Features February 2010 Issue

New Surgical Procedures Relieve Hand, Wrist Pain

Non-invasive treatments often work—but when they don’t, these recent advances in hand and wrist surgery are worth considering.

Approximately 20 percent of adults over the age of 55 suffer from symptomatic hand arthritis. If you’re one of them, you’ve probably already tried a combination of drug and non-drug treatments, including pain relievers, heat, and physical therapy. When these treatments fail, however, and severe pain and

Proximal row carpectomy involves removing the first (proximal) row of carpal bones (scaphoid, lunate, triquetrum) and moving the second row to the forearm bones (radius, ulna).

disability continue, it’s wise to consider surgery. Fortunately, with the advent of newer techniques, patients with hand or wrist arthritis who undergo surgery often can return to many of their regular activities, says Mark Hendrickson, MD, section chief, Hand and Wrist Surgery, at Cleveland Clinic.

 

Signs and Symptoms

The hand and wrist have many small joints that work together to produce movement. Because the joints are small, they permit the fine motion needed to do activities such as tying shoes, writing, playing an instrument, or threading a needle. But when these joints are affected by arthritis, inflammation, or trauma, it can be difficult to perform daily activities, and sports such as tennis can literally be out of reach.

Arthritis causes the cartilage in your wrist or hand to wear or become damaged, so that movement is no longer painless. Similar damage occurs if you fall; your natural instinct will likely be to break the fall with your hand, which can result in a fracture or dislocation, setting the stage for arthritis even if you don’t already have it. According to the American Academy of Orthopaedic Surgeons, an injured joint is about seven times more likely to become arthritic, even if the injury is properly treated.

Symptoms of joint damage in the hand and/or wrist can include pain, swelling, loss of function and strength, and a grating or grinding feeling in the affected joint.

 

Deciding on Surgery

"I never see an arthritis patient who then goes into surgery the next day," says Dr. Hendrickson. "Before deciding on surgery, we talk with the patient, see how serious the problem is, get a sense of the patient’s general health, and have the patient work with a hand therapist to see if that can control the problem. You can’t just focus on the wrist or fingers—you also must look at the entire picture." That includes the kind of activities the patient participates in, how much pain they’re in, what their level of function is, and what they expect from surgery.

"The right patient is someone with a serious problem who has already tried anti-inflammatories, hand therapy, a steroid injection, and is over their personal threshold for coping," Dr. Hendrickson explains. The extent of pain, the nature of the problem, the individual’s motion and grip strength, and how demanding their physical activities are will help determine which type of procedure is selected.

 

Fuse, Modify, or Replace?

The wrist joint is made up of two rows of small bones. "If the entire wrist joint is destroyed from arthritis, with no undamaged surfaces left on any of the bones, then you’re stuck with complete wrist fusion or an implant," Dr. Hendrickson says. If part of the joint is damaged, the surgeon must determine which surfaces are still good, and try to put those surfaces together.

If some of the wrist bones in both rows are functional, but the scaphoid bone—the large bone in the first row—is damaged, the surgeon may perform a four-bone fusion (arthrodesis). In this procedure, the scaphoid is removed and the smaller wrist bones are fused together, forming a ball-and-socket joint that runs across the base of the wrist (lunate fossa), permitting movement.

If the surface of the capitate—the large bone in the second row—is intact, but the first row of wrist bones is damaged, the surgeon may do a proximal row carpectomy (PRC), which involves removing the damaged row of bones so that the wrist and forearm come together at the capitate bone. This shortens the wrist by about 2-3 cm. and the muscle tendons require about a year to adjust to the new, shortened length, so final recovery of strength can take longer with a PRC.

One step beyond these options is osteochondral resurfacing. In this case, the surgeon grafts (or plugs) new cartilage into the damaged area in an effort to reduce pain and improve function. "However, the wrist and hand are not ideal areas" for this procedure, Dr. Hendrickson says. "The fundamental problem with the hand, base of thumb, and wrist is that these joints and joint surfaces are much smaller than the knee. It’s a very small area to work in, and it’s difficult to get things to take and work well."

Implants have been tried, particularly for the thumb joint. But though the intent may be good, these implants are often removed because they just don’t work as anticipated. "You need to be very careful with implants," he advises. "Look for someone experienced in working with these materials and procedures, and—best advice—try non-surgical options first."

A total wrist replacement should be considered only as a last resort and for the right person. "You can’t participate in contact sports or weight training after a wrist replacement. If you load the implant too much, it wears out and pops out of the bone that it’s sitting in," Dr. Hendrickson explains. "A replacement might be appropriate for someone who only does low-demand activities, such as keyboarding. With anything more demanding, the implant will not last."