficult activities. This is substantiated by our calculation that compensatory mechanism use decreases the difficulty of activity performance by up to 50%.

To our knowledge, this is the first study that has documented compensatory mechanism use following 4-corner wrist fusion. Compensatory mechanisms were frequently used by the study group, and this finding concurs with the results from studies on patients with other upper-extremity disorders (11, 21). Moreover, our results show that a variety of compensatory mechanisms are used by patients with 4-corner wrist fusions, and it appears that different compensatory mechanisms are used to address different types of activity limitations. Although this concurs with our finding in distal radius fracture patients (21), further research in patients following 4-corner wrist fusion is warranted due to the small sample size of the current study group. Further investigation could involve ascertaining whether the compensations are restorative (clinician-instructed) or reactive (developed by the patient), whether the type of compensation used changes over time postoperatively, and the point in time at which compensatory mechanisms are no longer required. This would provide clinicians with additional treatment strategies to reduce activity limitations, as well as provide an evidence base for the education of patients on what to expect during their postoperative recovery.

An unexpected finding was that 5 patients reported using a wrist brace for activities that potentially involve large forces through the wrist (sports, work, outside tasks). Wrist braces are recommended in the early rehabilitation phase following 4-corner wrist fusion to protect the healing arthrodesis (10). Currently there is little evidence that supports the long-term use of a wrist brace following surgery.

A strength of this study is that the Adelaide Questionnaire has excellent test–retest reliability in individuals with a 4-corner wrist fusion. Test–retest reliability is not an inherent property of an outcome instrument, but is directly related to the sample under study (14). It was considered crucial to ascertain this psychometric property prior to documenting specific activity limitations in the study group. It must be noted that the psychometric properties of other wrist outcome instruments have not been evaluated in patients with 4-corner wrist fusion or in any other type of limited wrist fusion. A limitation of this study is the small sample size, which limits the generalizability of results. However, the results provide areas for consideration in clinical practice and highlight avenues for further research.

In summary, patients with 4-corner wrist fusions report activity limitations following surgery, particularly with daily tasks that involve hand/forearm rotation and grip strength. Various compensatory mechanisms are used by the majority of patients, including taking longer to perform the task, altering the type of grip used, using 2 hands, and using the contralateral hand. The impact of these mechanisms on activity limitations varies between patients, but often decreases impact of the activity limitations on everyday life.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Dr. Bialocerkowski had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. Bialocerkowski.

Acquisition of data. Bialocerkowski.

Analysis and interpretation of data. Bialocerkowski.

Manuscript preparation. Bialocerkowski.

Statistical analysis. Bialocerkowski.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

We thank Dr. Greg Bain for providing access to his patients for this study.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
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