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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


  • 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


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


  • 60 patients with thumb arthritis in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

  • 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 in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

  • CMC interposition arthroplasty

    • Conventional techniques (LRTI, HTA)

    • Modern techniques (Tightrope suspensionplasty)


Cmc interposition arthroplasty
CMC Interposition in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.Arthroplasty

Step 1 (common to all)

  • Trapeziectomy

    Step 2 (varies)

  • Suspension and interposition through a wide variety of techniques


Cmc arthroplasty
CMC in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.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


  • 21 patients followed for over 2 years in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

  • Comparable results to other techniques

  • BUT able to come out of cast after 10 days

  • No major complications


Finger arthritis
Finger Arthritis in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

Finger arthritis can affect the:

  • DIP joint

  • PIP joint

  • MCP joint


Finger arthritis1
Finger Arthritis in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

Conservative treatments

  • Splinting

  • NSAIDs

  • Injections


Pip arthritis
PIP Arthritis in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

Surgical treatments

  • PIP joint arthroplasty

    • Silastic

    • Pyrocarbon

  • PIP joint fusion


Pip joint arthroplasty
PIP Joint in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.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 in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

  • Single cannulated compression screw

    OR

  • Plate-screw construct


Mcp arthritis
MCP Arthritis in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

MCP joint arthroplasty

  • Silastic – constrained

  • Pyrocarbon - unconstrained


Mcp joint arthroplasty
MCP Joint Arthroplasty in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

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 in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

Potential causes

  • Age-related degenerative changes

  • Anatomic variations

  • Unrecognized injury to

    • Ligament

    • Bone


Anatomic variations
Anatomic Variations in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

  • 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 in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

Conservative treatments

  • Casting for 4 weeks

  • NSAIDs

  • Corticosteroid injections

  • Activity modification


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 intervention.

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 surgical intervention.

  • 2mm incisions

  • Small joint camera for visualization

  • Shaver for debridement

  • Suture device for peripheral repairs


Lunate chondroplasty
Lunate Chondroplasty surgical intervention.

  • Puncture subchondral plate of lunate

  • Promote fibrocartilage formation

  • Biologic joint resurfacing


Feldon wafer procedure
Feldon Wafer Procedure surgical intervention.

  • Arthroscopic or open excision of distal ulnar head

  • Decreased pressure on ulnar wrist


Ulnar shortening osteotomy
Ulnar Shortening Osteotomy surgical intervention.

  • Surgical osteotomy of ulna

  • Remove a wafer of bone

  • Compress with plate and screws

  • Excellent long-term results


Salvage operations
Salvage Operations surgical intervention.

  • Distal ulna resection (Darrach resection)

  • Hemi-resection arthroplasty (Bower’s arthroplasty)

  • Distal radio-ulnar joint fusion (Sauve-Kapandji procedure)


Wrist injury
Wrist Injury surgical intervention.

Ligament injury

  • Scapholunate interosseous ligament (SLIL)

  • Holds scaphoid and lunate together

Bone injury

  • Scaphoid fracture

  • Crucial for normal wrist biomechanics


Wrist injury1
Wrist Injury surgical intervention.

  • 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 surgical intervention.

Conservative treatments

  • Splinting

  • NSAIDs

  • Corticosteroid injection


Slac and snac wrist1
SLAC and SNAC Wrist surgical intervention.

Surgical treatments

  • PIN neurectomy

  • Proximal row carpectomy (PRC)

  • Scaphoid excision and four-corner fusion


Pin neurectomy
PIN Neurectomy surgical intervention.

  • 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 surgical intervention.

  • Dorsal approach

  • Resect 1cm segment of nerve


Proximal row carpectomy
Proximal Row surgical intervention.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 surgical intervention.

  • 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 surgical intervention.

  • Excise scaphoid

  • Fuse capito-lunate and triquetro-hamate joints


Total wrist arthroplasty
Total Wrist Arthroplasty surgical intervention.

Indications

  • End-stage rheumatoid arthritis

  • Low-demand patient (lifetime restriction on weight bearing)


Total wrist arthoplasty
Total Wrist Arthoplasty surgical intervention.

  • Fuse and resurface the proximal carpal row

  • Resurface distal radius


Total wrist fusion
Total Wrist Fusion surgical intervention.

Indications

  • End-stage arthritis

  • High demand patients

    • Once healed, no limitations on weight-bearing


Total wrist fusion1
Total Wrist Fusion surgical intervention.

  • Dorsal approach

  • Fusion of radio-carpal and mid-carpal joints

  • Dorsal spanning plate application


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