“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.