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.

Figure 5 - a characteristic deformity is the lunar drift of the fingers, which drift toward the small finger side of the hand at the metacarpophalangeal joint.

Figure 6 - The extensor tendons are the ones that are the most vulnerable.

Figure 7 - X-rays demonstrate scalped or punched out lesions of bone destruction adjacent to the joint.

Figure 8 - the carpometacarpal joint of the thumb is the next most commonly involved joint.

Figure 9 - the wrist joint, also referred to as the radiocarpal joint, is the next most commonly involved joint after the the carpometacarpal joint.

Figure 10 - adapted devices will also decrease the stress in the joints and improve the life span of joints afflicted with arthritis.

Figure 11 - a brace that helps to support the wrist in a comfortable position is quite useful.

Figure 12 - Example of gentle stretching exercises known as the ?Six-Pack? exercises.

Figure 13 - shows an application of Parafin C.

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

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.

Summary

Overview

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

Characteristics of hand and wrist arthritis

Hand and wrist arthritis is best considered in the two major classifications that we discussed above: Inflammatory arthritis and the common wear and tear arthritis referred to osteoarthritis. In inflammatory arthritis, such as rheumatoid arthritis, the patient so affected often has marked stiffness in the morning lasting an hour or more, swelling of the joints of the hands as well as the wrists, and if untreated medically, may develop permanent damage to the bone and cartilage and loss of the ability of the supporting structures such as the tendons to maintain the normal alignment of the joints of the hands and wrists. As noted in rheumatoid arthritis, a characteristic deformity is the lunar drift of the fingers, which drift toward the small finger side of the hand at the metacarpophalangeal joint. (Figure 5) Inflammation can also erode tendons, which rarely happens in osteoarthritis. Once the tendons are eroded, the digits can droop, which is known as an extensor lag. The extensor tendons are the ones that are the most vulnerable (Figure 6), Nodules can also occur about the hand and wrist as well as elsewhere in the body. These tend to occur over joint surfaces on the extensor portion of the hand prime area is the posterior region of the elbow called the olecranon, but these are also noted in the small joints in the hand

The treatment of inflammatory arthritis has been revolutionized by the recent introduction of new medications that are directed against the immune processes that cause the major damage. Etanercept, Infliximab, and Adalumumab are three new “biologic” agents that are now approved to treat rheumatoid arthritis and have had a huge impact in just a few years. The can effectively suppress inflammation and prevent damage to the joints. Older drugs such as methotrexate are still widely used and are often combined with the newer agents with excellent effect.

Types

As discussed above, the two main categories include the arthritis associated with inflammatory disease such as rheumatoid arthritis and with the frequently strong genetic history and the more much more common but less world defined osteoarthritis. Osteoarthritis rarely affects the soft tissues such as the tendons although joint ligaments can be damaged as the joints become deformed. In rheumatoid arthritis, soft tissue damage is one of the hallmarks and frequently there is tendon rupture causing a loss of hand.

Similar conditions

Incidence and risk factors

Diagnosis

Arthritis is diagnosed by the patient’s history, physical examination, as well has x-rays showing ‘punched out lesions’ and laboratory studies. Swelling and tenderness around the joints with limitations of motion is one of the hallmark signs of arthritis. Instability and deformity of the joint occurs later in the course of the disease. The following clinical features correlate with certain types of arthritis.

1. Rheumatoid arthritis: The ulna deviation of the deformity of the hand at the level of the metacarpophalangeal joint (See Figure 5). Nodules can occur, particularly on the extensor surfaces and it is frequently warm when the swelling occurs.

2. Laboratory tests: Rheumatoid factor is positive in approximately 80% of patients and a newer test the anti-cyclic citrullinated peptide is even more specific for rheumatoid arthritis. The erythrocyte sedimentation is often elevated as well. This is a general sign of inflammation that can correlate with infection or arthritis. It is not a specific test, but helps to monitor the course of the disease. X-rays demonstrate scalped or punched out lesions of bone destruction adjacent to the joint. (Figure 7) The joint surfaces are referred to as the articular surfaces, and therefore the fact that these lesions occur adjacent to these lesions adjacent to the joint surface or on the perimeter of the joint surface has resulted in the term, ‘periarticular erosions.’

3. Lupus: This is also much more common in women, and is diagnosed by an elevated antinuclear antibody (ANA). There may be joint deformity with x-rays demonstrating far less destructive changes than occurs with rheumatoid arthritis. Redness around the face occurs around the eyes and cheeks in a hallmark fashion that is referred to a butterfly rash and occurs in a majority of patients at some point of their condition.

4. Psoriatic arthritis: In the majority of these patients, the rheumatoid factor and antinuclear antibodies are negative, but erythrocyte sedimentation rate can be elevated. The patients demonstrate joint swelling that that can affect an entire finger or toe and is referred to as a sausage digit. Psoriatic arthritis can damage the bone and cartilage just as rheumatoid arthritis. Patients usually demonstrate a scaly psoriatic rash along the scalp, trunk, or arms or legs in the course of the disease.

5. Gout: Men more commonly develop gout than women. It usually occurs n the third and fourth decades of life. In addition to the hands, the big toe is commonly affected and titled Podagra for its presentation. The joints are hot and swollen when the gout is active. The majority of patients have elevated uric acid levels that are tested on blood tests and when the joint tapped and fluid is drawn from the joints, the sharp edge to gouty crystals are frequently seen in the joint fluid. Gout responds well to medications that diminish inflammation such as indomethacin or even prednisone. Allopurinol can be an excellent way to treat the patient on a long-term basis. The destructive or punched out lesions are present around the joints similar to rheumatoid arthritis, but when the crystal deposits become large enough, they form masses called tophi that can also be seen as a hazy, mass on x-ray.

