Transcript Hand and Wrist Arthritis - Boulder Community Health

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
Overview
Thumb arthritis
Finger arthritis
Wrist arthritis
– Ulnar impaction
– SLAC wrist
– SNAC wrist
Thumb Arthritis
Thumb arthritis can affect the:
IP joint
MCP joint
CMC joint
Thumb CMC Arthritis
Causes
Repetitive key pinch
Post-traumatic
Thumb CMC Arthritis
Signs and symptoms
Pain at base of thumb
Decreased ROM
Adducted thumb
“Shoulder” sign
Compensatory MCP
hyperextension
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
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
Thumb CMC Surgery
CMC interposition arthroplasty
– Conventional techniques (LRTI, HTA)
– Modern techniques (Tightrope
suspensionplasty)
CMC Interposition Arthroplasty
Step 1 (common to all)
Trapeziectomy
Step 2 (varies)
Suspension and
interposition through a
wide variety of
techniques
CMC Arthroplasty
Conventional
Tightrope Suspensionplasty
• Temporary wire for
• Implanted suture device for
suspension
And/or
• Reliance on tendon
healing
• 6 weeks in a cast
suspension
• 10 days in a cast
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 can affect the:
DIP joint
PIP joint
MCP joint
Finger Arthritis
Conservative treatments
Splinting
NSAIDs
Injections
PIP Arthritis
Surgical treatments
PIP joint arthroplasty
– Silastic
– Pyrocarbon
PIP joint fusion
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
Single cannulated compression screw
OR
Plate-screw construct
MCP Arthritis
MCP joint arthroplasty
Silastic – constrained
Pyrocarbon - unconstrained
MCP Joint Arthroplasty
Silastic
• Constrained
Pyrocarbon
• Unconstrained
• Can have ligamentous
• Must have competent
insufficiency
• Inflammatory arthritis
• Excellent long-term track
record
ligaments
• May allow for slightly
better ROM in the MCP
Wrist Arthritis
Potential causes
Age-related degenerative changes
Anatomic variations
Unrecognized injury to
– Ligament
– Bone
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
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 Syndrome
Surgical treatments
Arthroscopic TFCC debridement or repair
Lunate chondroplasty
Feldon wafer procedure
Ulnar shortening osteotomy (USO)
Salvage operations
TFCC Debridement or Repair
• 2mm incisions
• Small joint camera for visualization
• Shaver for debridement
• Suture device for peripheral repairs
Lunate Chondroplasty
Puncture subchondral plate of lunate
Promote fibrocartilage formation
Biologic joint resurfacing
Feldon Wafer Procedure
Arthroscopic or open excision of distal ulnar
head
Decreased pressure on ulnar wrist
Ulnar Shortening Osteotomy
Surgical
osteotomy of ulna
Remove a wafer of
bone
Compress with
plate and screws
Excellent longterm results
Salvage Operations
Distal ulna resection (Darrach resection)
Hemi-resection arthroplasty (Bower’s
arthroplasty)
Distal radio-ulnar joint fusion (SauveKapandji procedure)
Wrist Injury
Ligament injury
•Scapholunate
interosseous ligament
(SLIL)
•Holds scaphoid and
lunate together
Bone injury
•Scaphoid fracture
•Crucial for normal wrist
biomechanics
Wrist Injury
Ligament or bone injury
If recognized  repair early
If unrecognized  SLAC or SNAC arthritis
Stage I
Stage II
Stage III
Stage IV
SLAC and SNAC Wrist
Conservative treatments
Splinting
NSAIDs
Corticosteroid injection
SLAC and SNAC Wrist
Surgical treatments
PIN neurectomy
Proximal row carpectomy (PRC)
Scaphoid excision and four-corner fusion
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 Neurectomy
Dorsal approach
Resect 1cm
segment of
nerve
Proximal Row Carpectomy
Excise the proximal row
Capitate then articulates with radius
Excellent pain relief without the need for
bony healing
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 Fusion
Excise scaphoid
Fuse capito-lunate and
triquetro-hamate joints
Total Wrist Arthroplasty
Indications
End-stage rheumatoid
arthritis
Low-demand patient
(lifetime restriction on
weight bearing)
Total Wrist Arthoplasty
Fuse and resurface the proximal carpal row
Resurface distal radius
Total Wrist Fusion
Indications
End-stage arthritis
High demand patients
– Once healed, no limitations on weight-bearing
Total Wrist Fusion
Dorsal approach
Fusion of radio-carpal and mid-carpal
joints
Dorsal spanning plate application