Hand and wrist surgery

Surgery is an option for people suffering from osteoarthritis or rheumatoid arthritis which has spread to the joints in their hands or wrists.

It is not necessary for every arthritis patient but it can ease the pain, inflammation and discomfort caused by this condition. It means improved flexibility and mobility and freedom from a long term disability.

Surgery is performed to improve the functionality of the affected hands or wrists and not their appearance. Plus it provides a good alternative to wrist splints and other similar aids.

Arthritis in the wrist can be treated by fusing the bones together or wrist joint replacement. For arthritis in the hands there are several procedures which include surgery on the thumb joint, knuckle replacement and tendon repair.

Hand and wrist surgery is discussed as follows:

• Why hand and wrist surgery?
• Criteria for hand and wrist surgery
• Not suitable for hand and wrist surgery?
• Benefits of hand and wrist surgery
• Disadvantages of hand and wrist surgery
• Preparation for surgery
• On the day of surgery
• Hand surgery procedures
• Thumb joint procedures
• Wrist surgery procedures
• Complications of hand and wrist surgery
• Recovery from hand and wrist surgery
• Alternatives to hand and wrist surgery

Why hand and wrist surgery?

Arthritis is often treated with conventional means such as medication, physiotherapy, cortisone injections and splints. These are effective forms of treatment but if they do not relieve the pain caused by arthritis or have failed to stop the progression of this condition then surgery is an answer.

This is also an option if your arthritis has progressed to such an extent that it is severely affecting your quality of life.

If your arthritis has got to this stage then speak to your GP about surgery. He or she is an ideal person to talk to about this as he/she will be able to advise you about the various procedures available and whether you are likely to benefit from this treatment.

Not everyone is suitable for surgery or benefits from it although many people are happy with their results.

If your GP considers you to be an ideal candidate for surgery then he or she will refer you to a specialist. This specialist is likely to be an orthopaedic surgeon or similar and will be responsible for your treatment.

A question for you: are you looking to have surgery on the NHS or at a private hospital?

There are pros and cons of both. If you choose to undergo surgery on the NHS then of course, this will be free but you will have to go on a waiting list.

Your other option is private treatment which means being seen that much quicker but you will have to pay for this and it can be expensive.

This is discussed in greater detail in our surgery for arthritis section.

Criteria for hand and wrist surgery

Whichever option you choose will involve an initial meeting with a surgeon. He or she will assess your suitability for surgery and will use a set of criteria to do so.

Your meeting with him/her will include a discussion about your symptoms; the type of arthritis you have, e.g. osteoarthritis; the extent of the pain and the effect this is having on your life.

Surgery is usually undertaken when non-surgical forms of treatment have failed to work or the person is experiencing a great deal of pain and discomfort.

The surgeon will also look at your lifestyle: whether you take exercise, what your diet is like, your current weight and alcohol consumption. If you smoke then you will be asked to stop especially if you are booked in for an operation as smoking has a range of negative effects during and after surgery.

The surgeon will also examine you and refer you for tests, e.g. blood tests, X-rays etc.

Not suitable for hand and wrist surgery?

Your surgeon may decide not to operate after reviewing your test results and taking other factors into account. For example, if you suffer from a chronic condition such as heart disease or a lung disorder.

If you are very overweight or obese then this may exclude you from surgery. The problem with this is that excess body fat tends to put a strain on not only the joints, but the rest of the body as well such as the heart.

Surgery puts the body under stress and excess weight will only compound that which can be dangerous.

The surgeon may decide to operate if you lose weight before your operation.

If your surgeon advises you against having surgery then he/she will be able to suggest an alternative form of treatment. This will mean managing the symptoms of arthritis whilst enabling you to carry on with your day to day living.

Benefits of hand and wrist surgery

The main factor in all of this is freedom from pain, which is often constant and restricted movement. Arthritis causes joints to become stiff, swollen and in some cases, severely deformed.

This affects the sufferer’s ability to perform tasks which we take for granted.

So any treatment which relieves this pain and restores flexibility and movement can only be welcomed. Plus there is the fact that surgery can help to slow down the rate of progression which is a common feature of many kinds of arthritis, for example rheumatoid arthritis.

