Our hands play a very important part in everyday activities. They allow us to make fine movements, as when writing, and also to grip powerfully, as when opening a jar. If we are to lead an active, independent life the joints in our hands need to work properly. We also care about how our hands look because they are constantly on view and we use them to help us communicate when we meet and talk to people.
For most people with arthritis in their hands surgery is unnecessary. Only those people with severe pain or hands which work very poorly may need surgery.
Most hand surgery for arthritis is performed by specialist hand surgeons. They can provide help or advice for many people with arthritis in the hands. The decision whether to operate depends on a number of factors: the severity of the symptoms, the patient’s wishes and the response to other treatments, including drugs. Surgery is usually carried out to relieve pain and improve how the hands work. It is rarely done to improve the look of the hands, although an improvement in their appearance may be a welcome additional benefit.
Carpal tunnel syndrome
This occurs when there is pressure on the nerve as it passes through the wrist . The early symptoms are pins and needles in the hand, especially at night. Carpal tunnel syndrome may happen without any obvious cause. It may also arise as a result of either rheumatoid arthritis or osteoarthritis. Swelling in the wrist joint or in the tendons that lie next to the nerve squeezes the nerve as it passes through a tunnel (the carpal tunnel) at the wrist.
The full name of the tendons which pass through the carpal tunnel is ‘flexor tendons’. These are the tendons which bend the fingers down. An electrical test confirms the diagnosis of carpal tunnel syndrome. The condition may improve with simple measures – for example, putting the wrist in a support at night prevents the wrist from bending and placing more pressure on the nerve while you are asleep. Sometimes steroid injections into the wrist are used to treat this condition. However, surgery may be needed if the symptoms persist. Surgical treatment can reduce the pressure on the nerve and lessen the pain, particularly at night.
In the operation, the surgeon is able to relieve the pressure by cutting a tight band (the transverse carpal ligament, or flexor retinaculum) that lies on top of the nerve (see Figure 1). It is often done under local anaesthetic with no need to stay in hospital overnight. Following the operation there will be a bulky bandage on your wrist and hand for a day or two. When this bandage is removed a small dressing will be placed over the stitches for 10–14 days. During this time you will have full use of your fingers and thumb for daily activities, although heavy tasks should be avoided.
It is important that you move your fingers to prevent the nerve and tendons becoming caught up in the scar tissue which may occur after the operation. People who have this operation will normally recover from the effects of surgery in less than 1 month. In a small number of people, the scar may ache and be sensitive for some months, though this usually settles without further treatment. (See arc booklet ‘Carpal Tunnel Syndrome’.)
Here, swelling in the tendon (the strong fibrous cord or ‘guider’) to the finger causes the tendon to catch when the finger is bent. This is often painful and the finger can stick in the bent position. A local injection helps in most cases. If this fails, a minor day-case operation (with no overnight stay in hospital) may be needed to release the tendon. Recovery within 1–2 weeks is usual.
These are cysts, often quite hard, forming on a joint or tendon. They are commonly found on the back of the wrist, but can occur elsewhere. They are sometimes uncomfortable and unsightly. They may get better on their own, but drawing out fluid with a needle and syringe, or minor surgery to remove them, may be needed, although they can recur.
Knuckle (MCP joint) arthritis
For some people, rheumatoid arthritis of the knuckles (metacarpophalangeal or MCP joints) causes deformity as the fingers ‘drift’ sideways away from the thumb (see Figures 2 and 3). This can lead to disability and affect everyday tasks. If the use of the hand is badly affected then surgery can be carried out to replace the knuckles with small artificial joints that act as flexible hinges. This operation reduces any pain and also corrects the deformity of the fingers so the hand will look better. Most importantly, it puts the fingers in a better position so that the hand can be used normally.
This type of surgery usually means several days in hospital and several months of out-patient treatment. Immediately after the operation the hospital staff will ensure your hand is rested for a few days before the process of rehabilitation is started. Before discharge from hospital the occupational therapist or physiotherapist will teach you exercises that will help you to move your fingers. These exercises are essential for your recovery and should be practised at home for several months. For 6–8 weeks after the operation you will need a support when not doing the exercises. It will be several months before the hand is strong enough to work properly. The occupational therapist will advise on adaptations around the home which will help in the recovery period. (See arc booklet ‘Your Home and Arthritis’.)
Your new joints will never be as hard-wearing as natural joints, so some care will always be needed using the hand. The occupational therapist or physiotherapist will advise you on how to take care of your hand to give the artificial joints a long life.
The MCP joint of the thumb is often affected by rheumatoid arthritis, but it is unusual to replace it with an artificial one. Instead, a surgeon may deliberately stiffen the joint, allowing the joints next to it to make up for its loss of movement. This operation is usually effective at relieving pain and improving pinch grip.
Wrist joint arthritis
Arthritis in the wrist joint is common in people with rheumatoid arthritis. For many, wearing wrist supports relieves the pain and improves the strength in the wrist. However, some people may need an operation if the joint is very painful and not responding to other treatment such as steroid injections.
The type of operation will depend on your individual needs and circumstances. The surgeon may choose to stiffen the wrist. This is known as a wrist fusion. This usually eliminates the pain and increases the strength, but prevents movement in the wrist. Having no wrist movement is not as bad as it sounds. It is very similar to wearing a support: you can still rotate the forearm, but the wrist will not move up and down. After the operation, to keep the wrist still for 6–8 weeks a lightweight cast will be fitted, but your fingers will be free for eating or writing. The hospital stay is for a few days only. Few exercises are needed after this operation as the aim is to eliminate wrist movement.
