Advances in Hand and Wrist Arthritis Surgery.

Figure 14 - demonstrates significant painful arthritis and joint destruction.

Figure 15 - demonstrates a fusion of a painful DIP joint.

Figure 16 - The PIP joint is extremely important to hand function and flexibility.

Figure 17 - demonstrates destructive changes on x-ray of a painful PIP joint.

Figure 18 - demonstrated the polished black implants being placed at surgery.

Figure 19 - Final implants tapped into position.

Figure 20 - 3. Metacarpophalangeal joint (MCP).

Figure 21 - flexible silicone implants can be used when patients have pain and arthritis.

Figure 22 - demonstrates the replaced MCP joint x-ray.

Figure 23 - shows the polished pyrocarbon implants being placed at surgery.

Figure 24 - shows the painful bone on bone contact at the CMC joint and the large bone spurs referred to as osteophytes.

Figure 25 - shows the placement of the donor cartilage into the joint space.

Figure 26 - demonstrates the joint replacement on x-ray.

Figure 27 - SLAC arthritis

Figure 28 - the ?Spider plate?.

Figure 29 - more extensive arthritis and the entire wrist joint is involved

Figure 30 - wrist replacement surgery.

Figure 31 - wrist replacement surgery.

Figure 32 - The swollen, inflamed material around the tendons causes erosion and eruption of the tendons.

Figure 33 - Tendon reconstruction

Considering surgery

Types of surgery recommended

The type of surgery that is recommended is probably best described by reviewing the joint that is affected in arthritis of the hand and wrist.

1. Arthritis of the DIP joint (Figure 14).
   Figure 14 demonstrates significant painful arthritis and joint destruction. Although small joint replacement can be accomplished for patients with arthritis without deformity, for most patients with arthritis, a fusion is often recommended (Figure 15). Figure 15 demonstrates a fusion of a painful DIP joint.

2. PIP joint (Figure 16).
   The PIP joint is extremely important to hand function and flexibility. Figure 17 demonstrates destructive changes on x-ray of a painful PIP joint. It is often referred to as the ‘soul of the hand’ because it is so critical for finger and hand motion. When painful arthritis occurs with destruction of bone on bone contact, joint replacement surgery is considered. (Figure 17, 18). Figure 17 shows an x-ray of the replacement PIP joint and figure 18 demonstrated the polished black implants being placed at surgery.

3. Metacarpophalangeal joint (MCP) (Figure 20).
   Destruction and deformity of the metacarpophalangeal joints often with ‘punched out defects in the bones’ are a hallmarks of rheumatoid arthritis as shown in figure 20. When deformity and arthritis is present especially in multiple joints, flexible silicone implants can be used when patients have pain and arthritis as demonstrated in figure 21. (Figure 21). When patients have significant arthritis but no deformity, replacements can be used that reconstruct joint surfaces and allow maximum motion components that can glide on top of one another (articulate) that more closely resemble the original joint. (Figure 22, 23). Figure 22 demonstrates the replaced MCP joint x-ray and figure 23 shows the polished pyrocarbon implants being placed at surgery.

4. Arthritis of the thumb basal joint (CMC Arthritis) (Figure 24).
   Figure 24 shows the painful bone on bone contact at the CMC joint and the large bone spurs referred to as osteophytes. Depending on the extent of the arthritis and the instability of the joint, joint replacements need to be designed to address all the structural problems that are caused by the arthritis. The key feature is providing the removal of the bone on bone contact. Donor cartilage restores the space between the bone surfaces with cartilage that is from the tissue bank that is carved to the particular patient’s dimensions. (Figure 25, 26). Figure 25 shows the placement of the donor cartilage into the joint space and figure 26 demonstrates the joint replacement on x-ray.

5. Arthritis of the wrist
   When the arthritis does not involve all the joint surfaces such as found in the SLAC arthritis, (Figure 27), a partial wrist fusion can be extremely successful in relieving pain while still preserving some joint motion. In this fusion, several arthritic bones are fused together using a small ring-like plate that has been referred to as the ‘Spider plate’ because of the way the eight screws branch out like the likes of a spider. (Figure 28). Surgery is performed with a special technique that uses specialized instruments to remove the arthritic bone surfaces and fuse them together while preserving joint surfaces that are normal to preserve joint motion. (See Movie SLAC Arthritis). When arthritis is more extensive and the entire wrist joint is involved (Figure 29), the surgeons needs to perform either wrist replacement surgery where the joint surfaces are removed and are replaced with an artificial joint (Figure 30, 31), or perform a wrist fusion surgery. Joint replacement surgery is indicated for patients with many areas of arthritis in their hands, arms and legs with a lower activity level and need to preserve as much motion as possible to do their activities of daily living. Wrist fusion surgery is indicated for patients who are active with involvement of only a single wrist and sparing the opposite wrist. Wrist fusion relieves pain and provides stability, but eliminates wrist motion. This technique is particularly helpful where an injury has caused the destruction of one wrist joint but the opposite wrist joint has no evidence of arthritis.

