Advances in Hand and Wrist Arthritis Surgery.

Edited By: Magee E. Saewert, MS, PA-C, Thomas Trumble, M.D.
Last updated Tuesday, March 28, 2006

Figure 34A - an incision to raise two small flaps on the dorsum or the back of the finger.

Figure 34B - a series of small wires woven between the two bones.

Figure 34C - using small hollow or cannulated screws that can be placed over a guide wire in order to secure and compress the joint surfaces.

Figure 34D - using small hollow or cannulated screws that can be placed over a guide wire in order to secure and compress the joint surfaces.

Figure 35 - joint fusion.

Figure 36 - Special sizes are used to select the correct implant

Figure 37 - Trial implants are used to insure that the measurements are correct.

Figure 38 - Special cutting guides are secured to the bone with pins and a power saw then trims the bone edges.

Figure 38A - the flexible implant in the joint.

Figure 38B - flexible implant with the repaired soft tissues.

Figure 39 - Special reaming devices prepare the canal so that there is an intimate fit for the components avoiding the need for bone cement.

Figure 40 - Another guide is attached to the bone in order to provide for accurate drill placement for the screws that will stabilize the implant to bone.

Figure 41 - a diagram of the plate applied to the wrist.

Figure 42 - a diagram of the plate applied to the wrist.

Figure 43 - the inflamed tissue is highlighted in pink.

Figure 44 - the tendon to the ring finger has ruptured with a loss of material so it can no longer be repaired primarily.

About the procedure

Technical details

The types of techniques used vary depending on the location f the problem and the severity of the problem, and the activity level of the patient. The patient’s anatomy and the duration of the arthritis play also have an impact in designing the correction procedure that is right for each patient. The procedures listed below are representative of the types of treatments that are available for the different locations and problems, but no mean all inclusive.

1. Arthritis of the DIP joint (Figure 14)
   When the patients have pain and deformity that limits them and impairs their function, joint fusion surgery is often recommended. Joint replacement surgery can be performed in patients with low demand and limited activities, but for most active patients, the DIP joint fusion is more practical. The technique involves making an incision to raise two small flaps on the dorsum or the back of the finger. This allows the bone surfaces to be trimmed (Figure 34A) and brought flush with either a series of small wires woven between the two bones (Figure 34B)or using small hollow or cannulated screws that can be placed over a guide wire in order to secure and compress the joint surfaces(Figure 34C&D). The screws can be left in permanently whereas the small longitudinal wires (as shown in the figure) are removed six to eight weeks after surgery in the office. Post operatively, the patients wear a splint for protection for one or two weeks and then they can usually wear small splints covering the fingertips to protect them while the fusions heal, but while still allowing motion in the joints. The fusions usually become solid in six to eight weeks, but patients can do lighter activities until that time.

2. Arthritis of the PIP joint (Figure 16)
   Although joint fusion can be performed for this joint (Figure 35) in most cases, the surgeons try to preserve motion in this very critical joint. A curving incision is made over the dorsum of the finger so that the arthritic bone ends can be trimmed and the bone canals enlarge with the use of small reaming devices (Figure 18). There are different types of joint replacement available. When the ligaments and other soft tissues have not been damaged by the arthritis, a special joint replacement is available with FDA approval for humanitarian use with articulating implants in special research hospitals. That means that the implants can actually glide on top of one another similar to the way normal joint functions. Special sizes are used to select the correct implant (Figure 36) and trial implants are then used to insure that the measurements are correct (Figure 37). The final implants are then tapped into position and the joints tested in a range of motion to confirm that the motion has been restored (Figure 19). The implants do not require cement, but do require an intimate bone fit for stability, which requires extremely precise surgery Joint motion is begun in a protected protocol at five days. On your first visit, the hand therapist will fabricate 2 thermoplastic splints: a dynamic splint with rubber bands that allows protected exercise of the new joints, and the second splint is used at night to protect the new joints while sleeping. The hand therapist will also instruct the patient in a gentle protected exercise program The patient should be aware that stitches remain in place for approximately 2 weeks from the time of surgery, and that it is normal for the hand to remain swollen for some time. The therapist will review signs of infection to watch for, and the patient is advised to contact the physician or therapist immediately if they are having any increased pain, swelling or other signs of infection.

