Most people are familiar with joint replacement surgery for the hip, knee, and shoulder joints. Joint replacement surgery in the wrist is less common but can be an option if you have painful arthritis that does not respond to other treatments.

Anatomy of the wrist
The wrist is a more complicated joint than the hip or the knee. At the base of the hand are two rows of bones, with four bones in each row. These are called the carpals. The long thin bones of the hand radiate out from one row of carpals toward the fingers and thumb. The two bones of the lower arm (radius and ulna) form a joint with the other row of carpals. All the bone ends are covered with a slick, elastic tissue called cartilage, which enables the bones to move smoothly against each other. However, if the cartilage is worn away or damaged by injury, infection or disease, the bones will rub against each other causing pain. During any total joint replacement, the worn-out bone ends are removed and replaced by an artificial joint (prosthesis).

Reasons for wrist replacement surgery
The typical candidate for wrist replacement surgery has severe arthritis but does not need to use the wrist to meet heavy demands in daily use. The primary reasons for wrist replacement surgery are to relieve pain and to maintain function in the wrist and hand.

• Osteoarthritis, the most common form of arthritis, results from a gradual wearing away of the cartilage covering on bones.
• Rheumatoid arthritis is a chronic inflammatory disease of the joints that results in pain, stiffness and swelling. Rheumatoid arthritis usually affects several joints on both the right and left sides of the body.

Both forms of arthritis may affect the strength of your fingers and hand, making it difficult for you to grip or pinch. In some cases, fusing the wrist bones together will reduce or eliminate pain and improve grip strength. However, if the bones are fused together, you will not be able to bend the wrist. Wrist replacement surgery may enable you to retain or recover wrist movements and improve your ability to perform daily living activities, especially if you also have arthritis in the elbow and shoulder.

Implant design
Wrist implants are made of the same kind of materials used for hip and knee joint replacements. There are several different designs. Most have two components and are made of metal; a high quality plastic called polyethylene is used as a spacer between the two components. Newer implant designs try to replicate the anatomy of the wrist.

The piece that attaches to the lower arm (radius bone component) fits into the bone of the lower arm. The top of this component has a curve that matches to the wrist part. The piece that attaches to the hand (carpal component) may have one long stem and one or two shorter stems that insert into the hand bones, or use small screws. The surface of this component is flat. The plastic spacer comes in different sizes so it can be matched to your hand. It is normally flat on one side and rounded on the other. This design enables it to fit into the carpal component while it rocks on the radial component, creating a more natural wrist motion.

Implant insertion
A wrist joint replacement can be done as an outpatient procedure, unlike a hip or knee replacement. Wrist replacement surgery is often combined with other procedures to correct deformities or disorders in the tendons, nerves, and small joints of the fingers and thumb.

The incision is made on the back of the wrist. The damaged ends of the lower arm bones are removed and the first row of carpal bones may also be removed. The radial component of the prosthesis is inserted into the center of the radius bone on the outside of the lower arm. It is held in place with bone cement. Depending on the component design, the carpal component is then inserted into the center hand bone (third metacarpal) or screwed into the remaining row of carpal bones. Bone cement may be used to hold the component in place. The carpal bones may be linked or fused together to better secure this component.

An appropriately sized spacer is used between the metal components.

After your surgery
You will have to wear a cast for the first several weeks. When the cast is removed, you will have to wear a protective splint for the next six to eight weeks. Although pain relief is immediate, you will have to do gradual exercises for several weeks to restore movement and, eventually, to increase power and endurance. Wrist arthroplasty can improve motion to about 50 percent of normal.

The physical demands that you place on the wrist prosthesis will have an effect on how long the implant lasts. You will not be able to use a hammer often or pneumatic tools. You may only be able to lift a limited amount of weight. A fall on the outstretched hand may break the prosthesis, just as it might fracture a normal wrist. So you will want to avoid activities such as roller sports that could result in a fall.

Although there have been significant advances in wrist prostheses, the implant may loosen or fail due to wear or deformation. In these cases, additional surgery may be necessary. On average, a wrist replacement can be expected to last 10 to 15 years with careful use. As with all implants, long-term follow-up is advised. Generally, you should see your hand surgeon every year or two years so that x-rays can be taken and used to identify any developing conditions or problems.

Arthroscopy (ar-THROS-ka-pea) is an outpatient surgical procedure used by orthopaedic surgeons to diagnose and treat problems inside a joint. The surgeon makes small incisions, less than half an inch long, and inserts a pencil-sized instrument called an arthroscope. The arthroscope contains a small lens, a miniature camera and a lighting system.

This projects three-dimensional images of the joint on a television monitor, enabling the surgeon to look directly inside the joint and identify the trouble. Tiny probes, forceps, knives and shavers can then be used to correct many problems at the same time.

Arthroscopy has been used for several years to treat conditions in large joints such as the knee and the shoulder. As cameras and instruments became smaller and more refined, arthroscopy was applied to other joints, including the wrist. The wrist is a complex joint, with eight small bones and many connecting ligaments. Arthroscopy enables the surgeon to see the anatomic parts and their movements and to make a more accurate diagnosis.

Diagnostic arthroscopy
Diagnostic arthroscopy may be used if the cause of your wrist pain cannot be identified or if wrist pain continues for several months despite nonsurgical treatment.

Before surgery, your doctor will do:

• A physical examination that focuses on your hand and wrist. Your doctor will also ask about your medical history.
• Provocative tests that involve moving your hand in ways that reproduce the pain.
• Imaging studies, such as X-rays of your hand and wrist. In some cases, additional imaging studies may be needed. These can include an MRI (magnetic resonance image) or an arthrogram, in which a contrast agent is injected into the joint before the image is taken.

