LRTI Post-operative Rehabilitation Protocol: A Randomized, Prospective, Multicenter Study Comparing a Conservative Casting Regimen to an Earlier Mobilization Splinting Regimen

Abstract

There is no financial information to disclose. Increased immobilization after LRTI creates a more stable thumb and better outcomes. We prospectively randomized patients undergoing ligament reconstruction tendon interposition (LRTI) surgery into two post-operative immobilization protocols at two different institutions. Our ‘immobilization’ protocol consisted of post-op thumb spica splinting for 10 days, followed by forearm-based thumb spica casting for 5 weeks, followed by a custom forearm-based thermoplastic thumb spica splint for an additional 6 weeks – range of motion (ROM) started at 6 weeks post-operatively. Our ‘early mobilization’ protocol consisted of the same post-operative splint for 10 days, followed by a forearm-based thermoplastic thumb spica splint for 3 weeks, then a hand-based thumb spica splint for 4 weeks – range of motion was initiated at 4 weeks. Primary outcomes were the DASH, strength, Nine-hole peg test (NHP), VAS pain and patient satisfaction, ROM (wrist and opposition): these were measured pre-operatively, and at 6, 12, 26, 52, and 104 weeks post-operatively. Basic descriptive statistics were calculated. Differences in continuous variables were evaluated using Tukey confidence intervals following one-way ANOVA, using Box-Cox transformation as needed for data displaying non-constant inter-group variance or skewness. Differences in categorical variables were determined using the Chi-square test. A 95% confidence level (a = 0.05) was chosen. 234 patients were randomized over a 5 year period and demographics including age (average 62 years), sex, and associated diseases were identical between groups and across institutions. In general for all patients, DASH, VAS satisfaction and pain levels, and other functional measures increased significantly from pre-operative levels (Fig. 46-1), though interestingly there was an increase in 52 week VAS pain levels compared to 26 weeks, which significantly improved by 104 weeks. Pinch strength decreased by an average of 21% between 0 – 12 weeks, but improved 19% over pre-operative levels at 52 weeks, and by 26% at 104 weeks demonstrating the gradual, generally slow improvement seen LRTI (Fig. 46-2). Likewise, whereas VAS satisfaction was good at all points post-operatively, this continued to significantly increase between 6 and 52 weeks, then plateaued through 104 weeks. No differences were noted between treatment groups on DASH, VAS satisfaction and pain, NHP tests, strength, or thumb opposition at 12, 26, 52, and 104 week time points. •A conservative immobilization protocol does not improve functional outcomes, satisfaction, strength, or ROM following LRTI as compared to an early motion protocol.•Further study is required to determine whether even more aggressive early mobilization protocols are efficacious and safe.Figure 46-2Lateral pinch for both groups as a function of time showing gradual improvement to a level significantly greater than pre-operative values.View Large Image Figure ViewerDownload Hi-res image Download (PPT)