This prevents deformity of the affected joint and in many cases, a permanent disability.

Many people who have this surgery report that they are able to return to work, can drive, and play sports as well as participating in society again. They can socialise, form close relationships with others and generally feel more confident and at ease with themselves.

These are all good reasons to consider having surgery.

Disadvantages of hand and wrist surgery

Whilst there are undeniably, advantages to undergoing surgery for arthritis, there are also some disadvantages as well.

These include:

• Artificial joints are not as hard wearing or long lasting as natural joints.
• An artificial joint such as a wrist replacement joint is subject to normal wear and tear.
• There is a risk of the artificial joint becoming dislocated or loosening over time.
• Revision surgery will be required once the artificial joint has reached the end of its lifespan. This surgery may be required more than once with diminishing results each time.

Most people are pleased with the results but there are a small number of people who are dissatisfied with the outcome. However this may due to unrealistic expectations.

Preparation for surgery

You will have been given a date and time for your operation. Once you have that date you can then start to plan for this important day.

Plan well in advance

But before you go into hospital there is a fair amount of preparation on your part. This includes learning as much as possible about your type of operation, making arrangements with your employer regarding time off work and adapting your home for your recovery period.

Arrange time off work

The recovery period is a long and at times, frustrating time when you will be relatively immobile and unable to do all the things you want to do. It will be 6 to 8 weeks before you are fit and able to return to work - if you have a desk job. But expect to be off for longer, for example 3 months if you have a manual or physically demanding job.

Financial issues

If you are in receipt of any benefits then you will have to notify the DWP that you are going into hospital. Also remember to notify them when you arrive back home.

Become fit and healthy

To get the best results from your surgery, it is a good idea to make sure that you are as fit and healthy as possible. This means strengthening the muscles around your hands or wrists which will help with your recovery. These exercises can be continued when you arrive home after your operation.

Adapting your home

You will be required to rest and allow your treated joint/s time to heal. But coupled with this is exercise and getting used to your new joint.

But you will need some help around the house while you are recuperating. Ask someone to undertake cooking, cleaning and shopping for you. Arrange for them or someone else to take you to the hospital and pick you up afterwards.

Ensure that you have stocked your freezer with plenty of food such as ready meals or cook and store large batches of food which can be heated up easily. Choose clothes which have loose, baggy sleeves so they can be slipped on and off easily.

Prepare a ‘recovery area’ in your home. This means ensuring things can be handled with one hand as your other will be in a sling. Have a table within reach and place on there the TV remote control, your medication, drinks, books and your mobile phone.

For more information visit our living with arthritis section.

Assessment clinic

About two weeks before your surgery you will be required to attend a pre-surgery admission clinic.

This clinic is where you get the chance to meet your surgeon and his/her team and discuss your operation with them. You can ask them as many questions as you need to which is particularly important if you have any concerns about this surgery.

What you may find helpful is to prepare a list of questions beforehand and take these with you on the day. These can include the following:

• How many years experience do you have in this type of surgery?
• How many operations of this kind do you perform each week?
• What are your success rates?
• What is the likelihood of an infection?
• What can I expect from this surgery?
• How long will my new joint/s last?
• How will I know if this surgery has not worked?
• If this surgery has failed then what can I do about this?
• Is there are any steps I can take to help with my recovery?
• How long will my recovery take?
• Will I need any follow up treatment?
• Will I require physiotherapy after this surgery and if so, for how long?
• Are there any alternatives to this surgery?

Make a note of the answers.

It is also a good idea to read up about your operation. Find out as much as you can about the type of procedure you will have so that you understand what it involves.

Your surgeon will ask you about your medical history before examining you. This is then followed by tests such as blood tests, X-rays and an ECG (electrocardiogram) to ensure that you are fit and healthy to undergo surgery.

The surgeon and his/her team will advise you about preparing for your operation and what you need to do afterwards to aid with your recovery. They will explain about the recovery process; how long this is likely to be and what you can expect.

They will want to be certain that you have someone who can help you with your recovery once you go back home. The reason for this is that you will be spending several months recuperating from this surgery which means being unable to do many of your usual jobs around the house.

If you live on your own then the surgical team can arrange for help before your admission to hospital.

