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A-1168 Restoring functional circumduction of the wrist after total arthroplasty
William Seitz, Cleveland, USA
Friday, June 15, 2018 · 11:29 a.m. · 22m 57s
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but that's all
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how what are are good morning on bill slides from the cleveland clinic in it is an honour to be here at the fashion meeting
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um and uh to be part of the h. the b. b. i. uh symposium
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um to begin with i'd like to uh recognise my collaborators a doctor's longingly
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who heads are by hand myopic annex a research laboratory at the clinic
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and to very brilliant young students from making that that team and jeremy last
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we've done a lot of the uh the uh research in the laboratory uh looking at some of the things will talk about
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i'd also like to sort of emphasise that this represents a collaboration
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of both clinical observation clinical execution of surgical procedures
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and uh the translation of bills concepts into the laboratory
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and then back to the clinical setting um
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and i hope that uh will be able to get the point across these are my disclosures
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so when we have an arthritic rest we have to ask what
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is the location of pathology which particular services are involved
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and uh and uh which are spare are there combination of such services
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and then what are our operate a option for management obviously we
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need to focus on the side of arthritis and reestablishing near
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or almost physiologically axis of motion to restore restore function to the patient
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a motion preservation of that is offered by a number of procedures short of a tall
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restart the plastic and if at all possible we try to use anything from uh
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a proximal record picked me to into carpal for corner fusion shark
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proceed your skin for intersection north reduces the real corporate joint
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before we get to tow restored the plastic and then ultimately remembering that tall restored produces
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is it is the ultimate salvage and in fact i never do a
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total restored plastic without having a knife reduces system in the room
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so we're gonna talk about preservation emotion through the uh
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through uh the the principles of total restart plastic
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and recognising that what we really need to do in in this eh when executing this procedure
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is to reestablish a radio carpal yeah kinda maddox
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system which provides function in the real world
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um basically are indications or pan carpal or and
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radio carpal arthritis need for functional motion
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good bone stock in this of differs substantially from the original um population of patients
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in whom a total rest was uh initially intended route white population
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we see very few rheumatoid is today unless they're burnt out remote so
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it's an have basically a u. n. stages two or three conditions
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uh who are candidates for total restored the plastic they must have good bone stuff
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they they should not be people with high demands because like many other of our
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implants in the upper limb uh they will they will fail if overload
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we we need to have an implant which has a nearly normal of carpal lever arm and we need
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to at least have partial restoration of a relatively normal
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into carpal axis of notation a motion and
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in the past we've thought about that as being you know flexion extension
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radio on the deviation then we've learned the importance the dart throws motion but in reality there's a three
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dimensional envelope that encompasses all that and that's what we're going to talk about in this um report
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so these up above or alternatively a motion sparing procedures
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and if you heard bryan adams in the last session given a excellent uh a tutorial on
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a total a wrist are for plastic pointed out that in fact you can convert
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p. r. c. a. four corner fusion or shark procedure to it will rest
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um procedure so those those should be your first line um
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motions sparing procedures if they can be performed uh
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but ultimately ultimately uh the total rest is is
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indicated when none of those are hot available
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so the rationale for joint replacement is to basically have a reasonably
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an atomic joint contour we've learned this in so many
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of our other joints if we try to design implant which
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does not manic normal anatomy usually does not fail
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and they can marks of our of our normal joint motion uh need to be reproduced and this tends
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to be in the lab so i'd second option which i'm gonna call ovoid action moving forward
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we simply it's very important again if you heard brian's talk in the last session choose to preserve and or
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repair your bowler uh ligaments if you do have to repair them they need to be protected longer
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um you need to provide a soft tissue bounce that
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may mean not even repairing your dorsal capsule but
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possibly augmenting it it it also may mean that you need to length in your extend your tendons
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oh and the been ultimately uh we need to have a enough time for healing
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and re education to provide motion and of course substantial pain relief
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the advantages is that retains the big cortical structure of just a radius
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and you should have from distal or carpal a fixation
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currently we tend to go across the corpus into the if index
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matter corporal and there are some problems with screws there i'm
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not sure that moving forward we need to do that we just need to make sure we have good fixation just early
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i need to have a a near centre of rotation axis of motion
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and this actually will include an envelope of centres of rotation and it allows for uh
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preservation and replacement and or replacement distal on a very important not to forget the pro nations super
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nation component of sir conduction or ovoid option and that requires some degree predation super nation
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just the ability to move isn't is not may not be enough you don't remove without pain at the d. r. u. g. a.
