- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
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.
- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
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 sample||Average followup time, months||Activity limitation outcome measure used||Activity limitations reported†|
|Bialocerkowski (current study)||25||55||AQ||SS 24 (8–48)‡|
| || || || ||IS 50 (12–80)§|
|Chung et al (8)||11||12||MHQ||Function 56.5 ± 22.5|
| || || || ||ADL 70.8 ± 25.1|
| || || || ||Work 64.0 ± 36.6|
|Cohen et al (3)||19||28||WOS||18 ± 12|
|Dacho et al (4)||49||47||DASH||29 (21–43)|
|Sauerbier et al (5)||36||25||DASH||28 (18–51)|
|Tomaino et al (6)||7||66||ARS||26¶|
|Vance et al (7)||P 21||P 15||DASH||P 27 (3–81)|
| ||T 31||T 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.