Hand and Wrist ArthritisHand and Wrist ArthritisDaniel Master, M.D.Daniel Master, M.D.

Mapleton Hill Orthopaedics, P.C.975 North Street, Suite 201Boulder, CO 80304Ph: 303-440-7941

Hand to Shoulder CareMapleton Hill Orthopaedics, P.C.

www.danielmastermd-handtoshoulder.com

OverviewOverview

Thumb arthritisThumb arthritis

Finger arthritisFinger arthritis

Wrist arthritisWrist arthritis– Ulnar impaction Ulnar impaction – SLAC wristSLAC wrist– SNAC wristSNAC wrist

Thumb ArthritisThumb Arthritis

Thumb arthritis can affect the:Thumb arthritis can affect the:

IP jointIP joint

MCP jointMCP joint

CMC jointCMC joint

Thumb CMC ArthritisThumb CMC Arthritis

CausesCauses

Repetitive key pinchRepetitive key pinch

Post-traumaticPost-traumatic

Thumb CMC ArthritisThumb CMC Arthritis

Signs and symptomsSigns and symptoms

Pain at base of thumbPain at base of thumb

Decreased ROMDecreased ROM

Adducted thumbAdducted thumb

““Shoulder” signShoulder” sign

Compensatory MCP Compensatory MCP hyperextensionhyperextension

Thumb CMC TreatmentThumb CMC Treatment

Conservative treatmentsConservative treatments

NSAIDsNSAIDs

Thumb splintingThumb splinting

Hand therapyHand therapy

InjectionsInjections

114 patients114 patients

3-4 weeks of continuous splinting3-4 weeks of continuous splinting

76% 76% of patients with early disease of patients with early disease had improvement had improvement

54% 54% of patients with more of patients with more advanced disease had advanced disease had improvementimprovement

The effectiveness of a manual therapy and exercise protocol in patients The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.with thumb carpometacarpal osteoarthritis: a randomized controlled trial.Villafane JH, Cleland JA, Fernandez-de-Las-Penas C.Villafane JH, Cleland JA, Fernandez-de-Las-Penas C.J Orthop Sports Phys Ther. 2013 Apr;43(4):204-13.J Orthop Sports Phys Ther. 2013 Apr;43(4):204-13.

60 patients with thumb arthritis60 patients with thumb arthritis

Randomly assigned to four weeks of:Randomly assigned to four weeks of:– Therapy program (joint mobilization, neural Therapy program (joint mobilization, neural

mobilization, exercise)mobilization, exercise)– Sham interventionSham intervention

Follow-up at 1,2, and 3 monthsFollow-up at 1,2, and 3 months

TherapyTherapy group had group had less pain overall less pain overall but no but no change in pressure pain threshold or pinch/grip change in pressure pain threshold or pinch/grip strengthstrength

60 patients with thumb arthritis60 patients with thumb arthritis

Randomly divided into three groups:Randomly divided into three groups:– PlaceboPlacebo– SteroidSteroid– HylanHylan

Follow-up at 2,4,12, and 26 weeksFollow-up at 2,4,12, and 26 weeks

NoNo statistically significant statistically significant differencesdifferences between between groupsgroups

Trend towards improvement with HylanTrend towards improvement with Hylan

Thumb CMC SurgeryThumb CMC Surgery

CMC interposition arthroplastyCMC interposition arthroplasty

– Conventional techniques (LRTI, HTA)Conventional techniques (LRTI, HTA)

– Modern techniques (Tightrope Modern techniques (Tightrope suspensionplasty)suspensionplasty)

CMC Interposition ArthroplastyCMC Interposition Arthroplasty

Step 1 Step 1 (common to all) (common to all)

TrapeziectomyTrapeziectomy

Step 2Step 2 (varies) (varies)

Suspension and Suspension and interposition through a interposition through a wide variety of wide variety of techniquestechniques

CMC ArthroplastyCMC Arthroplasty

ConventionalConventional

• Temporary wire for Temporary wire for suspensionsuspension

And/orAnd/or• Reliance on tendon Reliance on tendon

healinghealing• 6 weeks in a cast6 weeks in a cast

Tightrope SuspensionplastyTightrope Suspensionplasty

• Implanted suture device for Implanted suture device for suspensionsuspension

• 10 days in a cast10 days in a cast

21 patients followed for over 2 years21 patients followed for over 2 years

Comparable results to other techniquesComparable results to other techniques

BUT able to come out of cast after 10 daysBUT able to come out of cast after 10 days