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with stability is also very important and so this is something that i think we need to look into
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a little bit more closely as we look at future designs for total wrist replacements disadvantages obviously
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oh are that it requires precise alignment and positioning it's not applicable with
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really bad don't stack is in some very uh bad remote twice
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the it requires balancing of the the form tissues and this is demanding and you have to be very careful you
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can be be imac immaculate in your positioning of the implants but at the end you need to test them
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and in fact if you do it right you should be able to take the radius and try to translate it
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in the shop position from dorsal to palmer and it should be very stable without causing any of the capsule
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and then you don't wanna over tighten anything and brian pointed out the last
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session you don't wanna over stuff and make it too tight either
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and it may not be suitable for advanced disease and again in in which case always have a backup in the room
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so i i question you know the really bad remote tight as as having good enough
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bone stock but is dry rheumatoid early cinematic rheumatoid where they they're being uh
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their diseases being modulator they may still have a a a a chance for this
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we do it most commonly impose dramatic cases whether p. just a radius fractures slackers neck rest and
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pen carpal osteoarthritis of varying forms in maybe crystal light or
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um or otherwise um and then they'll partial fusion
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spaghetti generally these have much better bonsai and as brian pointed out the last k. in last series
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i'm usually very good uh conditions for doing a joint uh are for plastic
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i can't indications are basically the same as they would be in any me to join
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so you wanna preserve the polar caps o. ligaments very important you need to have a stable d. r. u. j.
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i've found that if it d. r. u. g. a. is on stable and if i remove the dust all
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all the and try to do a capsule are fake it's still unstable and i move things more approximately
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create a little um a a receptacle for the for the uh overhead and do it on the head implant
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i uh so historically these are for sedentary people low demand uh in initially remote type
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and uh a historically had poor outcomes however we do have advancing
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technology as many of the speakers have a demonstrated today
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it is gone through a series of uh evolution so i won't repeat all of those
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and in the current generation our midterm clinical results really are uh quite encouraging
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uh the the rationale again is to preserve an atomic join contour per
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person uh reap reproduced reasonably normal kinda mad so the rest
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and again very important to preserve our boulder support ligaments don't
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over tighten the dorsal ones soft tissue bouncing again
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very very commonly in those it's wrist that starts out terrorist festive to to
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lengthen your your extensive tendons if needed an improvement motion and function
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so this is for these these are next you slide the from the study that my colleague actually did
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uh a number of years ago and published in the journal by mechanics looking specifically at
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workstation movements and and ideal positioning to avoid
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that a potential for repetitive motion problems
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and basically what he noted was that there was a three d. angular motion
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results from the interplay of the complex and you regularly shape carpal bones
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they're highly developed limit the network is described by a wheel to lays like
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when synergistic muscle action as best as a as
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demonstrated by uh be cannons and as so
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how recently been demonstrated the laboratory uh by my my colleague that the word or
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so when we look at the kinetic analysis at different levels uh of the corporate ball a risk complex
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again we see that flexion extension radio on the deviation
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and to some degree rotation have been measured
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um but we also recognise that motion in different directions
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measured simply by themselves with the coney arbiter of one form or another
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give us very limited almost sterile information however that's studies have suggested
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that motion in one direction affects motion capability in the others
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and hence a lot of the work that's been done by scott wealth and demonstrating the doctor was motion
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has indicated to us that there's an a. m. mid range
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oblique uh a market motion which is very important
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i think the next step is to think about what happens around that particular plane and develop a functional envelope
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and that's what we have called circuit option in the past however and this patient has had a a total
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wrist arthur blast the in the past me see very little difference with this other side it's a summation
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through the physiological action axes of motion in a three dimensional plane
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and that's what we focus on terms are out there
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here's a patient who had a bad just a radius fracture radio carpal into carpal
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arthritis preamp motion on the left post up motion on on the right
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and is this concept that it doesn't really go through true circular motion or suffer commotion
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body goes through an ovoid motion will show you the by mechanics behind that so
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well what we what the doctor lee did was take some healthy a young
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um and and having go through a functional tasks at a workstation level
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and looking looking at forty uh flexion extension rate all the deviation and recognising
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back in the early to thousands that's or conduction was an important component
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you put markers and use the dike um is is a camera system
