Richard W. Barth MD
Washington Orthopaedics and Sports Medicine
Associate Clinical Professor, Department of
Orthopaedic Su...
I have no relevant financial
relationships to disclose
 Identify appropriate patients for referral to an
orthopaedic hand surgeon
 Describe current surgical options for the el...
 Identify appropriate patients for referral to an
orthopaedic hand surgeon
 Describe current surgical options for the el...
 Predictable
 Generally Predictable
 Less predictable
 Location
 Elbow
 Wrist
 Hand
 Etiology
 Inflammatory arthritis
 Osteoarthritis
 Post traumatic
 Idiopathic
 Osteoarthritis
 Inflammatory arthritis
 Cubital tunnel syndrome
 Tennis elbow
 Global ulnohumeral arthritis
 Post traumatic
 Overgrowth and impingement
 Primary osteoarthritis
 Total elbow arthroplasty
 Fascial arthroplasty
 Total elbow arthroplasty
 Permanent restrictions 10 pounds
 Higher complication rate than LE arthroplasty
 Fascial ar...
 Conservative treatment as long as possible
 Limited motion, pain at extremes of motion
 Not much pain at mid arc
 Difficulty with golf, tennis, manual activities
...
 Motion improve 45 to 60 degrees
 Pain and function significantly improved
 Excellent option in the proper patient
 Synovectomy and/ or radial head excision
 Arthrocopic
 Open
 Total elbow arthroplasty (TEA)
 Refer rheumatoid patien...
 Several studies show good results
 Likely slow disease progression
 Relatively low risk and quick recovery
 Does not ...
 TEA an excellent option
 RA patients historically lower demand
 Morrey et al, JBJS Am 1998
 10-15 year follow up
 92...
 Signs and symptoms
 Refer early
 Surgical options
 Generally good results if treat early
 Neurolysis in situ rather transposition
 Less risk
 Less dissection
 Much quicker recovery
 No bridges burned
shoulderhand
 Often severe especially in elderly
 Results related to severity AND
 Degree of cervical disease
 Often some degree of...
 Conservative, conservative, conservative
 80 percent better at a year
 Refer after prolonged conservative treatment
 ...
 Results generally good but not entirely
predictable
 Multiple techniques available
 Open
 Arthroscopic
 Experimental...
 Joints spared vs. pan carpal arthritis
 Post traumatic/ osteoarthritis vs inflammatory
arthritis
 Occupational/ avocat...
 Total wrist arthroplasty
 Total wrist fusion
 Limited wrist fusion (LWF)
 Proximal row carpectomy (PRC)
 Higher risk, higher reward
 High complication, revision rate
 Few indications
 Low demand patient with bilateral dise...
Conclusions: The results for the Universal wrist
prosthesis at a minimum of five years of follow-up
include a high rate of...
Long-Term Functional Outcomes After
Bilateral Total Wrist Arthrodesis
Conclusions Bilateral total wrist arthrodesis
improv...
 Functional range of motion
 Good pain relief
 Good strength
 Limited wrist fusion holds up better over time
but….
 H...
 Extremely common
 Conservative options
 Refer when patient chooses not to live with
pain and functional loss
 Burn no...
 Pain
 Deformity
 Loss of function
 I am worried it is going to get worse
 I will be too old to have surgery
 It will be too bad to fix
 I am worried it is going to get worse
 I will be too old to have surgery
 It will be too bad to fix
Normal or widening
CMC joint
Normal STT joint
 Stabilization
 Unloading procedure
 Arthrodesis
 Arthroplasty
Treatment of Eaton Stage I Trapeziometacarpal
Disease With Thumb Metacarpal Extension
Osteotomy. Tomaino, JHS 2000
Results...
Early CMC narrowing
vs. severe
Normal STT joint
Scar and tendon
Severe pantrapezial arthritis
Scar and tendon
 Generally very good results
 Average about 70 percent of normal strength
 Takes 1 year to reach maximal improvement
 ...
 Extremely common
 Conservative treatment effective early
 Surgery extremely effective
 Refer on earlier side
 Surgic...
 Patient tired of symptoms
 Numbness constant
 Hands feel like sandpaper
 Drop things
 Can’t button buttons
 Weaknes...
 Traditional open
 Open
 Mini open
 Endoscopic
 Ligament safely cut, all effective
 Recovery, return to activities/ work
 Light use immediately (typing, eating, ADLs)...
Not all the same
 Inflammatory vs. Degenerative Arthritis
 Multiple vs single digits
 Very good results in OA, single digit
 Mixed resu...
 Synovectomy
 Arthroplasty
 Arthrodesis
Conclusions: The outcome after silicone
metacarpophalangeal joint arthroplasty in patients
with rheumatoid arthritis worse...
 Generally improved cosmesis
 Function perceived as improved
 Multiple studies show no significant objective
improvemen...
 Single digit osteoarthritis or well controlled RA
 Soft tissues preserved
 Less deformity
 Much better outcome
 Results are more favorable
 Refer early before significant deformity
 Good pain relief and motion
 Inflammatory vs. Degenerative Arthritis
 Doesn’t matter
 Severity/ deformity
 Doesn’t matter
 Arthrodesis
 Excellen...
Osteoarthritis PIP and DIP joints
 Osteoarthritis vs. inflammatory arthritis
 Deformity (boutonniere, swan neck)
 Single vs multiple digits
 MPs and DIP...
 Synovectomy
 Arthroplasty
 Silastic implants
 Pyrocarbon
 Metal poly implants
 Arthrodesis
Pre op Post op
 Stable long term results
 Loss of PIP motion less well tolerated
 Improved cosmesis and function but …
 Fusion is best option when patient ready
 Predictable pain relief, deformity correction
 Motion loss usually well tole...
Questions?
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist
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Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist

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Surgery and Therapy for the Elbow and Hand: A Primer for the Rheumatologist

  1. 1. Richard W. Barth MD Washington Orthopaedics and Sports Medicine Associate Clinical Professor, Department of Orthopaedic Surgery, GW Medical School
  2. 2. I have no relevant financial relationships to disclose
  3. 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. 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
  5. 5.  Predictable  Generally Predictable  Less predictable
  6. 6.  Location  Elbow  Wrist  Hand  Etiology  Inflammatory arthritis  Osteoarthritis  Post traumatic  Idiopathic
  7. 7.  Osteoarthritis  Inflammatory arthritis  Cubital tunnel syndrome  Tennis elbow
  8. 8.  Global ulnohumeral arthritis  Post traumatic  Overgrowth and impingement  Primary osteoarthritis
  9. 9.  Total elbow arthroplasty  Fascial arthroplasty
  10. 10.  Total elbow arthroplasty  Permanent restrictions 10 pounds  Higher complication rate than LE arthroplasty  Fascial arthroplasty  Cheng SL, Morrey BF: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Br 2000;82:233-238.  62% satisfied at 5 years
  11. 11.  Conservative treatment as long as possible
  12. 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. 13.  Motion improve 45 to 60 degrees  Pain and function significantly improved  Excellent option in the proper patient
  14. 14.  Synovectomy and/ or radial head excision  Arthrocopic  Open  Total elbow arthroplasty (TEA)  Refer rheumatoid patient with refractory synovitis and pain early
  15. 15.  Several studies show good results  Likely slow disease progression  Relatively low risk and quick recovery  Does not burn bridges
  16. 16.  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
  17. 17.  Signs and symptoms  Refer early  Surgical options  Generally good results if treat early
  18. 18.  Neurolysis in situ rather transposition  Less risk  Less dissection  Much quicker recovery  No bridges burned
  19. 19. shoulderhand
  20. 20.  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
  21. 21.  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
  22. 22.  Results generally good but not entirely predictable  Multiple techniques available  Open  Arthroscopic  Experimental  Resume light activities immediately  Full use in 6-12 weeks
  23. 23.  Joints spared vs. pan carpal arthritis  Post traumatic/ osteoarthritis vs inflammatory arthritis  Occupational/ avocational needs of patient  Physiologic age
  24. 24.  Total wrist arthroplasty  Total wrist fusion  Limited wrist fusion (LWF)  Proximal row carpectomy (PRC)
  25. 25.  Higher risk, higher reward  High complication, revision rate  Few indications  Low demand patient with bilateral disease  Inflammatory arthritis  Failure can be salvaged to fusion
  26. 26. 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.
  27. 27. 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.)
  28. 28.  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
  29. 29.  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
  30. 30.  Pain  Deformity  Loss of function
  31. 31.  I am worried it is going to get worse  I will be too old to have surgery  It will be too bad to fix
  32. 32.  I am worried it is going to get worse  I will be too old to have surgery  It will be too bad to fix
  33. 33. Normal or widening CMC joint Normal STT joint
  34. 34.  Stabilization  Unloading procedure  Arthrodesis  Arthroplasty
  35. 35. 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
  36. 36. Early CMC narrowing vs. severe Normal STT joint
  37. 37. Scar and tendon
  38. 38. Severe pantrapezial arthritis
  39. 39. Scar and tendon
  40. 40.  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
  41. 41.  Extremely common  Conservative treatment effective early  Surgery extremely effective  Refer on earlier side  Surgical options  Poor results  Not CTS  Severe
  42. 42.  Patient tired of symptoms  Numbness constant  Hands feel like sandpaper  Drop things  Can’t button buttons  Weakness  Thenar atrophy
  43. 43.  Traditional open  Open  Mini open  Endoscopic
  44. 44.  Ligament safely cut, all effective  Recovery, return to activities/ work  Light use immediately (typing, eating, ADLs)  Unrestricted use at 3 weeks
  45. 45. Not all the same
  46. 46.  Inflammatory vs. Degenerative Arthritis  Multiple vs single digits  Very good results in OA, single digit  Mixed results in multiple digits, inflammatory
  47. 47.  Synovectomy  Arthroplasty  Arthrodesis
  48. 48. 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
  49. 49.  Generally improved cosmesis  Function perceived as improved  Multiple studies show no significant objective improvement in function
  50. 50.  Single digit osteoarthritis or well controlled RA  Soft tissues preserved  Less deformity  Much better outcome
  51. 51.  Results are more favorable  Refer early before significant deformity  Good pain relief and motion
  52. 52.  Inflammatory vs. Degenerative Arthritis  Doesn’t matter  Severity/ deformity  Doesn’t matter  Arthrodesis  Excellent results  Thumb needs stable post for pinch
  53. 53. Osteoarthritis PIP and DIP joints
  54. 54.  Osteoarthritis vs. inflammatory arthritis  Deformity (boutonniere, swan neck)  Single vs multiple digits  MPs and DIPs involved  Which digit is involved  Technical issues
  55. 55.  Synovectomy  Arthroplasty  Silastic implants  Pyrocarbon  Metal poly implants  Arthrodesis
  56. 56. Pre op Post op
  57. 57.  Stable long term results  Loss of PIP motion less well tolerated  Improved cosmesis and function but …
  58. 58.  Fusion is best option when patient ready  Predictable pain relief, deformity correction  Motion loss usually well tolerated
  59. 59. Questions?

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