Usually, regional anesthesia is used during arthroscopic surgery. This numbs your arm and hand. You may also be given a sedative to further relax you and enable you to doze through the surgery. Two or more small incisions (portals) are made on the back of the wrist, through which the arthroscope and instruments are inserted. After the surgery, the incisions are closed with a small stitch and a dressing is applied. Sometimes a splint may also be used.

Arthroscopic surgical treatment

Several conditions can be treated using arthroscopic surgery, including chronic wrist pain, wrist fractures, ganglion cysts and tears in the ligaments or the triangular fibrocartilage complex (TFCC). Wrist arthroscopy may also be used to smooth the bone surfaces and remove inflamed tissue. Arthroscopy can also be used to surgically treat carpal tunnel syndrome, but in that diagnosis, the arthroscope is not inserted into the wrist joint itself.

• Chronic wrist pain: Arthroscopic exploratory surgery may be used to diagnose the cause of chronic wrist pain when other tests are inconclusive. Often, there may be areas of inflammation, cartilage damage, or other findings after a wrist injury. In some cases, after the diagnosis is made, the condition can be treated arthroscopically as well.
• Wrist fractures: Doctors can remove small fragments and fracture debris, align the broken pieces of bone, and stabilize them by using pins, wires, or screws.
• Ganglion cysts: These cysts commonly grow from a stalk between two of the wrist bones. During an arthroscopic procedure, the surgeon can remove the stalk, which may also reduce recurrence of the cysts.
• Ligament/TFCC tears: Ligaments are fibrous bands of connective tissue that link or hinge bones. They provide stability and support to the joints. The TFCC is a cushioning structure within the wrist. A fall on an outstretched hand can tear ligaments, the TFCC or both, resulting in pain with movement or a clicking sensation. During arthroscopic surgery, the surgeon can trim or repair the tears.
• Carpal tunnel release: Carpal tunnel syndrome is characterized by numbness or tingling in the hand, and sometimes with pain up the arm. It is caused by pressure on a nerve that passes through the carpal tunnel, which is formed by the wrist bones and a thick tissue roof. Pressure can build up within the tunnel for many reasons, including irritation and swelling of the tissue (synovium) that covers the tendons. If the syndrome does not respond to conservative treatment, your doctor may recommend surgery to cut the ligament roof and enlarge the tunnel, thus reducing pressure on the nerve and relieving symptoms. This can sometimes be done using an arthroscope.

After surgery, you will need to keep your wrist elevated for the first two or three days and keep your bandage clean and dry. You can ice your wrist to help keep swelling down. Your doctor and/or your physical therapist will teach you exercises to help maintain motion and rebuild your strength. Analgesic medications will help relieve any postoperative pain, which is usually mild.

Complications
Complications during or after arthroscopic wrist surgery are unusual, but may include infection, nerve injuries, excessive swelling or bleeding, scarring or tendon tearing. An experienced surgeon, particularly one who specializes in treating the hand, can reduce the likelihood of complications.

Summary
Arthroscopic surgery is a valuable diagnostic and treatment tool. It is minimally invasive, and patients generally experience fewer problems and a more rapid recovery than with open surgery. Because it is an outpatient procedure, most patients are home several hours after surgery.

Description
A trigger finger is a common problem that causes pain and catching. Tendons that help bend the fingers and thumb slide through a snug tunnel. Irritation as the tendons slip into the tunnel can cause the opening of the tunnel to become smaller, or the tendon to thicken so that it can’t easily pass through the tunnel.

As you try to straighten the finger, the tendon becomes momentarily stuck at the mouth of the tunnel then pops as the tendon slips past the tight area. This can cause pain and catching as you try to move the finger. Your doctor can diagnose the problem by talking with you and examining your hand. No X-rays or other testing are usually needed.

Risk Factors/Prevention
It isn’t usually known what causes the problem. Trigger fingers are more common in women than men. They occur most frequently in people who are between the ages of 40 to 60 years. Trigger fingers are more common in people with certain medical problems such as diabetes and rheumatoid arthritis.

Symptoms
Symptoms usually start without any injury. You may feel pain in the palm, sometimes along with swelling or a small lump. You may feel the catching or popping sensation in the finger or thumb joints. Stiffness and catching tend to be worse after inactivity, such as when you wake in the morning, but will often loosen up with movement. When it breaks free, it may feel like the finger joint is dislocating. In severe cases the finger may become stuck in a bent position so that it can’t be straightened even with the help of other fingers. One or more fingers can be involved.

Treatment Options
If your symptoms are mild, simply resting the finger may be enough to relieve the problem. Over-the-counter medications such as Tylenol® or Advil® can be used for pain. Splints are sometimes used to rest the finger. Your doctor may recommend an injection that helps in most cases, but sometimes the improvement is temporary. More than one injection may be needed. Injections are less likely to bring about permanent relief when the triggering has been present for a long time, or if you have associated medical problems like diabetes. If the problem remains troubling, you may want to consider surgery.

Treatment Options: Surgical
A trigger finger isn’t a dangerous condition, so the decision whether to proceed with surgery is a personal one based on the severity of your symptoms. If the finger is stuck in a bent position, surgery may be recommended to prevent permanent stiffness. Surgery widens the opening of the tunnel so the tendon can slide through more easily. This is usually done through a small incision in the palm as an outpatient surgery.

Sometimes the tunnel can be safely opened with the tip of a needle in your doctor’s office. You can move the fingers immediately after surgery. Elevating the hand after surgery can help minimize swelling and pain. Some soreness in the palm is common but recovery is usually complete in a few weeks. If the finger was quite stiff before surgery, a therapist may help you to loosen up the finger.