“IMMEDIATE EARLY ACTIVE MOTION AFTER RECONSTRUCTIVE HAND SURGERY IN LEPROSY AND PATIENT SATISFACTION”
Presented by: Dr. Indra Bahadur Napit Medical Director, Anandaban Hospital Leprosy Mission Nepal Co-authors: Sapkota P, Bista RB, Ghimire A., Karki A., Shahi G.
NUMBERS OF SURGICAL PROCEDURES at Anandaban Hospital
2007 2008 2009 2010 2011 2012
• RCS 83 100 120 135 126 151
• SEPTIC 51 304 184 184 192 268
• Non Leprosy 0 230 559 708 877 915
• Grand Total 134 634 863 1027 1195 1334
Trend of surgery at Anandaban Hospital
Purpose of this study
1. To study the outcome of
• Group I: active motion of hands from day 7 with hand therapy started after 3 weeks
• Group II:. immediate early active motion of hands from day 2 with hand therapy started after 2 weeks
2. To study the patient satisfaction between these 2 groups at the time of discharge.
Methods
• Retrospective study of Hand RCS with review of
-180 procedures (Correction of Claw hand & thumb opposition)
-157 patients
-Patient charts & physiotherapy assessment register book
-Post-operative surgical assessment forms
-Patient satisfaction assessment forms
Hand Therapy Protocol at Anandaban Hospital
Pre-operative:
- Physio assessment on day 2 after admission.
- Pre-operative exercise on day 2 onwards.
- If supple joints- can go for RCS within first week .
- If stiff joints- exercise for 1-2 weeks depending on the severity of stiffness.
Hand Therapy Protocol at Anandaban Hospital Post-operative
From 2008 to 2010:
- Mobilization of fingers from day 7 post operative.
- POP cast for 3 weeks.
- Hand therapy started after 3 weeks (on day 22).
- Duration of therapy- 4 weeks.
- Total - 7 weeks
- Night splints for 3 months post operative
From 2011- 2012:
- Immediate early active motion of fingers from day 2 post operative.
- POP cast for 2 weeks.
- Hand therapy started after 2 weeks
(on day 15).
- Duration of therapy- 3 weeks.
- Total – 5 weeks
- Night splints for 3 months post operative
2 groups of Hand RCS-
Group I: Late Mobilization
• 92 procedures (87 patients)
• from 2008 to 2010
• Active motion of fingers from day 7
• Hand therapy after 3 weeks (started on day 22)
Group II: Early Mobilization
• 88 procedures (70 patients)
• from 2011 to 2012
• Immediate active motion of fingers from day 2
• Hand therapy after 2 weeks (started on day 15)
Note: The new protocol of Early Mobilization was developed
with the help of Hands Across Borders, Netherlands.
Post-Operative cast for claw hand correction
Post-Operative dorsal blocking POP backslab
Mobilization of fingers on
day 2 Post-operative
First attempt of mobilization on day 2
Hand Therapy for Claw hand
First week post operative Third week post Operative
Post-Operative cast for Lasso+Opponensplasty
Dorsal blocking POP backslab
for Lasso & Opponenplasty.
First attempt of mobilization
on day 2
Surgical procedures for claw hand deformity and loss of thumb opposition:
Lasso with FDS transfer to pulley 1
Lumbrical reanimation (Intrinsic replacement) with FDS transfer to lateral bands
Opponensplasty with FDS transfer
Lasso + Opponensplasty with FDS (middle and ring fingers) transfers at a same time
Patient satisfaction scale • Patient satisfaction assessments performed using
“0 to 10 scale”. • Score 0 = worst & score 10= best as compared to a
normal hand. • Satisfaction scale subdivided into poor= scores 1 to 3 good= scores 4 to 6 excellent= scores 7 to 9
RESULTS: Age wise distribution of gender Age Male % Female % Total
< 15 years
8 5.1 4 2.6 12 (7.7%)
16 - 35 52 33.1 29 18.5 81 (51.6%)
36 - 55 30 19.1 11 7.0 41 (26.1%)
> 56 years
22 14.0 1 0.6 23 (14.6%)
Total 112 patients
71.3% 45 patients
28.7% 157 patients
Minimum age= 10 years
Maximum age= 78 years
Pattern of nerves palsies Nerves
affected Male Female Total
Ulnar palsy
61 27 88
Ulnar+Median palsy
49 18 67
Median palsy
2 0 2
Total
112
45
157
Surgery procedures
Procedures Right % Left % Total
Lasso 41 26.1 31 19.7 72 (45.8%)
Opponensplasty 32 20.3 17 10.8 49 (31.2%)
Lasso+Opponens 12 7.7 10 6.4 22 (14.0%)
Lumbrical reanimation
7 4.5 7 4.5 14 (9.0%)
Total 92 58.6% 65 41.4% 157 patients
Patient satisfaction age wise- contd. <15 years 16- 35 years 36- 55 years > 56 years Total
procedures
Gr. I Gr. II Gr. I Gr. II Gr. I Gr. II Gr. I
Gr. II
Poor 0 0 1 0 1 0 0 0 2 (1.1%)
Good 1 0 13 6 8 4 6 2 40 (22.2%)
Excellent 8 3 34 40 15 16 5 17 138 (76.7%)
Total 9 3 48 46 24 20 11 19 180 (100%)
Patient satisfaction- comparative in 2 groups
Group I Group II Total
Poor 2 (2.1%) 0 (0.0%) 2 (1.1%)
Good 28 (30.4%) 12 ((13.6%) 40 (22.2%)
Excellent 62 (67.5%) 76 (86.4%) 138 (76.7%)
Total cases 92 (100%) 88 (100%) 180 (100%)
Patient satisfaction- Scores for Functional & Cosmetic outcomes
Functional outcome
Cosmetic appearance
Average score
Group I 6.51 6.18 6.35
Group II 7.72 7.53 7.63
Group I= Late mobilization
Group II= Early mobilization
Post-Operative complications
Group I Group II Remarks
Tendon insertion pull out
0
0
Adhesion 5 0 Improved after physiotherapy
Wound Infection (superficial)
2 2 Subsided after treatment
Pain 5 2 Subsided after physiotherapy
Swelling 6 3 Subsided by the time of discharge
Less complications in group II
Group I= Late mobilization
Group II= Early mobilization
Hospital admission period -protocol
Pre-operative
Post-operative -on cast
Post-operative
-hand therapy
Total Admission duration
Remarks
Group I 1 week 3 weeks 4 weeks 8 weeks
Group II 1 week 2 weeks 3 weeks 6 weeks Less by 2 weeks
Result of hospital admission period
Average hospital stay Result
Group I 55.3 days (7.9 weeks)
Group II 46.9 days (6.7 weeks) Less by 8.4 days
Hospital stay reduced by average 8 days in group II.
Note: Principally it should be less by about 14 days, but patient are admitted
for RCS with stiff joints and sometimes with small ulcers, so it took slightly
longer than the protocol.
Claw correction of left hand- 12 years old boy
Claw hand correction
Pre operative Post operative
Conclusion
Early active hand therapy protocol (group II) is safe in leprosy RCS & improved surgical outcome-
Improved patient satisfaction
No tendon insertion pullout
Reduced complications
Reduced hospital stay by average 8 days.
Reduced physiotherapy staffs time, even though closed supervision needed during first week of hand therapy.
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