Hand Arthritis: When Do I Need Surgery?

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Presented by: Amy Ladd, MD
Professor of Orthopaedic Surgery (Hand Surgery) and by courtesy of Medicine (Immunology & Rheumatology) and Surgery
Stanford University Medical Center
January 28, 2009

Lecture Overview:

  • Arthritis of the fingers and thumb afflicts most adults.
  • There are a number of non-surgical treatments for arthritis. Working with a hand therapist may improve patients’ function and decrease their pain.
  • Surgery is worthwhile for patients who experience loss of function, pain or deformity in the hand.

“If you’re lucky to live long enough, you will get arthritis,” according to Amy Ladd, MD, professor of orthopaedic surgery (hand surgery) at Stanford in a presentation on hand arthritis. Speaking before a room full of arthritis sufferers at the Redwood City Public Library, Ladd outlined the treatment options available, and how to determine when surgery is needed.Arthritis, or inflammation of the joints, occurs when cartilage – the Teflon-like coating of the joints – wears down. Most people suffer from osteoarthritis, the “wear and tear” arthritis that occurs over time. Normally a joint consists of two cartilage-covered bone surfaces that glide smoothly against one other. Arthritis results when these smooth surfaces become irregular and lose their glide. Arthritis can affect any joint in the body, but it is quite visible when it affects the hands and fingers.

Who Gets Arthritis?
Everyone over the age of 40 typically has some type of arthritis, often without symptoms, Ladd explained. Arthritis at the base of the thumb is a common, and the most likely place to require surgery. The unique anatomy of women’s hands probably makes them more susceptible to hand arthritis. Also, Caucasians have a higher prevalence. Some individuals are at an increased risk for arthritis because of the type of work they do. Dentists, for example, and others who regularly use tools for grasping and pinch, are more at risk of acquiring hand arthritis.In a brief anatomy lesson of the thumb, Ladd pointed out that the thumb basal joint, which is saddle-shaped, is formed by a small wrist bone (trapezium) and the first of the three bones in the thumb (metacarpal). The specialized shape of this joint allows the thumb its wide range of movement-”hitchhiking” the thumb up, opening away from the fingers, reaching across the palm and pinching against the fingers.”Your thumb allows you to turn a key, pick up a pen, collect a coin and grasp an object,” Ladd pointed out. “It is this same mobility that also makes it more prone to arthritis.”

What Can I Do if I Have Arthritis?
If you experience pain or loss of function in your hand, Ladd recommends scheduling an appointment with a hand surgeon. Hand surgeons complete an additional four to six years of surgical training in orthopaedic surgery, plastic surgery or general surgery after medical school, followed by an additional year focused completely on hand surgery.Even though you visit a hand surgeon, surgery is not the first course of action for treating arthritis. Your surgeon will most likely work in concert with a hand therapist who will teach you better ways to perform your daily tasks. Hand therapists can help patients learn new ways to complete these activities of daily living to reduce pain and improve function.At your first appointment, your surgeon or hand therapist will most likely suggest one or more of the following options:

  • You will be fitted for a splint. Splints help stabilize the joint and provide needed rest. According to Ladd, splints are the mainstay of pain management at night. She often recommends using neoprene splints during the day because they keep the joint warm and allow patients more function – if their pain isn’t too severe.
  • Avoid activities that put a lot of stress on the thumb. For example, opening packaging such as a pound of sealed coffee or a DVD is extremely stressful on the thumb. Keep a pair of scissors handy instead and give your thumb a break. Modified scissors also exist that take the pressure off the thumb.
  • Use adaptive tools to help you perform daily activities. These can be purchased at a medical supply store or online at northcoastmedical.com.
  • Take anti-inflammatory medications, if your health permits. These can help reduce the swelling and the pain associated with arthritis. Prescription strength anti-inflammatories require a doctor’s prescription.
  • Selected patients benefit from cortisone injections into the affected area, performed by a hand surgeon. Relief may be temporary or substantial.
  • Surgery is available when other treatment options fail to reduce pain significantly. “Probably only one in six to eight patients with thumb arthritis will schedule surgery on their first visit,” Ladd pointed out, “since simple measures may do the trick, or delay the need for surgery.”

Is Surgery Really Necessary?
Patients with advanced arthritis or who do not respond to non-surgical treatment may be candidates for surgical reconstruction.”If the pain keeps you up at night, that is a good indication you need to see a hand surgeon.” Ladd said. “Far and away, pain relief is why we perform surgical procedures. In most cases, the patient knows best and actually tells the doctor when it is time for surgery.”A variety of surgical techniques are available. The goal is to restore as much function as possible and to eliminate pain or reduce it to a tolerable level.

  • Joint reconstruction (“arthroplasty”) is commonly performed because it maintains the motion at the base of the thumb, although it typically does not restore strength to the level of a young adult. The surgeon removes the trapezium-the small saddle bone-to eliminate the rough, irregular bone-to-bone contact that causes pain and restricts motion. The space is replaced with rolled-up tissue, such as a tendon, or natural scar, to cushion the area.
  • Joint fusion, in which the arthritic surface is removed and the bones on each side of the joint are fused together, eliminates motion from the problem joint. This means the motion for pinch and grasp are more restricted, but strength is typically good. Many surgeons like Ladd use this procedure less often because of the restricted motion.

Recovery for thumb surgery is progressive, with the first four to six weeks the most limiting – wearing a full cast or splint – and a total of four to six months before patients can engage in vigorous activity. Typically patients wear a removable splint after the first few weeks as function returns. Working with a hand therapist is often a key part of a patient’s recovery.

The Future of Arthritis Hand Surgery
“The base of the thumb is the black box of musculoskeletal medicine,” said Ladd. “One of my research goals is to develop a way to predict, prevent and treat thumb arthritis.” Her current and avid research interest is developing high-resolution imaging techniques such as MRI, CT and motion analysis to learn more about joints and how they move, and identify arthritis earlier in the future. She showed several colorful, detailed images from her research at her presentation. She and other Stanford colleagues are also researching predictors and markers for early detection, delaying progression of arthritis, and ultimately preventing hand and thumb arthritis.

About the Speaker
Amy Ladd, MD, is a Professor of Orthopaedic Surgery (Hand Surgery) and by courtesy of Medicine (Immunology & Rheumatology) and Surgery at Stanford University Medical Center. She is Chief of the Robert A. Chase Hand Center at Stanford, and the Chief of the Pediatric Hand & Upper Clinic at Lucile Packard Children’s Hospital. Renowned for his expertise in hand surgery, Ladd is interested in the complexity of the human hand and upper limb. Her research interests include how high resolution imaging of human anatomy (CT, MRI, and photography) will provide new tools in diagnosing and treating arthritis in the future; synthetic bone substitutes and factors such as mechanical and biologic materials; and understanding the fractured distal radius, the most common fracture requiring treatment. Her other research and clinical interest focuses on congenital hand anomalies in children.Ladd graduated from SUNY Upstate Medical University in 1984 and completed an orthopaedic residency at University of Rochester School of Medicine in 1989. She also completed the Harvard combined hand fellowship at Brigham and Women’s Hospital & Boston Children’s Hospital in 1990.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Stanford Hand & Upper Extremity Center
http://stanfordhospital.org/clinicsmedServices/COE/orthopaedics/handUpperLimb/The

American Academy of Orthopaedic Surgeons
http://www.aaos.org/

American Society for Surgery of the Hand
http://www.assh.org/AM/Template.cfm?Section=Patients_Public

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