by Nancy Callinan, MA, OTR, CHT
When arthritis strikes the hands or wrists, it can change how they look, cause pain, and make it difficult for us to do things we’ve taken for granted, from opening a door to grasping a cup of coffee to working at a computer. There are numerous joints in the hand and wrist, and arthritis can affect any of them. (For more information about these joints and the makeup of the hand and wrist, see “The Hand and Wrist.”) There are also many different surgical options for each joint.
Surgery isn’t necessarily the best option in every case. Doctors usually try conservative measures first. These can help reduce pain and inflammation while slowing the rate at which the arthritis worsens. Conservative management of arthritis may include medicines, rest, exercise, heat or cold treatment, activity modification, and the use of splints. Corticosteroid injections may control symptoms that affect only one or two joints. Often these conservative methods are effective in managing arthritis. If they don’t provide adequate relief, or if the arthritis has affected the position of the fingers or wrist so that the hand can’t function well, surgery may be the answer.
Everyone is affected by arthritis differently, and the decision to proceed with surgery is a very individual one. Many factors have to be weighed, including the type of arthritis, the damage it has done, how quickly it is getting worse, the individual’s health, the individual’s activity level and job requirements, the surgical options available, and the individual’s goals.
If you are considering hand or wrist surgery, it’s a good idea to start off by finding a qualified surgeon with whom you can discuss the options available, what goals are realistic, and the expected outcome. (To find a surgeon, ask your primary-care physician or rheumatologist to make a recommendation. You can also check the Web sites listed in “For More Information.”) For some people, the main goal is pain relief. Others are more concerned with restoring lost function or with improving the hand’s appearance. In any case, the surgeon needs to understand your particular goal or goals so he or she can tell you what options might help you reach them, and whether your expectations are realistic. So that you can make the most informed decision, the surgeon should also discuss with you the possible risks and complications of any surgery. You should also understand that in many cases, the surgery won’t really be successful unless you are careful to follow an after-surgery program of therapy and splinting. You may also face restrictions on some activities for a time after surgery. It’s vital that you understand this ahead of time because if you don’t follow after-surgery recommendations, you won’t get the full benefit of the surgery. In a sense, it will have been a waste of time. The best outcome will depend on a cooperative effort between you, your surgeon, and your therapist.
Several different types of surgery are used for the hand and wrist affected by arthritis.
Arthrodesis means surgical fusion, or joining together, of the joint. This is usually done to align a joint in a more cosmetically acceptable position or to position it so that it will function better. With arthrodesis, the joint is more stable and thus less painful. In most cases, the surgeon takes the cartilage and surface layer of bone from the ends of the bones to be fused and then puts a pin or wire through the joint to hold it together. New bone grows on the ends of the existing bones and fuses them. When the pin is removed several weeks later, the joint is stiff, but it is in a better position for functional use. This surgery is used for joints in which stability is more important than mobility. It is done most often in the wrist.
Arthroplasty means joint replacement. Joint replacements may be done on joints in the fingers, on the joint at the base of the thumb, or less often, on the wrist. Damaged bone at the joint is removed and, depending on the particular joint involved, is replaced with tendon tissue or with implants made of carbon, silicone, or plastic and metal.
Excision is usually the removal of a cyst or bony prominence from a finger or wrist.
Synovectomy means removal of inflamed synovial tissue from a joint. Removing the inflamed tissue can relieve the pain and swelling and possibly slow or prevent joint damage that inflammation can cause. In time, however, the diseased tissue usually grows back.
Tenosynovectomy means removal of inflamed synovial tissue from around a tendon. Inflamed tissue around a tendon, or tenosynovitis, may cause pain when the tendons try to move the fingers, and in severe cases it may actually get in the way of movement. If medicines are not effective in controlling the tenosynovitis, tenosynovectomy may be considered.
Now let’s take a closer look at some of the surgeries most commonly used in arthritis: arthroplasty and arthrodesis for osteoarthritis (OA) of the thumb, arthroplasty for fingers affected by RA, and excision and arthrodesis for the wrist.
Pain at the base of the thumb can signal destruction of the cartilage at the carpometacarpal (CMC) joint. The damage is most often found on the trapezium, the carpal (wrist) bone at the base of the thumb. If you have thumb OA, you may experience pain when pinching or grasping, collapse of the thumb at the base joint, and loss of the ability to make the thumb movements that let you grasp large objects. One arthroplasty option for OA in the CMC joint is called Ligament Reconstruction Tendon Interposition. When you have this surgery, the surgeon removes the trapezium and then takes a nonessential tendon from your forearm, hand, or wrist, coils part of it up, and places it in the space previously occupied by the trapezium. The other part of the tendon is used to reconstruct the ligament so as to reinforce the joint. The surgeon may insert a wire or pin into the joint for additional stability. This wire protrudes through the skin, and after three to four weeks it will be removed (without further surgery).
