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Hand and Wrist Arthritis. Hand to Shoulder Care Mapleton Hill Orthopaedics, P.C. www.danielmastermd-handtoshoulder.com. Daniel Master, M.D. Mapleton Hill Orthopaedics, P.C. 975 North Street, Suite 201 Boulder, CO 80304 Ph: 303-440-7941. Overview. Thumb arthritis Finger arthritis

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hand and wrist arthritis

Hand and Wrist Arthritis

Hand to Shoulder Care

Mapleton Hill Orthopaedics, P.C.

www.danielmastermd-handtoshoulder.com

Daniel Master, M.D.

Mapleton Hill Orthopaedics, P.C.

975 North Street, Suite 201

Boulder, CO 80304

Ph: 303-440-7941

overview
Overview
  • Thumb arthritis
  • Finger arthritis
  • Wrist arthritis
    • Ulnar impaction
    • SLAC wrist
    • SNAC wrist
thumb arthritis
Thumb Arthritis

Thumb arthritis can affect the:

  • IP joint
  • MCP joint
  • CMC joint
thumb cmc arthritis
Thumb CMC Arthritis

Causes

  • Repetitive key pinch
  • Post-traumatic
thumb cmc arthritis1
Thumb CMC Arthritis

Signs and symptoms

  • Pain at base of thumb
  • Decreased ROM
  • Adducted thumb
  • “Shoulder” sign
  • Compensatory MCP hyperextension
thumb cmc treatment
Thumb CMC Treatment

Conservative treatments

  • NSAIDs
  • Thumb splinting
  • Hand therapy
  • Injections
slide7

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
slide8

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 Apr;43(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
slide9

60 patients with thumb arthritis

  • Randomly divided into three groups:
    • Placebo
    • Steroid
    • Hylan
  • Follow-up at 2,4,12, and 26 weeks
  • Nostatistically significant differencesbetween groups
  • Trend towards improvement with Hylan
thumb cmc surgery
Thumb CMC Surgery
  • CMC interposition arthroplasty
    • Conventional techniques (LRTI, HTA)
    • Modern techniques (Tightrope suspensionplasty)
cmc interposition arthroplasty
CMC Interposition Arthroplasty

Step 1 (common to all)

  • Trapeziectomy

Step 2 (varies)

  • Suspension and interposition through a wide variety of techniques
cmc arthroplasty
CMC Arthroplasty

Conventional

Tightrope Suspensionplasty

Implanted suture device for suspension

10 days in a cast

  • Temporary wire for suspension

And/or

  • Reliance on tendon healing
  • 6 weeks in a cast
slide13

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
finger arthritis
Finger Arthritis

Finger arthritis can affect the:

  • DIP joint
  • PIP joint
  • MCP joint
finger arthritis1
Finger Arthritis

Conservative treatments

  • Splinting
  • NSAIDs
  • Injections
pip arthritis
PIP Arthritis

Surgical treatments

  • PIP joint arthroplasty
    • Silastic
    • Pyrocarbon
  • PIP joint fusion
pip joint arthroplasty
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
pip joint fusion
PIP Joint Fusion
  • Single cannulated compression screw

OR

  • Plate-screw construct
mcp arthritis
MCP Arthritis

MCP joint arthroplasty

  • Silastic – constrained
  • Pyrocarbon - unconstrained
mcp joint arthroplasty
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
wrist arthritis
Wrist Arthritis

Potential causes

  • Age-related degenerative changes
  • Anatomic variations
  • Unrecognized injury to
    • Ligament
    • Bone
anatomic variations
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
ulnar impaction syndrome
Ulnar Impaction Syndrome

Conservative treatments

  • Casting for 4 weeks
  • NSAIDs
  • Corticosteroid injections
  • Activity modification
slide24

The rate of triangular fibrocartilage injuries requiring surgical intervention.Park MJ, Jagadish A, Yao J.Orthopedics. 2010 Nov 2;33(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
ulnar impaction syndrome1
Ulnar Impaction Syndrome

Surgical treatments

  • Arthroscopic TFCC debridement or repair
  • Lunate chondroplasty
  • Feldon wafer procedure
  • Ulnar shortening osteotomy (USO)
  • Salvage operations
tfcc debridement or repair
TFCC Debridement or Repair
  • 2mm incisions
  • Small joint camera for visualization
  • Shaver for debridement
  • Suture device for peripheral repairs
lunate chondroplasty
Lunate Chondroplasty
  • Puncture subchondral plate of lunate
  • Promote fibrocartilage formation
  • Biologic joint resurfacing
feldon wafer procedure
Feldon Wafer Procedure
  • Arthroscopic or open excision of distal ulnar head
  • Decreased pressure on ulnar wrist
ulnar shortening osteotomy
Ulnar Shortening Osteotomy
  • Surgical osteotomy of ulna
  • Remove a wafer of bone
  • Compress with plate and screws
  • Excellent long-term results
salvage operations
Salvage Operations
  • Distal ulna resection (Darrach resection)
  • Hemi-resection arthroplasty (Bower’s arthroplasty)
  • Distal radio-ulnar joint fusion (Sauve-Kapandji procedure)
wrist injury
Wrist Injury

Ligament injury

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

Bone injury

  • Scaphoid fracture
  • Crucial for normal wrist biomechanics
wrist injury1
Wrist Injury
  • Ligament or bone injury
  • If recognized  repair early
  • If unrecognized  SLAC or SNAC arthritis

Stage II

Stage IV

Stage I

Stage III

slac and snac wrist
SLAC and SNAC Wrist

Conservative treatments

  • Splinting
  • NSAIDs
  • Corticosteroid injection
slac and snac wrist1
SLAC and SNAC Wrist

Surgical treatments

  • PIN neurectomy
  • Proximal row carpectomy (PRC)
  • Scaphoid excision and four-corner fusion
pin neurectomy
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
pin neurectomy1
PIN Neurectomy
  • Dorsal approach
  • Resect 1cm segment of nerve
proximal row carpectomy
Proximal Row Carpectomy
  • Excise the proximal row
  • Capitate then articulates with radius
  • Excellent pain relief without the need for bony healing
four corner fusion
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
four corner fusion1
Four-Corner Fusion
  • Excise scaphoid
  • Fuse capito-lunate and triquetro-hamate joints
total wrist arthroplasty
Total Wrist Arthroplasty

Indications

  • End-stage rheumatoid arthritis
  • Low-demand patient (lifetime restriction on weight bearing)
total wrist arthoplasty
Total Wrist Arthoplasty
  • Fuse and resurface the proximal carpal row
  • Resurface distal radius
total wrist fusion
Total Wrist Fusion

Indications

  • End-stage arthritis
  • High demand patients
    • Once healed, no limitations on weight-bearing
total wrist fusion1
Total Wrist Fusion
  • Dorsal approach
  • Fusion of radio-carpal and mid-carpal joints
  • Dorsal spanning plate application
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