Surgery Options for Wrist Arthritis
Surgical alternatives may help relieve wrist pain, but they have risks.
By Mary Anne Dunkin
When arthritis pain in the wrist isn’t controlled by more conservative measures, it might be time to consider surgery. Orthopedic surgeons generally recommend one of three types of surgery for wrist arthritis, says Jennifer Wolf, MD, professor of orthopedic surgery and rehabilitation medicine at the University of Chicago. The best surgery for any particular situation or part of the wrist depends in large part on the type of arthritis as well as one’s personal preferences and goals for surgery.
When other treatments don’t provide enough pain relief, you may consider one of these three common surgeries for wrist arthritis. Here’s what you need to know — and ask — before having one.
Proximal row carpectomy. Where the forearm meets the hand sit two rows of small, irregularly shaped bones known as the carpals. When breakdown and loss of the cartilage between the carpals results in pain, the surgeon may remove three of the bones closest to the forearm in a procedure called proximal row carpectomy.
This can relieve wrist pain while preserving some movement, says Dr. Wolf. Recovery time is also shorter than for other wrist surgeries. It is commonly used for osteoarthritis (OA), which can develop years after a sprain or ligament tear in the wrist, she says. Proximal row carpectomy may also be useful for wrist pain related to gout or pseudo gout; rheumatoid arthritis usually requires a more extensive or invasive treatment.
Wrist fusion. If every wrist movement causes pain, fusion may be an appropriate option. In wrist fusion the surgeon removes the damaged cartilage between the bones of the wrist, then uses pins or screws to hold the bones together until they grow and fuse into a single unit, much like a broken bone grows back together.
Wrist fusion can be partial or complete, says Dr. Wolf. In a partial fusion, the surgeon removes the damaged cartilage from just the affected carpal bones, leaving healthy bones and cartilage undisturbed to allow some motion. In a complete fusion, all of the carpal bones are fused together along with the radius (the long bone of the forearm). All wrist motion is eliminated in a complete fusion; however, thumb and fingers motion is generally preserved. Partial fusion is often used for wrist OA, because people with OA typically have jobs or daily activities that place high demands on their wrists so they choose to maintain the wrist range of motion that partial fusion or proximal row carpectomy allows, says Dr. Wolf. Complete fusion is generally used for people with inflammatory arthritis — most commonly rheumatoid arthritis, but also psoriatic arthritis. Unlike those with OA, they often have daily activities that cause less strain due to the systemic nature of their disease, she adds.
Total wrist replacement. Sometimes called arthroplasty, total wrist replacement involves removing damaged bones and cartilage in the wrist and replacing them with components made of metals and plastics. Replacing the wrist joint relieves pain while allowing more movement than fusion does, says Dr. Wolf.
But replacements can be fragile and wear out over time, so they are not appropriate for people who do heavy lifting or whose jobs or daily activities place high demands on their wrists. “I tell patients they have a very limited lifting limit for life,” says Dr. Wolf.
Total wrist replacement is most commonly used for RA. It has shown a high rate of failure with wrist OA, she says.
When to Consider Surgery
Wrist surgery of any type should be considered only when pain interferes with daily life and when other treatments — including splinting, corticosteroid injections, nonsteroidal anti-inflammatory drugs and topical analgesics — fail to reduce pain to acceptable levels, says Dr. Wolf.
Uncontrolled pain, not X-ray findings, should be the reason to consider surgery, she says.
If you are considering having wrist surgery, get answers first to these questions:
Ask your doctor:
- What is involved in the surgery?
- What kind of anesthesia will be used? When possible, Dr. Wolf prefers regional anesthesia — deadening the area of surgery— because it is done without a breathing tube, it numbs the whole arm for surgery and it provides good initial pain relief for hours afterward. However, general anesthesia may be a better choice for those on blood thinners or who have a risk that precludes regional anesthesia, she says.
- Will I be immobilized after surgery; if so, in a cast or splint? In most cases, a splint is preferable because it can be taken off and on for hygiene.
- Will I need therapy after surgery?
- How long do you expect total recovery to take?
- What range of motion can I expect long-term after surgery?
- Have I exhausted all other proven treatments?
- Is my wrist pain bad enough that I am willing to undergo surgery and possibly diminished wrist mobility to relieve it?
- I am I ready for my wrist to be immobilized during recovery or, in the case of fusion, permanently?
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