You will be given a splint or cast immediately after the surgery to immobilize the operated-on joint for three to four weeks. Once the initial cast or splint has been removed, you can begin moving the joint again. You will probably wear a lighter splint for several weeks to give the thumb additional support and protection. At about 6–8 weeks after surgery, you can use the hand for light activities, wearing the splint only for heavy activities or if pain persists. You can usually resume normal use of the hand after 12 weeks.
Most people have an excellent outcome after this surgery. They are pleased that they can resume activities with less pain. However, some pain is common. If it persists, you may continue to use your lighter splint, or another version of it, for some activities.
If you have severe arthritis and work in a job that demands heavy thumb use, the surgeon may suggest arthrodesis rather than arthroplasty. In this case, the doctor fuses the CMC joint, using a pin to provide stability. If you choose this option, you should realize that there will be a permanent loss of some thumb motion. However, the stability of the joint will be improved. Usually, the surgeon positions the joint in such a way that when it fuses, it will give you the best possible function for most activities. You will usually wear a splint or cast for several weeks after surgery to immobilize the thumb.
Often a surgeon will recommend surgery for OA in the CMC joint after conservative measures have failed to provide relief. Conservative treatments for the early stages of this condition include use of a thumb splint, thumb-strengthening exercises, joint protection, activity modification, and taking nonsteroidal anti-inflammatory drugs. Sometimes, people are given injections of corticosteroids into the thumb joint.
When RA affects the large knuckle (MCP) joints, causing pain and reducing stability, arthroplasty can help. Carbon, silicone, or plastic and metal joint replacements can be surgically inserted to replace the damaged joints. The middle (PIP) joints can also be replaced, although these surgeries are not as common. The tip (DIP) joints are not usually replaced, but they may be fused for more effective positioning.
When you have the large knuckles replaced, the surgeon makes an incision over the top of the knuckles on the back of the hand. Then the surgeon removes the damaged ends of the metacarpal bones and prepares the canals of the adjoining finger bones (the proximal phalanges) so the implants can be inserted into them. Next, the surgeon repositions the tendon over the top of each finger so that the fingers are aligned more effectively. MCP replacement surgery often involves synovectomy, in which the surgeon removes inflamed tissue from the joint.
After this surgery, the short-term goal is to achieve a balance between mobility and stability while the tissues around the implants heal. Immediately after surgery, you’ll be given a cast and a bulky gauze dressing. Within days you’ll be fitted with a splint for daytime use that allows some protected movement of the fingers and a splint to wear at night that rests the hand. Therapy usually begins within the first week and is an important part of after-surgery care. Your doctor may recommend hourly exercises. Splinting and therapy can continue for up to 12 weeks. Replacement of the MCP joints is often effective in reducing pain and in improving the position of the fingers, the hand’s appearance, and the hand’s ability to function. The outcomes are usually quite good. However, implants may fracture, dislocate, or wear out over time, meaning they’ll need to be replaced.
The ulna, the long forearm bone that joins the wrist at the little finger side of the hand, has a knob-like bony prominence on its wrist end. Sometimes, this knob becomes enlarged, causing pain when the tendons glide over it. Sometimes, the tendons may even rupture or tear, worn down by the constant friction. Excision surgery is used to correct it. During surgery, the surgeon smooths the enlarged bone and covers the area with a layer of soft tissue taken from the joint capsule or a ligament so that the tendon won’t wear down.
When the wrist is unstable or painful, arthrodesis helps to stabilize it. Arthrodesis is an effective alternative to arthroplasty at the wrist, but it does result in loss of wrist motion. How much wrist motion is lost depends on how many bones need to be fused. Usually, two of the small wrist (carpal) bones are fused to the radius, the long bone of the forearm that attaches to the thumb side of the hand. If you have this surgery, your surgeon may use bone taken from another part of your body to help promote healing and new bone growth so that the carpals will fuse. After surgery, your wrist will be immobilized in a splint or cast for up to 10 weeks. You may retain 25% to 50% of normal wrist motion following arthrodesis.
You may feel pain after your surgery. Be sure to take any pain medicine recommended by your physician. Sometimes, after-surgery swelling can contribute to pain, but you can minimize swelling by propping your hand up above your heart whenever possible for the first two days. You can also use a cold pack to reduce swelling and pain. If swelling persists, your surgeon may recommend a compressive wrap or glove. It is important to keep the surgical incision clean and dry, so you may need to put a plastic bag over your hand for showering and bathing. Follow the recommendations of your surgeon or therapist regarding moving your hand after surgery.
You depend on your hands every day for numerous tasks, so the restrictions in hand use that occur after surgery can significantly affect your independence. If you are planning to have hand or wrist surgery, here are a few things you can do ahead of time to make life easier when you can only use one hand:
With careful planning, a qualified surgeon, and attention to proper after-surgery care and therapy, you could be on the way to some wonderful changes in your life.
Last Reviewed on September 15, 2010
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