6. Tenosynovitis of the Hand and Wrist
   This commonly occurs on the wrist in patients with rheumatoid arthritis, particularly on the dorsum or backside of the wrist. The swollen, inflamed material around the tendons causes erosion and eruption of the tendons. (Figure 32). An incision has to be made over the tendons and the inflamed material thoroughly removed. Studies have clearly shown that removing the inflamed synovium early (tenosnovectomy) dramatically decreases the rate of tendon rupture.

7. Tendon reconstruction
   Once the tendons have ruptured, a lag or loss motion has occurred (Figure 6) reconstruction of the tendons needs to be performed, frequently using tendon transfers where an intact rupture tendon is sutured to an adjacent intact tendon or tendon grafts where a motion of one tendon that is not essential is used to splice into or graft a ruptured tendon. (Figure 33). Consideration for arthritis surgery for the hand and wrist should be considered in more cases.

Downloads

• SLAC Arthritis Video (5.25 MB)

Who should consider hand and wrist arthritis surgery?

Patients with severe joint pain that interferes with simple daily activities or sleep

• Swelling around tendons despite six months of appropriate drug treatment to reduce the arthritis should consider a synovectomy.

• Joint replacement or joint fusion surgery

• Tenosynovectomy to prevent tendon rupture

• Patients who have had tendon rupture with loss of function should consider reconstructive tendon surgery.

What happens without surgery?

The outcome depends on how the arthritis has manifested itself.

• Patients with severe joint arthritis can notice loss of function over time with increasing pain. The rate of symptom change with arthritis can be highly variable. In some cases, in joint arthritis a deformity develops over time that requires more extensive reconstructive surgery if the initial surgery to replace or refuse a joint is delayed. The particulars depend on the individual case and should be reviewed with a hand surgeon skilled in the treatment of hand and wrist arthritis.

• Patients with persistent swelling around the tendons (tenosynovitis) have a high risk to go on to tendon rupture. Tendon rupture result in significant loss of function that require much more extensive reconstructive surgery with a much longer period of rehabilitation. A simple tenosynovectomy can prevent tendon rupture and allow patients to return to activities within two to four weeks. Once a tendon rupture has occurred, much more extensive surgery is required and the rehabilitation period can take several months.

• Permanent stiffness can develop once tendons have ruptured. If patients develop stiffness following tendon rupture, their outcome following reconstructive surgery is much more limited than if the joints repair supple and flexible. The rehabilitation period takes several months and usually requires some period of immobilization to protect the repair of reconstructed tendons. If patients have joint stiffness prior to the surgery, the stiffness can be much worse during the period of immobilization after the surgery.

Surgical options

The type of surgery depends on the way the arthritis has manifested itself causing:

• Joint destruction • Tendon swelling and inflammation • Tendon rupture

The joint that the arthritis is involved also plays a large role in what type of reconstruction would best improve the patient’s function. Another important factor is the patient’s activity level. Younger patients are more active will provide such severe stress to replace joints that they will often break or dislocate. Although the recommendation appears paradoxical, joint fusions are more likely to be recommended for the younger, active patient who will provide significant stress on the reconstructive joint.

Effectiveness

Joint replacement surgery can be very effective in restoring comfort and function to the hand of the well-motivated patient. The greatest benefits are often the ability to sleep without the need for protective braces and the ability to perform the usual activities of daily living. As long as proper hand care is preserved and subsequent injuries are avoided, the benefit can last for decades.

Joint fusion surgery is extremely durable because the bones are solidly fused. The difficulty becomes in active patients who have joints that are involved on either side of the fused joints. The patients supply added stress to the unfused joints and occasionally this can exacerbated the development of arthritis in these joints. Tenosynovectomy surgery can provide long lasting and even permanent relief. Tenosynovectomy can dramatically reduce the risk of tendon rupture in rheumatoid arthritis. Tendon reconstruction surgery is often the only way that patients can regain function after tendon rupture. This usually provides permanent function for the patient and disease rarely occurs in the reconstructed tendons.

Urgency

In most cases, surgery for hand and wrist arthritis is not an emergency. Probably the most urgent case for such surgery occurs in patients who have increasing symptoms with long standing tenosynovitis that has not responded to drug therapy. The concern is that these patients are a risk for tendon rupture and that urgent surgery can prevent the need for a more extensive surgery to reconstruct ruptured tendons. In most cases, the surgery is elective and can be scheduled at the patient’s convenience. Before the surgery is undertaken, the patient needs to: 1. Be in optimal health 2. Understand the risk to alternative surgery 3. Understand the post operative rehabilitation program 4. Have the appropriate adjustment of medications prior to surgery in order to prevent increased bleeding or infection that can occur with some of the more potent arthritis medications.

Risks

Managing risk

Surgery for Hand and Wrist Arthritis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington

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