6. Osteoarthritis: This condition is the most common and has the least characteristic signs. Radiographs are often quite classic with patients with development of changes in bone spurs with new bone formation outside the normal confines of the skeleton. The laboratory tests are generally negative. When fluid is dropped from the joint, there is noted to be an increased level of numbers of white blood cells, but far less than that occurs the types of inflammatory arthritis or gouty/crystal and arthritis described above. In osteoarthritis, the PIP joints are frequently affected. The distal phalangeal (DIP) joints are frequently affected. (Figure 3B). In addition, the carpometacarpal joint of the thumb is the next most commonly involved joint (Figure 8) followed by the wrist joint also referred to as the radiocarpal joint (Figure 9)

Medications

Although nonsteroidal inflammatory drugs (NSAIDS) like ibuprofen and naproxen as well as newer drugs rofecoxib and celecoxib can help to relieve symptoms in the majority of patients with arthritis. Braces that help to alleviate stress in the joints can be uniformly helpful. In addition, adapted devices that help to improve the leverage that the patient can apply to opening jars, cutting food, etc. will also decrease the stress in the joints and improve the life span of joints afflicted with arthritis. (Figure 10) When the thumb is involved, a special splint called opponents splint can be extremely helpful. (Figure 4B) When the wrist is involved, a brace that helps to support the wrist in a comfortable position is quite useful. (Figure 11).

Specific Drug Treatment by Diagnosis:

1. In order of increasing immunosuppressant power, available drugs include Hydroxychloroquine, Sulfasalazine, Azathioprine, and Methotrexate. Steroid medication has a rapid effect, but can cause a significant side effects such as osteoporosis. The disease modifying Antirheumatic drugs are referred to DMARDs.

2. Systemic lupus erythematosus: Treatment depends on disease severity. Steroids are the mainstay with Hydroxychloroquine, Methotrexate, Azathioprine, and Cyclophosphamide used as needed.

3. Rheumatoid arthritis: Hydroxychloroquine, Sulfasalazine, Methotrexate, Leflunomide, Etanercept, Infliximab, Adalumumab are medications that can be used in this disease.

4. Scleroderma (CREST Disorder): The acronym CREST stands for: C – calcinosiscutis R – raynaud’s syndrome E – esophageal motility disorders S – sclerodactyly, thickening of the skin of the fingers T – telangiectasia Medical therapy can include calcium channel blocking drugs, nitrogen paste, and infusion of prostaglandin analogs.

5. Psoriatic Arthritis: For the medical management of psoriatic rheumatoid arthritis, high-dose steroids should be avoided.

6. Crystalline arthropathies:

Gout The acute attacks respond well to high-dose non-steroidal anti-inflammatory drugs (NSAIDS), Colchicine can be used to prevent attacks. Oral and injectable steroids can also be effective. Allopurinol blocks the breakdown pathway of purines and was thought to be effective in preventing attacks of gout, but more recent evidence questions the efficacy of the drug.

Chondrocalcinosis (Pseudogout) Steroid injections into the inflamed joint and NSAIDS can be a very effective treatments.

Exercises

Possible benefits of hand and wrist arthritis surgery

Prior to surgery for the hand and wrist can be extremely helpful when other modalities such as drug therapy and splints no longer provide the patients with sufficient pain relief or improvement of function. When patients have difficulty performing even simply household tasks despite braces and therapy, surgery can be extremely helpful.

Reconstructive Hand and Wrist Arthritis Surgery includes one of four types of treatments:

1. Joint replacement surgery: This surgery corrects the deformed and arthritic joints to prevent the bone on bone contact that produces the severe grinding pain. It is particularly important where motion is a high priority, including the CMC joint at the base of the thumb, the PIP joint in the middle of the digits, and the MCP joints at the base of the digits as well as in the wrist.

2. Joint fusion or arthrodesis or fusion of the joint: Fusion eliminates the motion in the joint that produces pain by fusing the two bone surfaces together. Patients obtain relief of pain and stability, but they lose the joint motion. This is most successful in the small Dip joints, but can also be used in the wrist for a partial fusion or complete fusion.

3. Synovectomy to remove the inflamed joint or tendon lining: There is strong clinical evidence to suggest that the persistence of the swelling around tendons or joints referred as synovitis can produce severe destructive changes if careful medical management cannot eliminate the synovitis within a six month period of time. The synovectomy can relieve pain and prevent tendon rupture that causes severe loss of hand and wrist function.

4. Tendon repair and reconstructive surgery: In severe cases, once the arthritis has caused erosion of tendons with rupture, tendon reconstruction with transfers or grafting can restore function to the patient’s hand.

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

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

Pain and pain management

Use of medications

Effectiveness of medications

Important side effects

Hospital stay

Recovery and rehabilitation in the hospital

Summary of hand and wrist arthritis surgery for hand and wrist arthritis

References

Trumble TE: Principles of Hand Surgery and Therapy. Published 2000 by W.B. Saunders, Philadelphia, Pennsylvania, Chapter 23, Arthritis, p. 401-35.

Trumble TE, Rafijah G, Allan CH, North E, McCallister WV, Gilbert M: Thumb trapeziometacarpal joint arthritis: partial trapeziectomy with Ligament Reconstruction and interposition Costochondral Allograft. J Hand Surg [Am]. 2000 Jan;25(1):61-76.

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