As yet wrist replacement is not a common operation. The aim of wrist replacement is to keep some wrist movement and eliminate pain. After the operation the wrist is kept still for 3–6 weeks before you start rehabilitation. Rehabilitation is aimed at improving the movement in the wrist and function in your hand. The therapist will discuss with you what you should and should not do with the replacement joint to keep it in good condition. You will be in hospital for a few days but it will be several months before recovery is complete.
The muscles in the forearm move the fingers by acting through the tendons that pass through or over the back of the wrist and into the hand. The tendons on the back of the forearm and hand lift the fingers up (extensor tendons); those on the front (palm) bend the fingers down (flexor tendons). The tendons are lined with synovium, a material similar to that which lines joints, and which may be inflamed by some forms of arthritis. For this reason, arthritis may lead to rupture of a tendon, which will impair movement of the affected finger. Sudden loss of movement may occur in any finger, but it is most common in the little and ring fingers and the thumb. It requires early treatment if surgery is to be successful. The surgeon may use undamaged tendons from other fingers in order to repair the ruptured tendon. If the tendon snaps because it has rubbed against rough bone in the wrist joint, then the bone will also have to be smoothed or removed to prevent the tendons snapping again.
Repaired tendons need at least 6 weeks to heal. During this time you will not be able to use your hand at all and must do only the exercises shown to you by the therapist. You will have to wear a support on your hand day and night to protect the healing tendons from damage. It is important that your support and the movement in your fingers are checked regularly. Usually this means seeing a therapist at least once a week. It will be around 2–3 months before recovery is complete.
Osteoarthritis of the thumb
Arthritis in the joint at the base of the thumb may cause pain and interfere with simple tasks such as opening jars, knitting and writing. This condition is most common in women in their 50s and 60s, but it can affect men. It is not necessarily the beginning of a more general arthritis. Using a protective support for work and household tasks may control the pain. It is also possible to have an injection of steroid into the joint to reduce the pain.
For some people the pain persists and an operation is needed. The operation involves the removal of the joint and affected bone. Sometimes the space this leaves is filled with a silicone rubber spacer or a metal and plastic joint. More recently, surgeons have been using natural body materials from the surrounding tendons to fill the space. After the operation the base of the thumb is put in a support for 6 weeks. You will be given exercises to do at home to help you regain the movement in the thumb and increase its strength. It will be several months before the thumb feels comfortable but this operation usually relieves pain and improves the function of the joint. Only occasional visits to the hospital are needed so that your progress can be checked.
This is a painless condition. The cause of the condition is unknown. Scar tissue forms in the palm of the hand and the fingers. It may cause only skin nodules, but it can also form bands of scar that make the fingers curl down into the palm of the hand. If this continues or becomes severe surgery may be needed. This will need 1–4 days in hospital depending on the severity. It will take 2–3 weeks for the skin to heal. It usually takes 6–12 weeks for the effects of the surgery to pass and for full use to return. A night support will be used for some weeks in order to keep the fingers straight while the internal scars heal. Hand physiotherapy may form part of the treatment plan. During the day it is essential to try to use the hand normally and to keep it supple.
The problem sometimes comes back, and full correction of the finger deformity is not always possible.
What will happen if an operation is necessary?
Before the operation
Waiting times vary across the country and depend on the type of anaesthetic and the type of operation. The surgeon will decide whether to use a local or general anaesthetic. If a local anaesthetic is chosen you will be fully awake during the operation, but you will not experience any pain or discomfort. You should talk to the doctor if you have any worries.
Before the operation you will be asked to sign a consent form, so that the surgeon has permission to carry out the necessary treatment. It is important to ask any questions you may still have at this stage. Ask the doctor, nurse or therapist to explain anything you don’t understand. A doctor or nurse will check your general health to ensure there will be no problems with a general anaesthetic if this is being used. After the operation it is customary for people to be checked over in a recovery room for a short period before they return to the ward.
Very often after operations on the hand and wrist it is necessary to wear supports to protect the healing tissues and bone, which will make everyday tasks difficult. In particular, you may have difficulty cooking, cleaning, driving the car, or getting dressed. To minimise these difficulties it is a good idea to make preparations before the operation. Simple things like choosing clothes with wide arms, stocking up the freezer, or arranging to have some help in the home will all make it easier to manage one-handed. It is also sensible to arrange help with transport, as it is nearly always necessary to attend the hospital regularly to see the doctor or therapist. If you are concerned that you will have difficulties following your operation then arrange to speak to a therapist at the hospital before you are admitted to find out exactly what is involved and how best to manage.
After the operation
Different surgeons have different ideas about the treatment required after an operation. This is affected by the type of operation and your own physical health. Support will be given by the nurse or therapist. After you have been discharged from hospital an appointment will be made for you to come in as an out-patient so that your progress can be checked. Sometimes a local GP will help with this after-care. A district nurse may be asked to remove stitches and change dressings.
Operations needing a general anaesthetic usually mean a longer stay in hospital. This will depend on the type of operation and your own health, as well as home or other circumstances that might affect your recovery.
For people who are generally healthy the risk of a serious complication from an operation is very small. Every possible care is taken to prevent complications but in a few cases these do happen. For example some people may develop an infection, but this can be treated with antibiotics. Some people may develop swelling and stiffness, but physiotherapists and occupational therapists can help with exercises and other advice.
Surgery is not necessary for most people who have arthritis in their hands. For those who do need surgery, it is usually very helpful in reducing pain and improving hand function.