No major complicationsNo major complications

Finger ArthritisFinger Arthritis

Finger arthritis can affect the:Finger arthritis can affect the:

DIP jointDIP joint

PIP jointPIP joint

MCP jointMCP joint

Finger ArthritisFinger Arthritis

Conservative treatmentsConservative treatments

SplintingSplinting

NSAIDsNSAIDs

InjectionsInjections

PIP ArthritisPIP Arthritis

Surgical treatmentsSurgical treatments

PIP joint arthroplastyPIP joint arthroplasty– SilasticSilastic– PyrocarbonPyrocarbon

PIP joint fusionPIP joint fusion

PIP Joint ArthroplastyPIP Joint Arthroplasty

SilasticSilastic•ConstrainedConstrained

• single componentsingle component

•Can have ligamentous Can have ligamentous insufficiencyinsufficiency•Inflammatory arthritisInflammatory arthritis•Gold standard for PIP Gold standard for PIP jointjoint

PyrocarbonPyrocarbon•UnconstrainedUnconstrained

• two separate two separate componentscomponents

•Must have competent Must have competent ligamentsligaments

PIP Joint FusionPIP Joint Fusion

Single cannulated compression screwSingle cannulated compression screw

OROR

Plate-screw constructPlate-screw construct

MCP ArthritisMCP Arthritis

MCP joint arthroplastyMCP joint arthroplasty

Silastic – constrainedSilastic – constrained

Pyrocarbon - unconstrainedPyrocarbon - unconstrained

MCP Joint ArthroplastyMCP Joint Arthroplasty

SilasticSilastic•ConstrainedConstrained

•Can have ligamentous Can have ligamentous insufficiencyinsufficiency•Inflammatory arthritisInflammatory arthritis

•Excellent long-term track Excellent long-term track recordrecord

PyrocarbonPyrocarbon•UnconstrainedUnconstrained

•Must have competent Must have competent ligamentsligaments

•May allow for slightly May allow for slightly better ROM in the MCPbetter ROM in the MCP

Wrist ArthritisWrist Arthritis

Potential causesPotential causes

Age-related degenerative changesAge-related degenerative changes

Anatomic variationsAnatomic variations

Unrecognized injury toUnrecognized injury to– LigamentLigament– BoneBone

Anatomic VariationsAnatomic Variations• Ulnar positive varianceUlnar positive variance

• i.e. the ulna bone is too longi.e. the ulna bone is too long• Increased pressure along the ulnar wristIncreased pressure along the ulnar wrist• Ulnar impaction syndromeUlnar impaction syndrome

– Ulnar-sided wrist arthritisUlnar-sided wrist arthritis– Degenerative TFCC injuryDegenerative TFCC injury

Ulnar Impaction SyndromeUlnar Impaction Syndrome

Conservative treatmentsConservative treatments

Casting for 4 weeksCasting for 4 weeks

NSAIDsNSAIDs

Corticosteroid injectionsCorticosteroid injections

Activity modificationActivity modification

The rate of triangular fibrocartilage injuries requiring surgical intervention.The rate of triangular fibrocartilage injuries requiring surgical intervention.Park MJ, Jagadish A, Yao J.Park MJ, Jagadish A, Yao J.Orthopedics. 2010 Nov 2;33(11):806.Orthopedics. 2010 Nov 2;33(11):806.

84 patients with ulnar-sided wrist pain84 patients with ulnar-sided wrist pain

All patients treated with short-arm casting All patients treated with short-arm casting for 4 weeksfor 4 weeks

57% of patients of patients did not require surgery

43% required surgery43% required surgery

Ulnar Impaction SyndromeUlnar Impaction Syndrome

Surgical treatmentsSurgical treatments

Arthroscopic TFCC debridement or repairArthroscopic TFCC debridement or repair

Lunate chondroplastyLunate chondroplasty

Feldon wafer procedureFeldon wafer procedure

Ulnar shortening osteotomy (USO)Ulnar shortening osteotomy (USO)

Salvage operationsSalvage operations

TFCC Debridement or RepairTFCC Debridement or Repair• 2mm incisions2mm incisions• Small joint camera for visualizationSmall joint camera for visualization• Shaver for debridementShaver for debridement• Suture device for peripheral repairsSuture device for peripheral repairs