Remember to take any medication along with you the clinic. It is important that you do this as some arthritis drugs suppress the immune system which increases your risk of an infection and the time it takes to recover from an illness or injury.

So, you may be asked to stop taking any medication such as this before your operation. Plus your surgeon may prescribe an alternative drug before surgery but you can revert back to your original medication after surgery.

Admission to hospital

You will be admitted to hospital the day before surgery although some people are admitted on the day of their actual operation. You will have been given guidelines about when to have your last meal and drink before surgery. But as a reminder, do not eat and drink anything on the day of your operation.

Pack a case or bag with the following items:

• Nightwear
• Toiletries
• Medication
• Change of clothes
• Antiseptic gel and hand wipes
• Book
• Personal music player
• Important phone numbers

In respect of bringing a mobile phone into hospital: check that you are able to do so as mobile phone signals can interfere with medical equipment.

Your surgeon will come and visit you once you are settled in. He/she will be accompanied by the anaesthetist who will discuss the anaesthesia procedure with you. There are several types of anaesthesia which include general anaesthetic (where you are asleep), local anaesthetic (awake but unable to feel anything), regional anaesthetic (sedated but awake) and spinal or epidural anaesthetic (awake but unable to feel anything below the waist).

You will be asked to sign a consent form which is a document that gives the surgeon permission to operate. Read through this carefully and ask if there is anything you do not understand.

You will be asked to have a bath or shower unless you have already done so at home before changing into a hospital gown. Remove any jewellery, nail polish and make up but you can leave your wedding ring on. You will be given a pair of compression stockings to wear which help with circulation and prevent the risk of a blood clot forming in your legs.

You will then be taken down to the operating theatre.

Hand surgery procedures

These range from repair of tendons or ligaments through to knuckle joint or wrist joint replacement.

Popular procedures include:

• Dupuytren’s contracture
• Carpal tunnel release
• Trigger finger release
• Tendon/ligament repair
• Knuckle joint replacement

Dupuytren’s contracture

This occurs when scar tissue develops in the fingers and palm of the hands. This usually results in the formation of scar nodules but in some cases, thick bands of scar tissue form which cause the fingers to curl down towards the palm. An operation is required to cut through these bands or contractures which enable the fingers to move more easily. This does not guarantee a complete recovery but it does mean that the fingers can extend, flex and grip.

Carpal tunnel release

This is often performed to treat carpal tunnel syndrome. This condition occurs when there is excess pressure on the median nerve (a nerve which passes through the carpal tunnel of the wrist to join with the fingers and thumb).

This can be caused by several factors which include rheumatoid arthritis.

Surgery is performed to relieve pressure on the wrist. This involves separating the carpal tunnel ligament which runs across the median nerve. This is carried out under a local anaesthetic.

Trigger finger release

This condition is caused by a thickening of the tendon which allows movement in that finger. This tendon becomes trapped in a surrounding sheath which causes the finger to become remain in a curled position.

In other words, the finger appears to be pulling an imaginary trigger.

Surgery is required to ease the tendon and enable a normal range of movement.

Tendon/ligament repair

There are two sets of tendons, responsible for the hands and wrists which are: flexor tendons and extensor tendons. Flexor tendons enable the fingers to curl up into a fist. They also enable the fingers to grip an object.

Extensor tendons enable the fingers to open out.

Problems with these such as rheumatoid arthritis can cause the tendons to split which impairs normal movement of the fingers. Surgery is required to repair these tendons to prevent other tendons from suffering in the same way.

Knuckle joint replacement

Surgery is carried out on the knuckles if these have suffered damage or are severely misspoken due to rheumatoid arthritis. The knuckles are replaced with small artificial components which behave as a series of hinges and allow the fingers to open and close.

This also corrects any misshapen fingers which improves the appearance of the hands.

Thumb joint procedures

There are two techniques for dealing with arthritis of the thumb. These include:

• Thumb stiffening: known as ‘arthrodesis’
• Thumb joint replacement

Thumb stiffening

Also known as thumb fusion: this is where the arthritic thumb is surgically fused together which prevents movement. The other joints make up for this loss of movement which means that the hand has a good level of functionality.

