Hand and Wrist Arthritis

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Hand and Wrist Arthritis

• Daniel Master, M.D.

Hand to Shoulder Care Mapleton Hill Orthopaedics,
P.C. www.danielmastermd-handtoshoulder.com
Mapleton Hill Orthopaedics, P.C. 975 North
Street, Suite 201 Boulder, CO 80304 Ph
303-440-7941
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Overview

• Thumb arthritis
• Finger arthritis
• Wrist arthritis
• Ulnar impaction
• SLAC wrist
• SNAC wrist

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Thumb Arthritis

• Thumb arthritis can affect the
• IP joint
• MCP joint
• CMC joint

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Thumb CMC Arthritis

• Causes
• Repetitive key pinch
• Post-traumatic

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Thumb CMC Arthritis

• Signs and symptoms
• Pain at base of thumb
• Decreased ROM
• Adducted thumb
• Shoulder sign
• Compensatory MCP hyperextension

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Thumb CMC Treatment

• Conservative treatments
• NSAIDs
• Thumb splinting
• Hand therapy
• Injections

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• 114 patients
• 3-4 weeks of continuous splinting
• 76 of patients with early disease had
  improvement
• 54 of patients with more advanced disease had
  improvement

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The effectiveness of a manual therapy and
exercise protocol in patients with thumb
carpometacarpal osteoarthritis a randomized
controlled trial.Villafane JH, Cleland JA,
Fernandez-de-Las-Penas C.J Orthop Sports Phys
Ther. 2013 Apr43(4)204-13.

• 60 patients with thumb arthritis
• Randomly assigned to four weeks of
• Therapy program (joint mobilization, neural
  mobilization, exercise)
• Sham intervention
• Follow-up at 1,2, and 3 months
• Therapy group had less pain overall but no change
  in pressure pain threshold or pinch/grip strength

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• 60 patients with thumb arthritis
• Randomly divided into three groups
• Placebo
• Steroid
• Hylan
• Follow-up at 2,4,12, and 26 weeks
• No statistically significant differences between
  groups
• Trend towards improvement with Hylan

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Thumb CMC Surgery

• CMC interposition arthroplasty
• Conventional techniques (LRTI, HTA)
• Modern techniques (Tightrope suspensionplasty)

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CMC Interposition Arthroplasty

• Step 1 (common to all)
• Trapeziectomy
• Step 2 (varies)
• Suspension and interposition through a wide
  variety of techniques

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CMC Arthroplasty

• Conventional

• Tightrope Suspensionplasty

• Temporary wire for suspension
• And/or
• Reliance on tendon healing
• 6 weeks in a cast

• Implanted suture device for suspension
• 10 days in a cast

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• 21 patients followed for over 2 years
• Comparable results to other techniques
• BUT able to come out of cast after 10 days
• No major complications

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Finger Arthritis

• Finger arthritis can affect the
• DIP joint
• PIP joint
• MCP joint

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Finger Arthritis

• Conservative treatments
• Splinting
• NSAIDs
• Injections

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PIP Arthritis

• Surgical treatments
• PIP joint arthroplasty
• Silastic
• Pyrocarbon
• PIP joint fusion

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PIP Joint Arthroplasty

• Silastic
• Constrained
• single component
• Can have ligamentous insufficiency
• Inflammatory arthritis
• Gold standard for PIP joint

• Pyrocarbon
• Unconstrained
• two separate components
• Must have competent ligaments

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PIP Joint Fusion

• Single cannulated compression screw
• OR
• Plate-screw construct

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MCP Arthritis

• MCP joint arthroplasty
• Silastic constrained
• Pyrocarbon - unconstrained

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MCP Joint Arthroplasty

• Silastic
• Constrained
• Can have ligamentous insufficiency
• Inflammatory arthritis
• Excellent long-term track record

• Pyrocarbon
• Unconstrained
• Must have competent ligaments
• May allow for slightly better ROM in the MCP

