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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. Thumb arthritis Finger arthritis

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Hand and Wrist Arthritis

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  1. 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

  2. Overview • Thumb arthritis • Finger arthritis • Wrist arthritis • Ulnar impaction • SLAC wrist • SNAC wrist

  3. Thumb Arthritis Thumb arthritis can affect the: • IP joint • MCP joint • CMC joint

  4. Thumb CMC Arthritis Causes • Repetitive key pinch • Post-traumatic

  5. Thumb CMC Arthritis Signs and symptoms • Pain at base of thumb • Decreased ROM • Adducted thumb • “Shoulder” sign • Compensatory MCP hyperextension

  6. Thumb CMC Treatment Conservative treatments • NSAIDs • Thumb splinting • Hand therapy • Injections

  7. 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

  8. 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

  9. 60 patients with thumb arthritis • 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

  10. Thumb CMC Surgery • CMC interposition arthroplasty • Conventional techniques (LRTI, HTA) • Modern techniques (Tightrope suspensionplasty)

  11. CMC Interposition Arthroplasty Step 1 (common to all) • Trapeziectomy Step 2 (varies) • Suspension and interposition through a wide variety of techniques

  12. CMC 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

  13. 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

  14. Finger Arthritis Finger arthritis can affect the: • DIP joint • PIP joint • MCP joint

  15. Finger Arthritis Conservative treatments • Splinting • NSAIDs • Injections

  16. PIP Arthritis Surgical treatments • PIP joint arthroplasty • Silastic • Pyrocarbon • PIP joint fusion

  17. 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

  18. PIP Joint Fusion • Single cannulated compression screw OR • Plate-screw construct

  19. MCP Arthritis MCP joint arthroplasty • Silastic – constrained • Pyrocarbon - unconstrained

  20. MCP Joint Arthroplasty 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

  21. Wrist Arthritis Potential causes • Age-related degenerative changes • Anatomic variations • Unrecognized injury to • Ligament • Bone

  22. 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

  23. Ulnar Impaction Syndrome Conservative treatments • Casting for 4 weeks • NSAIDs • Corticosteroid injections • Activity modification

  24. 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

  25. Ulnar Impaction Syndrome Surgical treatments • Arthroscopic TFCC debridement or repair • Lunate chondroplasty • Feldon wafer procedure • Ulnar shortening osteotomy (USO) • Salvage operations

  26. TFCC Debridement or Repair • 2mm incisions • Small joint camera for visualization • Shaver for debridement • Suture device for peripheral repairs

  27. Lunate Chondroplasty • Puncture subchondral plate of lunate • Promote fibrocartilage formation • Biologic joint resurfacing

  28. Feldon Wafer Procedure • Arthroscopic or open excision of distal ulnar head • Decreased pressure on ulnar wrist

  29. Ulnar Shortening Osteotomy • Surgical osteotomy of ulna • Remove a wafer of bone • Compress with plate and screws • Excellent long-term results

  30. Salvage Operations • Distal ulna resection (Darrach resection) • Hemi-resection arthroplasty (Bower’s arthroplasty) • Distal radio-ulnar joint fusion (Sauve-Kapandji procedure)

  31. Wrist Injury Ligament injury • Scapholunate interosseous ligament (SLIL) • Holds scaphoid and lunate together Bone injury • Scaphoid fracture • Crucial for normal wrist biomechanics

  32. Wrist Injury • Ligament or bone injury • If recognized  repair early • If unrecognized  SLAC or SNAC arthritis Stage II Stage IV Stage I Stage III

  33. SLAC and SNAC Wrist Conservative treatments • Splinting • NSAIDs • Corticosteroid injection

  34. SLAC and SNAC Wrist Surgical treatments • PIN neurectomy • Proximal row carpectomy (PRC) • Scaphoid excision and four-corner fusion

  35. 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

  36. PIN Neurectomy • Dorsal approach • Resect 1cm segment of nerve

  37. Proximal Row Carpectomy • Excise the proximal row • Capitate then articulates with radius • Excellent pain relief without the need for bony healing

  38. 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

  39. Four-Corner Fusion • Excise scaphoid • Fuse capito-lunate and triquetro-hamate joints

  40. Total Wrist Arthroplasty Indications • End-stage rheumatoid arthritis • Low-demand patient (lifetime restriction on weight bearing)

  41. Total Wrist Arthoplasty • Fuse and resurface the proximal carpal row • Resurface distal radius

  42. Total Wrist Fusion Indications • End-stage arthritis • High demand patients • Once healed, no limitations on weight-bearing

  43. Total Wrist Fusion • Dorsal approach • Fusion of radio-carpal and mid-carpal joints • Dorsal spanning plate application

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