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looking at a hundred samples per second to track motion uh and this is a arm to today's
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i'm sorry that's going on right now looking looking at the similar things too
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many tasks of daily living uh performed um in uh in in people
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what we see is that we get a bit in arc
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of uh of motion which varies from from uh
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a task the task the task but they all fit within
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this sort of oblique plane and around that oblique
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a plane line this is how it appears only prove you some all of those and we plot them on a on a graph
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and you can see that very if the there's nothing uh that is circular we saw that in
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many of the studies to degrade you pointed that out in yours and and i think that
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that one of the things that happens regardless of whether we think we have a set single set of rotation
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the normal forces and the egg and the the constraints of all the soft tissue envelope
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require us to go through more of an oblique motion and can possibly change what we think is a fixed centre
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oh this is this is uh what that the current study that's going on now i'm
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a in our laboratory and we're looking at normal healthy subjects doing many many activities
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calculating a lot of a lot of this data and we'll move forward
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into some of the disease states in post operative states moving forward
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however it was my experience that when i get a total rest replacement annotation wore a p. r. c.
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or for core or short procedure patients that were happy said look what i can do that
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and this was what was important to them and if you just think about as surgeons
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putting a suture it guy respecting a piece of tissue screwing in a screw the things that you have
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to do a now that we have to do in order to this act and so forth
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it's not there's nothing that we do in the single plane the same is true with musicians and so forth
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so basically what actually did back in the early two thousand
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scored it'll take whizzed basically create these you are angles
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and get a correlation and regression analysis of what this to to what what what
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this represented and what you can see is that there is a natural arc
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but what one of the things that doctor walters shown way back is that if you extend the rest
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use rate is radial deviation involved when you flex the rest there's only deviation involved
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and that's the natural arc that we today call the door throws motion
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but i i you the fact that there's a large envelope around that linear
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doctors angle in which we do everyday activities
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and i would be labour that's but ultimately ultimately uh we could we could get demonstrate that for every task
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here's this envelope and get smaller as you limit some of the motions
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and it's very interesting that you may be able to measure wide radio on the deviation but if
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you only have a little bit of flexion if you only have five degrees of flexion this
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envelope gets smaller and limitation in any one plane will limit the
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motion in all planes when it comes to functional rotational movement
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and these are this is the calculations that doctor lee uh it went through
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to uh to demonstrate this in terms of constraining motion in certain planes
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similar to the work that david nelson did that was referred to by by fred
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uh that uh that demonstrates that limiting motion still
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can provide a certain envelope of functional activity
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but learning it the more you limit the with that are just going to be
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so this circuit action or is i'm calling it now all white option in the health the rest is h. shaped
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the first has the greatest range of motion at the anatomically neutral position so if we start out here but provide
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adequate motion at all around the mid replaying it doesn't have to be full it can be very functional
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and in fact i think in one of in in one of the last slide
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so shown by brian out of maybe showing a patient with very good results
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who actually you could see only had about fifteen degrees of extension but had a very functional arc of ovoid option
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so here's a case example the seventy four euro man went avian eliminate
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and it ultimately a slack kristen pan carpal radio carpal
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arthritis we did this operation in probably about
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fifteen years ago or eighteen years ago i think this is uh the last generation of these
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and um this is another patient who had a slack rest uh
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we did a we did a yeah a shark procedure in
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um and ultimately um did converter that to a total rest their owner was long
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and and not a on stable so we did a yeah only have replacement
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well we're all we've done forty six patients primer these uh primary cases no revisions
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thirty two men fourteen women why change from but some of them are
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young fifty eight eighty three the average age is about sixty four
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most were osteoarthritis that nine rheumatoid all were burnt out remote twice with good
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bone stock and twenty nine had had some form of prior surgery
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uh fifteen had a fifteen patients require only have replacement for stability
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and thirty one uh uh were um radio carpal replacements only
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again this is the kind result just see see somewhat limited in extension
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uh but bilaterally very functional um sir conduction air ovoid option
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so basically these demonstrated the very promising mid
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to long term results we've all these
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now for for a number of years for eighteen years at the most
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um that that one patient there was the what was the one who's x.