3. Arthritis of the metacarpophalangeal joint (MCP) (Figure 20)
   most frequently occurs with rheumatoid arthritis, but can occur in cases of osteoarthritis as well as other types of arthritis less frequently.

The type of surgery and implant selected depends on the degree of destruction of ligaments and other soft tissues. When the patients have a severe ulnar drift deformity, meaning that the fingers angle towards the small finger side of the hand (Figure 7) is important to use more stable implants that can be inserted into both bone canals of the finger as well as the hand (Figure 38 A&B). When all four fingers are involved, a transverse incision over the knuckles or the MCP joints can be performed for surgical exposure. When only one or two digits are involved, longitudinal incisions can be used. The tendon is incised longitudinally. Arthritic metacarpal heads are removed (Figure 38A) and the bone canals are enlarged using special power reaming devices (Figure 38B) For patients with significant ligament destruction, efforts are made to suture the ligaments back into position and place the stem shaped silicone rubber implants that have one stem in each canal in order to help support the joint and restore alignment (Figure 21) When the ligaments have been preserved, special articulating implants can be used that restore more gliding motion as the implants glide upon one another similar to the way the actual joint performs (Figure 20-23).

1. Arthritis of the basal joint of the thumb
   Arthritis in this joint severely disables patient function (Figure 24). A key factor is whether only the single bone serves between the thumb metacarpal and the small square bone called the trapezium are affected or whether the bone surfaces on either side of the trapezium are affected with destructive arthritis. When the arthritis only involves the CMC joints, the single (the CMC joint) efforts are made to spare the other joint and only a portion of the square trapezium bone is removed in order to insert a bone spacer (Figure 26). A variety of different materials are available including silicone rubber implants and in many cases are performed at the University of Washington Medical Center, a special allograft cartilage can be designed specifically to the patient’s specifications and inserted. (Figure 25) demonstrates the partially carved specimen being with the excess portion being used as a handle to measure the size of placement to restore the normal height between the two bones as demonstrated on the x-ray. The cartilage is radial loose and does not show on the x-ray, but does restore the normal height between the two bones and prevent the bone on bone contact that causes pain.

2. Arthritis involving only a portion of the wrist joint (SLAC) arthritis, which stands for Scapholunate Advance Collapse Arthritis.
   In this pattern of arthritis, the most severe pain is on the radial or thumb side of the wrist as arthritic changes occur between the scaphoid and the radius (Figure 27). For this type of arthritis, the most common procedure recommended is the partial fusion of the four bones on the ulnar side of the wrist and the removal of the painful contact between the scaphoid and radius by removing the scaphoid bone. As demonstrated by the video below, a straight incision is made over the back of the wrist, also known as the dorsum. The tendon to the thumb (the extensor pollicis longus) (EPL) is released from this compartment and retracted to one side of the wrist. The scaphoid bone is cut in half and then removed, first removing the proximal half close to the wrist using small levers or osteotomes as demonstrated in the video, and then the distal or the portion closest to the fingertips is removed with a special curved scalpel blade. A small saw or osteotomes can be used to remove a window bone from the radius so that bone graft can be used. Bone graft from the patient’s own bone provides the best quality materials to stimulate bone fusion. The defect in the radius where the bone graft has been harvested can be filled with a bone substitute. High-speed burrs remove the bone from the surfaces where the fusion is desired striping away all the cartilage remnants enhances the fusion. Any cartilage remnants in the arthritic area inhibit the bone fusion. Guide wires are then used to stabilize and correct the deformity and additional wires are used to hold the position. The fore bones are fixed together, and this can be done in a variety of methods, but one way that is very stable and minimizes the amount of time that the patient needs to spend in a cast is a small circular plate referred to as a spider plate. This is placed into a conical defect prepared with a special reamer and then small screws are used to stabilize the plate since eight screws span out from the center of the plate, they resemble the legs of a spider, and hence the name. The capsule and soft tissues are then repaired and a drain is frequently used that is brought out through the skin to prevent the formation of hematoma and clots beneath the skin. The patient or the family can then remove the drain the following day at home using the instructions that are provided at the time of the discharge from the surgery. The special ring like plate then fuses the four bones together (Figure 28).

