C. Noel Henley, MD

Hand and Upper Extremity Specialist

Surgery For Wrist Arthritis

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The most common type of wrist arthritis creates pain at the thumb, or radial side of the wrist. Pain can flare up and down, with good days and bad days. Sometimes a wrist brace, anti-inflammatory pills, heat or ice can help. Hand surgeons can help with occasional cortisone (steroid) shots in the joint. 

When all these treatments fail (or when you’re just sick of them), surgery is a good option. All these other treatments just deal with the symptoms. 

Surgery is the only way to get rid of the arthritis forever. 

Two surgeries exist for wrist arthritis: proximal row carpectomy (PRC) and partial wrist fusion, also known as four corner wrist fusion. 

Both surgeries stop the arthritis pain because the worst and most painful carpal bone, the scaphoid, is completely removed. Unfortunately, just taking out this bone isn’t good enough. Something else has to be done to prevent the rest of the wrist from becoming arthritic. 

In the PRC procedure, the scaphoid, lunate, and triquetrum bones are removed. These three bones form the “proximal carpal row”, basically a row of three bones close to the radius and ulna (where the forearm bones join with the tiny wrist bones). 

PROXIMAL ROW CARPECTOMY

This leaves a big space, obviously, but it’s filled in as the distal row of carpal bones sinks into the space, forming a new joint. This surgery takes about six weeks to recover from. You’re in a temporary splint for 10 days, then into a cast for 3 weeks. Then you start some gentle motion and maybe visit the hand therapist a few times. 

In the partial wrist fusion surgery, after the scaphoid bone is removed, instead of taking out more bones, I fuse together four of the remaining carpal bones: the lunate, triquetrum, capitate, and hamate. A fusion means forcing the bones to grow together into a solid, stable mass of bone. 

PARTIAL WRIST FUSION

A wrist fusion requires hardware – this could be anything from simple stainless steel wires to special staples, to a small plate and screws. Most of the time I use a plate and screws. The fused bones take about six weeks to heal solid. During that time, you’re in a cast with your fingers free, but can’t lift or grip anything. You may need some therapy afterwards to get the wrist moving again. 

A “total” wrist fusion means the wrist never bends again. That’s different than the “partial” wrist fusion I’m talking about here. 

Deciding which is best

PRC versus partial wrist fusion is controversial. Most of the research that tries to study which one is better tells us that they’re equal. Both are pretty good at stopping pain. Both options let patients function very well after surgery. 

My advice is to have the least complicated surgery that stops the pain. For most people, that’s a PRC. No hardware to worry about; no fusion to heal, and a slightly faster recovery time. 

The advantage of a partial wrist fusion is mostly theoretical, in my opinion. It leaves more of your natural anatomy in place than a PRC. But with higher risk of complication (the fusion not healing or having to take hardware out later). Some surgeons believe that a PRC weakens the grip, but there’s no good science to tell us that for sure. 

Surgery For Thumb Arthritis

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Many operations have been designed over the last 100 years to treat this type of arthritis. They all have one thing in common: removing a bone called the trapezium, which is covered with arthritis.

LRTI Surgery

Taking out the trapezium leaves a hole, an empty space with bones, tendon, and muscle all around it. Most of the videos on YouTube show the surgeon taking a tendon from the forearm (usually the FCR – flexor carpi radialis), rolling it up, and putting it in this space to form a cushion for the remaining bones. This is commonly known as an “LRTI” thumb surgery, which stands for ligament reconstruction tendon interposition.

I used to do this operation as well, but after a few years found a simpler way to accomplish the same thing, save the FCR tendon, and with lower risk of complications for patients.

In the current version of this surgery, which I’ve used since about 2011, I only work through the original incision. No extra tendon is harvested or rolled up.

Steps of the Operation

In this drawing, I show the internal anatomy of the thumb from a side view – as if you just rested the back of your left hand on the table in front of you and looked at the thumb from the side, pointing your fingers to your right.

The thumb has three bones. Naming them from the tip toward the wrist, they’re called distal phalanx, proximal phalanx, and metacarpal.

The metacarpal base joins up with the trapezium – that’s where the worst thumb arthritis is in most people. This is where most people see a big bony lump at the base of their thumb. The next bone back towards the wrist is the scaphoid (skay-foid) bone.

I make the incision directly over the trapezium bone, on the top side of the thumb. When I take out the trapezium, as mentioned above, the space that’s left is between the thumb metacarpal bone and the scaphoid bone.

Visualize the space as a room with a ceiling and floor. Strung across the ceiling, or top of the incision (top of the thumb) is a large tendon called the APL (abductor pollicis longus). Deep in the “floor” of the space (toward the palm side of your thumb) is another large tendon called the FCR (mentioned above – same one).

