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 1 - Inflammatory arthritis and rheumatoid arthritis manifest themselves in very different forms.

Figure 1a - For additional information regarding hand and wrist arthritis, please see our textbook titled, Principles of Hand Surgery and Therapy

Figure 2 - the hand on the left has not had corrective surgery while the hand on the right has been corrected with surgery including joint replacement.

Figure 3a - In rheumatoid arthritis the MCP joints are most often affected.

Figure 3b - In osteoarthritis the DIP joints are most frequently affected.

Figure 4a - the thumb CMC joint.

Figure 4b - This splint helps to support the thumb and improve the patient?s function with grip and pinching activities.

Summary

What are the key points about hand and wrist arthritis surgery for hand and wrist arthritis?

Arthritis of the hand and wrist occurs in one of two major forms: inflammatory arthritis, including conditions such as rheumatoid arthritis, and the more common form of degenerative arthritis is known as osteoarthritis. For additional information regarding hand and wrist arthritis, please see our textbook titled, Principles of Hand Surgery and Therapy. (Figure 1A)Inflammatory arthritis such as rheumatoid arthritis, have evidence of an autoimmune malfunction where the body appears to be attacking its own joints. These conditions often have a hereditary component and can often be diagnosed with specific blood tests such a rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), antinuclear antibodies (ANA) and erythrocyte sedimentation rate (ESR). Many types of inflammatory arthritis also produce systemic illness. Osteoarthritis is not associated with any clear hereditary pattern although it does seem to be more pronounced in certain families. There are no corresponding blood tests to confirm the diagnosis of osteoarthritis and is more of a rule out diagnosis or exclusion once forms of arthritis have been eliminated from the diagnosis. As seen in Figure 1 the two forms of arthritis manifest themselves in very different forms. Inflammatory arthritis and rheumatoid arthritis creates clear-cut areas of destruction of the bone with loss of the overall architecture of the joint. In osteoarthritis, the body attempts to heal the joint destruction and create bone spurs known as osteophytes that extend pass the normal confines of the bone. After performing a clinical examination and obtaining the necessary laboratory tests as well as x-rays, the physician managing the arthritis can actually diagnosis the type of arthritis in most cases in order to determine the best type of medical treatment. Recently, a number of newly designed medications, such as Etanercept, a medication that inhibits an immune messenger know as TNF, have been designed to address the immune dysfunction that occurs in diseases such as rheumatoid arthritis and psoriatic arthritis. In inflammatory arthritis, the joint can frequently undergo significant deformity. One characteristic in rheumatoid arthritis is the ulnar drift or the drift where the fingers all rotate toward the small finger. (Figure 2) For these patients, special night splints can be fabricated in order to minimize or slow the progression of the joint deformity. The splints can be custom fabricated by a hand therapist using special thermoplastic material that can be molded to the patient’s hand. The frequency that the joints are affected are effected provides a pattern that is characteristic of a certain type of arthritis. (Figure 3A and 3B) In osteoarthritis, the small joint near the fingertips (distal interphalangeal) (DIP) joints are often affected first with minimal functional loss although often with significant cosmetic deformity. The thumb carpal metacarpal (CMC) joint is frequently affected in osteoarthritis, particularly in women. In osteoarthritis, braces that help to support the thumb when it is involved or the wrist can help relieve the patient’s symptoms and avoid or delay the need for reconstructive joint surgery. (Figure 4A & B)

Often combining these splinting and therapy techniques with anti-inflammatory medication can provide the patient with substantial periods of relief and improve their function.

When these techniques do not work and the patient has pain or loss of function reconstructive surgery with joint replacement surgery or tendon repair is often required to relieve pain and improve patient function. The pain occurs when the arthritis has caused destruction of a joint or tendon. To perform replacement surgery and tendon repair surgery, it is best performed by a surgical team skilled in hand surgery with a special emphasis in the reconstruction of arthritis. Such a team can maximize the benefits and minimize the risks. The operations can usually be performed under regional or general anesthesia as an outpatient. In regional anesthesia, the patient’s arm is made numb with a nerve block and mild sedation is used. Patients are encouraged to begin motion after surgery, depending on the exact type of operation that has been performed. In many cases, the hand therapy is coordinated with therapy in advance.

• A patient interview with UWTV

Surgery for Hand and Wrist Arthritis at the University of Washington

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