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Wrist Arthritis

• Potential causes
• Age-related degenerative changes
• Anatomic variations
• Unrecognized injury to
• Ligament
• Bone

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Anatomic Variations

• Ulnar positive variance
• i.e. the ulna bone is too long
• Increased pressure along the ulnar wrist
• Ulnar impaction syndrome
• Ulnar-sided wrist arthritis
• Degenerative TFCC injury

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Ulnar Impaction Syndrome

• Conservative treatments
• Casting for 4 weeks
• NSAIDs
• Corticosteroid injections
• Activity modification

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The rate of triangular fibrocartilage injuries
requiring surgical intervention.Park MJ,
Jagadish A, Yao J.Orthopedics. 2010 Nov
233(11)806.

• 84 patients with ulnar-sided wrist pain
• All patients treated with short-arm casting for 4
  weeks
• 57 of patients did not require surgery
• 43 required surgery

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Ulnar Impaction Syndrome

• Surgical treatments
• Arthroscopic TFCC debridement or repair
• Lunate chondroplasty
• Feldon wafer procedure
• Ulnar shortening osteotomy (USO)
• Salvage operations

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TFCC Debridement or Repair

• 2mm incisions
• Small joint camera for visualization
• Shaver for debridement
• Suture device for peripheral repairs

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Lunate Chondroplasty

• Puncture subchondral plate of lunate
• Promote fibrocartilage formation
• Biologic joint resurfacing

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Feldon Wafer Procedure

• Arthroscopic or open excision of distal ulnar
  head
• Decreased pressure on ulnar wrist

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Ulnar Shortening Osteotomy

• Surgical osteotomy of ulna
• Remove a wafer of bone
• Compress with plate and screws
• Excellent long-term results

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Salvage Operations

• Distal ulna resection (Darrach resection)
• Hemi-resection arthroplasty (Bowers
  arthroplasty)
• Distal radio-ulnar joint fusion (Sauve-Kapandji
  procedure)

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Wrist Injury

• Ligament injury
• Scapholunate interosseous ligament (SLIL)
• Holds scaphoid and lunate together

• Bone injury
• Scaphoid fracture
• Crucial for normal wrist biomechanics

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Wrist Injury

• Ligament or bone injury
• If recognized ? repair early
• If unrecognized ? SLAC or SNAC arthritis

Stage I
Stage II
Stage III
Stage IV
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SLAC and SNAC Wrist

• Conservative treatments
• Splinting
• NSAIDs
• Corticosteroid injection

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SLAC and SNAC Wrist

• Surgical treatments
• PIN neurectomy
• Proximal row carpectomy (PRC)
• Scaphoid excision and four-corner fusion

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PIN Neurectomy

• Resection of a nerve on the top of the wrist
  which only innervates the joint capsule
• Therefore, no sensory deficit from resection
• Can provide pain relief without a major operation

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PIN Neurectomy

• Dorsal approach
• Resect 1cm segment of nerve

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Proximal Row Carpectomy

• Excise the proximal row
• Capitate then articulates with radius
• Excellent pain relief without the need for bony
  healing

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Four Corner Fusion

• Excise the scaphoid only
• Fuse the following four bones
• Lunate
• Triquetrum
• Capitate
• Hamate
• All load now transmitted across the radio-lunate
  joint

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Four-Corner Fusion

• Excise scaphoid

• Fuse capito-lunate and triquetro-hamate joints

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Total Wrist Arthroplasty

• Indications
• End-stage rheumatoid arthritis
• Low-demand patient (lifetime restriction on
  weight bearing)

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Total Wrist Arthoplasty

• Fuse and resurface the proximal carpal row
• Resurface distal radius

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Total Wrist Fusion

• Indications
• End-stage arthritis
• High demand patients
• Once healed, no limitations on weight-bearing

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Total Wrist Fusion

• Dorsal approach
• Fusion of radio-carpal and mid-carpal joints
• Dorsal spanning plate application