The next step in the surgery is to “pinch” those two tendons closer together with a strong suture. This forms a cushion where the metacarpal can glide smoothly when everything is healed up. It also pulls the base of the metacarpal down from its “kicked up” position (reducing the big bony lump most people have).

This is the part that has to heal for a solid four weeks after the surgery. That’s why you can’t use your thumb for a month afterwards.

Recovery From Thumb Arthritis Surgery

The surgery takes about 45 minutes from start to finish. Afterwards you’re in a bulky, well-padded dressing and splint from the tip of the thumb all the way up the forearm for ten days. Your elbow and all other fingers are free.

After ten days, you come back to the office and get sutures out, then you’re fitted for a custom thumb splint, which will protect the surgery for another two and a half weeks. Then you’ll finally start getting the thumb loosened up by doing therapy exercises – mostly at home.

Most patients are pinching and gripping by three months on average. Some move faster, some move slower. You should be free of the splint by six weeks after surgery.

For a detailed description of the recovery process and how to prepare for it, click here. This was written by one of my patients who thoughtfully took notes on her experience.

Bad Thumb Arthritis – What Does It Look Like?

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The video below shows a patient’s thumb moving back and forth. As you’ll see, most of the range of motion is at the MP (metacarpophalangeal) joint. This is abnormal – in a normal thumb, the majority of the motion is through the CMC (carpometacarpal joint, at the base of the thumb).

When the CMC joint stiffens up from arthritis, the next joint toward the tip of the thumb gets hyperflexible to compensate.

What Is A Fusion?

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A fusion is a surgery done to stop two things: motion and pain. A fusion creates a solid bone where a joint used to be. In this article, I’ll share an example of a common fusion surgery I do to cure finger pain.

Why would someone want a fusion surgery?

A fusion (also called an arthrodesis) is almost always done for arthritis. It’s a cure for arthritis. Fusing a joint cures the arthritis forever and stops pain.

Because the pain of arthritis comes from a worn out joint grinding on itself, if you stop the grinding, you stop the pain.

Patients with arthritis in the fingers try many treatments – from splints, to steroid shots, to medicines, and even surgeries to replace joints and repair bones.

When all these stop working, a fusion is the last option to try in most cases. It’s a good, reliable operation that’s been working for centuries.

How does a fusion work?

In a fusion surgery, the surgeon opens up the joint, exposing the worn out joint surfaces. He uses tools (scraping tools and often a burr) to expose raw spongy bone on either side of the old joint.

Sometimes bone graft is packed into this space, and the two bones are held together by some type of hardware, like a screw or wires.

In this example, you can see an xray of a finger joint fused together by a single screw.

fingertip dip fusion

The hardware keeps the two bones still and squeezed next to each other while they heal. Eventually solid bone grows across the junction between the two bones, forming a solid bridge of hard, normal bone.

How long does it take for a fusion to heal?

Because I’m putting two bone surfaces together to let them heal, fusions heal like a fractured bone. Instead of two broken bone fragments healing together, there are two normal bones healing together.

This process takes about six weeks in a finger.

Signs of healing include new calcified bone on an xray – growing across like a bridge between the bones, and no tenderness when the patient pushes on the old joint.

Usually patients can use the finger for light activities while the fusion is healing – typing, writing, getting ready in the morning. The screw is strong enough to withstand some light daily activity.

How does a fusion cure arthritis?

In the process of fusing the joint, the old joint surfaces are removed. Therefore, technically, there isn’t a joint there anymore.

Without a joint, you can’t have arthritis, so it’s gone forever!

What’s the big downside to a fusion surgery?

No motion.

The motion of the fused joint stops forever. The joints around the fused joint may move normally, but the fused bones become permanently stiff.

A fusion is a tradeoff between motion and pain. You get stiff, but the pain goes away forever. The happiest patients after a fusion surgery are patients who had daily pain in the finger before surgery, even with light activities.

Another thing that surprises patients is that the finger is still somewhat enlarged or lumpy after the fusion. This is common, and often cannot be corrected completely. However, the finger should be straight, not twisted, and pain-free once it’s healed.

What will the finger look like after the surgery?

Here’s a video of one of my patients with a fused, pain-free pinky finger joint after healing. The finger moves at the MCP and PIP joints, but the end knuckle doesn’t move at all.

Finger Joint Arthritis

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Arthritis can appear anywhere in your finger. Osteoarthritis is the most common type of arthritis that affects the middle joint of the finger, also called the proximal interphalangeal joint. I’ll show you where this joint is in your finger and what can be done to treat it.