3. Arthritis involves the entire wrist joint (Figure 29)
   When the arthritis involves the main joint, the two main choices are joint replacement and joint fusion. Joint fusion provides a stable wrist, but no motion is stronger than a joint replacement. Joint replacement preserves motion, but of course the cost is decrease in overall motion and a higher chance of higher complication such as dislocation of the implants or loosen. For replacement surgery, a longitudinal incision is made over the dorsum or back of the wrist. Once the tendons are protected and retracted, a flap of the joint capsule is elevated off the radius for use in reconstruction of the wrist once the final implant has been placed. Special cutting guides are secured to the bone with pins and a power saw then trims the bone edges to provide the correct fit for the joint replacement (Figure 38). Special reaming devices prepare the canal so that there is an intimate fit for the components avoiding the need for bone cement (Figure 39). Another guide is attached to the bone in order to provide for accurate drill placement for the screws that will stabilize the implant to bone (Figure 40). Trial implants are used to insure that the correct fit will be obtained with the final implants (Figure 30). When the soft tissue tension has been balanced, the final insertion components are inserted.

4. Total wrist fusion for a patient with arthritis of the wrist joint.
   Using a similar exposure of the entire wrist and the distal portion of the form is exposed so that the bone surface can be denuded a special plate is applied that helps to lock together the radius, the carpus, and the metacarpal to the middle finger using small cortical screws. (Figure 41 & 42) This is designed to fit intimately with the bone and minimize the irritation of the soft tissues of the tendons and skin gliding over the plate. A protective splint is used after surgery for approximately six weeks and then exercise can begin with a removable brace. This technique eliminates all wrist flexion extension but preserves the rotation of the forearm.

5. Persistent synovitis of the hand and wrist
   This most often occurs in rheumatoid arthritis with bulging symposium along the course of the wrist (Figure 43). Once the inflamed tissue has been removed by incising the layer around the tendons called the reticulum, a portion of the reticulum is then placed beneath the tendons and a portion is left on top of the tendons to both protect and prevent synovitis from invading the tendons again and to prevent the tendons from shifting during wrist motion particularly during wrist extension. Often times, the end of the ulna has become destroyed from the arthritis and creates sharp surfaces that can abrade or cut into the tendons. If that is the case, this is then trimmed and removed and a layer of soft tissue is wrapped around it .

6. Repair and reconstruction of ruptured tendons
   There are many different patterns of tendon ruptures that can occur, and the surgeon needs to design the correct reconstruction for each pattern. In some cases, this can be performed by rotating the ruptured tendon into a nearby intact tendon (Figure 44). In this figure, the tendon to the ring finger has ruptured with a loss of material so it can no longer be repaired primarily. It has been attached to the adjacent middle finger so that the two will act together.

In other cases, a tendon needs to be removed from an area where a tendon can be spared and rotated and attached to support a tendon that has ruptured. Also shown in the figure is the transfer of the tendon to the index finger referred to as the extensor indicis proprius (EIP) to support the small finger. The small finger tendon was too severe in angle to attach it to the middle finger and a more direct routing can be performed with an end-to-end repair by transferring the EIP to the small finger extensor tendon also known as the extensor digiti quinti (EDQ). After the tendon reconstruction of surgery, dynamic splints have to be used with special rubber band traction to help maintain the alignment of the digits and allow protected joint motion without causing the tendons to rupture. This protective splinting needs to be maintained for approximately six weeks after the surgery.

Anesthetic

Length of hand and wrist arthritis surgery

Surgery for Hand and Wrist Arthritis at the University of Washington

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