Features November 2013 Issue

Know Your Surgical Options for Wrist Arthritis

Advances in wrist surgery can provide relief when non-operative treatments fail.

Your wrist relies on two rows of carpal bones and numerous small joints and even more ligaments to provide the fine motion necessary for activities such as writing or knitting.
But this high concentration of bones and joints also means more potential places in which arthritis can develop. The cartilage that allows for smooth movement of the wrist bones can degenerate, leaving bone to rub against bone. The result is pain, swelling, loss of function and strength, and, in some cases, a grinding feeling in the wrist. Often, arthritis develops from a prior traumatic injury.

If wrist arthritis pain persists despite medications and other conservative treatments, consider surgery, a Cleveland Clinic expert advises. Newer surgical procedures not only can ease the pain, but also may preserve wrist function, especially if performed before too much damage is done.
“There is a timing issue,” says Peter J. Evans, MD, PhD, Director of the Upper Extremity Center in Cleveland Clinic’s Department of Orthopaedic Surgery. “If it hurts enough that you have to take medicine and wear a brace, and if you’ve changed your lifestyle because of it, have it looked at.”

Surgical decisions
Before you decide on wrist surgery, your surgeon will evaluate your pain severity, range of motion, and grip strength. The choice of operation will be based on these factors and the types of activities you perform and what you expect to gain from surgery.

Circular locking fusion plates made from a radiolucent polymer are improving limited carpal fusion rates by allowing multiple screws to be anchored into each bone.

If most or all of the carpal bones are damaged by arthritis, a total wrist fusion or total wrist replacement may be in order. In total wrist fusion, the surgeon uses pins, screws, staples or plates to join, or fuse, the carpal bones to your forearm. Afterward, you can’t bend the wrist, but you can rotate it and turn your palm up or down.

Replacment’s reality
In total wrist replacement, the affected bones are removed and replaced with a prosthesis that allows for movement while providing pain relief. However, patients should avoid high-impact activities afterward.

If the surface of the capitate (the large bone in the second row of wrist bones) is intact but the first row of bones abutting the forearm bones (radius and ulna) is damaged, the surgeon may recommend proximal row carpectomy (PRC), removing the damaged first row of bones so that the wrist and forearm meet at the capitate bone. Dr. Evans says a PRC is preferable especially for patients with stiff wrists and good cartilage in the mid-carpal joint (between the capitate and lunate bones), as it can improve motion in the wrist.

For patients with intact cartilage on at least one of the proximal bones (usually the lunate) articulating against the radius, limited carpal fusion, or four-corner fusion, becomes an option. In this procedure, the surgeon removes the scaphoid and fuses the lunate and other smaller carpal bones, forming a ball-and-socket joint with the radius.

Advances for mobility
Traditionally, limited carpal fusion was performed using pins, but the bones would not adequately fuse, or unite, in about one-quarter of patients, Dr. Evans says. Newer advances, such as a circular locking fusion plate made from a radiolucent polymer, are improving fusion rates by allowing multiple screws to be anchored into each bone.
Unlike total wrist fusion, limited carpal fusion can preserve more motion in your wrist, but only about 50 percent of normal. “However, it doesn’t require the activity restrictions associated with total wrist replacement,” Dr. Evans says.