Lunate ChondroplastyLunate Chondroplasty

Puncture subchondral plate of lunatePuncture subchondral plate of lunate

Promote fibrocartilage formationPromote fibrocartilage formation

Biologic joint resurfacingBiologic joint resurfacing

Feldon Wafer ProcedureFeldon Wafer Procedure

Arthroscopic or open excision of distal Arthroscopic or open excision of distal ulnar headulnar head

Decreased pressure on ulnar wristDecreased pressure on ulnar wrist

Ulnar Shortening OsteotomyUlnar Shortening Osteotomy

Surgical Surgical osteotomy of ulna osteotomy of ulna

Remove a wafer of Remove a wafer of bone bone

Compress with Compress with plate and screwsplate and screws

Excellent long-Excellent long-term resultsterm results

Salvage OperationsSalvage OperationsDistal ulna resection (Darrach resection)Distal ulna resection (Darrach resection)

Hemi-resection arthroplasty (Bower’s Hemi-resection arthroplasty (Bower’s arthroplasty)arthroplasty)

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

Wrist InjuryWrist Injury

Ligament injuryLigament injury•Scapholunate Scapholunate interosseous ligament interosseous ligament (SLIL)(SLIL)•Holds scaphoid and Holds scaphoid and lunate togetherlunate together

Bone injuryBone injury•Scaphoid fractureScaphoid fracture•Crucial for normal wrist Crucial for normal wrist biomechanicsbiomechanics

Wrist InjuryWrist Injury

Ligament or bone injuryLigament or bone injury

If recognized If recognized repair early repair early

If unrecognized If unrecognized SLAC or SNAC arthritis SLAC or SNAC arthritis

Stage I Stage II Stage III Stage IV

SLAC and SNAC WristSLAC and SNAC Wrist

Conservative treatmentsConservative treatments

SplintingSplinting

NSAIDsNSAIDs

Corticosteroid injectionCorticosteroid injection

SLAC and SNAC WristSLAC and SNAC Wrist

Surgical treatmentsSurgical treatments

PIN neurectomyPIN neurectomy

Proximal row carpectomy (PRC) Proximal row carpectomy (PRC)

Scaphoid excision and four-corner fusionScaphoid excision and four-corner fusion

PIN NeurectomyPIN Neurectomy

Resection of a nerve on the top of the wrist which Resection of a nerve on the top of the wrist which only innervates the joint capsuleonly innervates the joint capsule

Therefore, no sensory deficit from resectionTherefore, no sensory deficit from resection

Can provide pain relief without a major operationCan provide pain relief without a major operation

PIN NeurectomyPIN Neurectomy

Dorsal Dorsal approachapproach

Resect 1cm Resect 1cm segment of segment of nervenerve

Proximal Row CarpectomyProximal Row Carpectomy

Excise the proximal rowExcise the proximal row

Capitate then articulates with radiusCapitate then articulates with radius

Excellent pain relief without the need for Excellent pain relief without the need for bony healingbony healing

Four Corner FusionFour Corner Fusion

• Excise the scaphoid onlyExcise the scaphoid only• Fuse the following four bones:Fuse the following four bones:

• LunateLunate• TriquetrumTriquetrum• CapitateCapitate• HamateHamate

• All load now transmitted across the radio-All load now transmitted across the radio-lunate jointlunate joint

Four-Corner FusionFour-Corner Fusion

Excise scaphoidExcise scaphoid Fuse capito-lunate and Fuse capito-lunate and triquetro-hamate jointstriquetro-hamate joints

Total Wrist ArthroplastyTotal Wrist Arthroplasty

IndicationsIndications

End-stage rheumatoid End-stage rheumatoid arthritisarthritis

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

Total Wrist ArthoplastyTotal Wrist Arthoplasty

Fuse and resurface the proximal carpal row Fuse and resurface the proximal carpal row

Resurface distal radiusResurface distal radius

Total Wrist FusionTotal Wrist Fusion

IndicationsIndications

End-stage arthritisEnd-stage arthritis

High demand patientsHigh demand patients– Once healed, no limitations on weight-bearingOnce healed, no limitations on weight-bearing

Total Wrist FusionTotal Wrist FusionDorsal approachDorsal approach

Fusion of radio-carpal and mid-carpal Fusion of radio-carpal and mid-carpal jointsjoints

Dorsal spanning plate applicationDorsal spanning plate application