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rays actually and he's the uh the longest file up i have
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um basically uh in this series we did not have any infections we did not have any any uh
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dislocations or sublet stations i think you know when the when you put the implants in reasonably well
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instability is not a problem it's stiffness it's a bigger problem and they can
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lead to loosening as well we've done two revisions in this group
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thought to secondary do that just to uh and and we did it we
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too we added a d. r. u. j. secondary uh um implants
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and overall i the flexion extension art was about eighty degrees
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of motion but everyone had a functional sir conduction
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and of the uh of the entire forty six forty five said that they would go through it again
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so restoration of function really requires the ability to restore this
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so rotational avoid dutch and it is a combination of the radio carpal
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well i'm kinda mad river or we could re creation as well as
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the d. r. u. j. uh motions stability and freedom from pain
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and is it just a an example a patient in the upper left is at his right wrist done is left
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is still quite stiff it needs to be done you can see the difference in the motion in the upper right
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patient on the lower right is had both done as as one in the middle german on the left
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uh had the a just just a um a left and the one on the right uh huh right
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there we go so this is what's going on in our laboratory today
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oh i hope to be able to uh within about two years
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be able to be the same data with patients prix and post op with arthritic wrist
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i'm in a variety of a wrist um a motion preserving procedures
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um and ultimately as you can see what as the as the per as
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the as the tracking is going on we can pick up these uh
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these trace things again which all of ten to sit within a
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or oblique central line but it but a three dimensional envelope around so
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based on based on uh my only observations
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um i i wanna share something with you i was asked let two years ago at the hundred fiftieth uh
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anniversary than your cord pinnacle hospital where i did my training um to
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give a a a talk on what i thought was the most significant
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development in upper limb surgery in my thirty four years impact us
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and uh i an idea did so and i said that uh
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uh that that that that i would and i said the most significant was also the worst had nothing
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to do with the upper limit first it was the development of charlie's low friction arthur plastic
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in the hat and is most important because this gave us
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the concept that we could save joints and make people
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better turn around lives of severely arthritic people and
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give them give them their uh mobility back uh and it's and it was also
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an extremely important concept which is translated into
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the upper limb at every articulation
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and we're getting better at it and no question that we're able to put reduce pain and preserve or restore function
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but it's also all the worst and why it's the what is it the worse 'cause this is still all we're doing for
00:21:47
treating are bad arthritis and the reason that ad is money
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the implant manufacturers are invested heavily in metal and plastic
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i thought for sure when i first entered into practised in nineteen eighty five but i would no longer be
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doing these types of procedures but we still are because that's all we can do
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you see the major grants that are being given a by
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things like the n. i. h. another um institutions
00:22:16
for the study of of recruit recreating um biologic joints and the range
00:22:23
the realm of about one point three to two million hours
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that's a rounding error for some of the big companies we need to get the
00:22:31
big companies involved in investing in biology again and this is uh
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my challenge to the next generation of engineers and surgeons
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don't focus so much on metal and plastic things more
00:22:43
about translating what our engineers teaches about normal