Thumb joint replacement

The joint at the base of the thumb is often affected by arthritis so is removed and replaced with an artificial joint. In other cases, the offending joint and bone are removed and the remaining area filled with natural materials from the joint capsule.

Wrist surgery procedures

The wrist is another part of the body which is also affected by rheumatoid arthritis. If the wrist fails to respond to conventional treatment then surgery will be required. There are two types of surgery:

• Wrist fusion
• Wrist joint replacement

Wrist fusion

This is another form of arthrodesis: the medical term for stiffening of the joint. This eases any pain in the wrist and improves the grip, but it also prevents it from bending or rotating. But it does not affect the movement of the forearm or hand.

The fingers are also unaffected.

This restriction of movement means that this surgery is only recommended for severely arthritic wrists.

Wrist joint replacement

This surgery also aims to relieve pain and discomfort as well as restoring some degree of movement in the wrist. The damaged bones of the joint are replaced with artificial components made from metal and plastic.

An incision is made in the back of the wrist followed by the removal of the damaged ends of the ulna and radius bones. The components are then inserted into wrist and fixed in place with acrylic cement.

This is also known as wrist arthroplasty. Ganglion removal

Ganglions are small cysts which develop on the back of the wrist and are caused by a leakage of synovial fluid from a tendon or joint sheath.

The fluid within these can be removed with a needle but they may need to be surgically removed. There is a risk of recurrence.

Whatever surgery you have you will need to wear some form of splint and undertake a range of exercises provided by a physiotherapist/occupational therapist.

These exercises will enable you to strengthen the hand/wrist/fingers and prevent these from becoming stiff. It is also a case of becoming accustomed to the new range of movement.

Complications of hand and wrist surgery

There is a small risk of complications with any type of surgery but these are rare in fit, healthy people. Whilst every measure is taken to reduce the likelihood of these happening, nevertheless, they do happen. But the good news is that most of them are easy to treat.

They include:

• Infection
• Swelling and/or stiffness
• Blood clot
• Problems with wound healing
• Loosening/dislocation of the artificial joint

Infection can be treated with antibiotics. Exercise will ease any swelling, pain and stiffness.

Your surgeon will discuss these risks with you at your initial consultation.

Recovery from hand and wrist surgery

You will spend a few days in hospital following your operation.

To start with, you will be taken to a recovery room after surgery where your condition will be monitored. This is standard procedure for anyone who undergoes surgery via a general anaesthetic.

You will feel drowsy and disorientated and may not be fully awake until you are taken back on your ward.

You will have been placed on an intravenous drip which contains strong painkillers. There may be slim tubes called drains running from your surgical wound which help to remove excess fluids.

These drains are removed a couple of days later.

As soon as you are able, you will be encouraged to get up and move around. You will be visited by the hospital physiotherapist and/or occupational therapist who will give you exercises to do that will tone and strengthen your new joint. They will also increase flexibility and get you used to using your joint.

You will have been given an appointment for a follow up visit as an outpatient. This will take place around 6 to 8 weeks after your surgery.

Once you are back home the main issue is then learning to adapt to your new joint. You will have periods of rest whilst your joint heals but it is important that you use it and gradually return to your normal routine.

You may have to learn new ways of doing things such as taking up a new sport or using aids to help you with tasks around the house.

For more help and information about this visit our living with arthritis section.

Symptoms which require urgent medical attention

If you notice any of the following symptoms then seek urgent medical advice. These include:

• Chest pain
• Difficulty in breathing
• Shortness of breath

These may be signs of a blood clot in the lungs or pulmonary embolism. This can lead to a collapse and is potentially fatal if left untreated.

Another risk is that of a blood clot forming in a leg, known as a thrombosis. The danger with this is if it becomes dislodged and travels through the bloodstream to the lungs which can be life threatening.

Thrombosis and pulmonary embolism can be treated but sooner rather than later.

Alternatives to hand and wrist surgery

Surgery is not usually required in most cases of arthritis but it is an option.

If you prefer not to have surgery then alternatives include wearing a splint, e.g. wrist splint, cortisone injections, painkillers such as non-steroidal anti-inflammatory (NSAID’s) and other similar medication.

Consider all of the alternatives before deciding whether surgery is right for you.