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Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
1. Richard W. Barth MD
Washington Orthopaedics and Sports Medicine
Associate Clinical Professor, Department of
Orthopaedic Surgery, GW Medical School
2. I have no relevant financial
relationships to disclose
3. Identify appropriate patients for referral to an
orthopaedic hand surgeon
Describe current surgical options for the elbow
and hand
Describe rehabilitation consideration for
patients undergoing surgery
4. Identify appropriate patients for referral to an
orthopaedic hand surgeon
Describe current surgical options for the elbow
and hand
Timing of referral
Expected outcomes of surgical intervention
Conservative treatment
Office evaluation
Surgical techniques
12. Limited motion, pain at extremes of motion
Not much pain at mid arc
Difficulty with golf, tennis, manual activities
Overgrowth and impingement
Primary osteoarthritis
Refer
13.
14.
15.
16. Motion improve 45 to 60 degrees
Pain and function significantly improved
Excellent option in the proper patient
17. Synovectomy and/ or radial head excision
Arthrocopic
Open
Total elbow arthroplasty (TEA)
Refer rheumatoid patient with refractory
synovitis and pain early
18. Several studies show good results
Likely slow disease progression
Relatively low risk and quick recovery
Does not burn bridges
19. TEA an excellent option
RA patients historically lower demand
Morrey et al, JBJS Am 1998
10-15 year follow up
92% rate survivorship at 10-12 years
Good motion and function
20. Signs and symptoms
Refer early
Surgical options
Generally good results if treat early
21. Neurolysis in situ rather transposition
Less risk
Less dissection
Much quicker recovery
No bridges burned
23. Often severe especially in elderly
Results related to severity AND
Degree of cervical disease
Often some degree of both
Start with cubital tunnel surgery
Always get a nerve test
24. Conservative, conservative, conservative
80 percent better at a year
Refer after prolonged conservative treatment
No bridges burned by living with it
Pain issue
Surgery removes diseased tissue
25. Results generally good but not entirely
predictable
Multiple techniques available
Open
Arthroscopic
Experimental
Resume light activities immediately
Full use in 6-12 weeks
26. Joints spared vs. pan carpal arthritis
Post traumatic/ osteoarthritis vs inflammatory
arthritis
Occupational/ avocational needs of patient
Physiologic age
27. Total wrist arthroplasty
Total wrist fusion
Limited wrist fusion (LWF)
Proximal row carpectomy (PRC)
28. Higher risk, higher reward
High complication, revision rate
Few indications
Low demand patient with bilateral disease
Inflammatory arthritis
Failure can be salvaged to fusion
29. Conclusions: The results for the Universal wrist
prosthesis at a minimum of five years of follow-up
include a high rate of failure, most often because of
carpal component loosening, resulting in revision of
ten (50%) of twenty wrists at the time of the latest
follow-up (with the inclusion of one revision in a
patient who died before five years). Patients with a
stable prosthesis maintained a functional range of
motion and had improvement in patient-reported
outcome measures.
JBJS 2011: Adams et al.
30.
31. Long-Term Functional Outcomes After
Bilateral Total Wrist Arthrodesis
Conclusions Bilateral total wrist arthrodesis
improved pain while enabling patients with
severe carpal arthrosis to maintain a satisfactory
level of extremity function and quality of life. In
general, patients adapted and were satisfied with
functional capabilities. This is a viable salvage
option for patients with severe bilateral disease. (J
Hand Surg Am. 2015, Wagner et al.)
32.
33.
34.
35. Functional range of motion
Good pain relief
Good strength
Limited wrist fusion holds up better over time
but….
Higher complication rate
Longer recovery
Patient selection
36.
37. Extremely common
Conservative options
Refer when patient chooses not to live with
pain and functional loss
Burn no bridges by waiting
Surgical options depend on stage
X-ray findings do not correlate well with sx
44. Treatment of Eaton Stage I Trapeziometacarpal
Disease With Thumb Metacarpal Extension
Osteotomy. Tomaino, JHS 2000
Results: 11/12 satisfied
Long-Term Outcomes of First Metacarpal
Extension Osteotomy in the Treatment of Carpal-
Metacarpal Osteoarthritis. Parker et al, JHS 2008
Results: Excellent 6/8 at 9 years
49. Generally very good results
Average about 70 percent of normal strength
Takes 1 year to reach maximal improvement
Cast 1 month, then splint 1 month
50. Extremely common
Conservative treatment effective early
Surgery extremely effective
Refer on earlier side
Surgical options
Poor results
Not CTS
Severe
51. Patient tired of symptoms
Numbness constant
Hands feel like sandpaper
Drop things
Can’t button buttons
Weakness
Thenar atrophy
53. Ligament safely cut, all effective
Recovery, return to activities/ work
Light use immediately (typing, eating, ADLs)
Unrestricted use at 3 weeks
57. Inflammatory vs. Degenerative Arthritis
Multiple vs single digits
Very good results in OA, single digit
Mixed results in multiple digits, inflammatory
63. Conclusions: The outcome after silicone
metacarpophalangeal joint arthroplasty in patients
with rheumatoid arthritis worsens with long-term
follow-up. Given these findings, the indications for
and long-term expectations of silicone
metacarpophalangeal arthroplasty must be
carefully examined in light of the improvements in
the medical management of rheumatoid disease.
JBJS Oct 2003 Goldfarb and Stern
64.
65. Generally improved cosmesis
Function perceived as improved
Multiple studies show no significant objective
improvement in function
66. Single digit osteoarthritis or well controlled RA
Soft tissues preserved
Less deformity
Much better outcome
67.
68. Results are more favorable
Refer early before significant deformity
Good pain relief and motion
69. Inflammatory vs. Degenerative Arthritis
Doesn’t matter
Severity/ deformity
Doesn’t matter
Arthrodesis
Excellent results
Thumb needs stable post for pinch
71. Osteoarthritis vs. inflammatory arthritis
Deformity (boutonniere, swan neck)
Single vs multiple digits
MPs and DIPs involved
Which digit is involved
Technical issues