Dr. Richard Barth

1. Richard W. Barth MD
Washington Orthopaedics and Sports Medicine
Associate Clinical Professor, Department of
Orthopaedic Surgery, GW Medical School

2. I have no relevant financial
relationships to disclose

3.  Identify appropriate patients for referral to an
orthopaedic hand surgeon
 Describe current surgical options for the elbow
and hand
 Describe rehabilitation consideration for
patients undergoing surgery

4.  Identify appropriate patients for referral to an
orthopaedic hand surgeon
 Describe current surgical options for the elbow
and hand
 Timing of referral
 Expected outcomes of surgical intervention
 Conservative treatment
 Office evaluation
 Surgical techniques

5.  Predictable
 Generally Predictable
 Less predictable

6.  Location
 Elbow
 Wrist
 Hand
 Etiology
 Inflammatory arthritis
 Osteoarthritis
 Post traumatic
 Idiopathic

7.  Osteoarthritis
 Inflammatory arthritis
 Cubital tunnel syndrome
 Tennis elbow

8.  Global ulnohumeral arthritis
 Post traumatic
 Overgrowth and impingement
 Primary osteoarthritis

9.  Total elbow arthroplasty
 Fascial arthroplasty

10.  Total elbow arthroplasty
 Permanent restrictions 10 pounds
 Higher complication rate than LE arthroplasty
 Fascial arthroplasty
 Cheng SL, Morrey BF: Treatment of the mobile,
painful arthritic elbow by distraction interposition
arthroplasty. J Bone Joint Surg Br 2000;82:233-238.
 62% satisfied at 5 years

11.  Conservative treatment as long as possible

12.  Limited motion, pain at extremes of motion
 Not much pain at mid arc
 Difficulty with golf, tennis, manual activities
 Overgrowth and impingement
 Primary osteoarthritis
 Refer

16.  Motion improve 45 to 60 degrees
 Pain and function significantly improved
 Excellent option in the proper patient

17.  Synovectomy and/ or radial head excision
 Arthrocopic
 Open
 Total elbow arthroplasty (TEA)
 Refer rheumatoid patient with refractory
synovitis and pain early

18.  Several studies show good results
 Likely slow disease progression
 Relatively low risk and quick recovery
 Does not burn bridges

19.  TEA an excellent option
 RA patients historically lower demand
 Morrey et al, JBJS Am 1998
 10-15 year follow up
 92% rate survivorship at 10-12 years
 Good motion and function

20.  Signs and symptoms
 Refer early
 Surgical options
 Generally good results if treat early

21.  Neurolysis in situ rather transposition
 Less risk
 Less dissection
 Much quicker recovery
 No bridges burned

22. shoulderhand

23.  Often severe especially in elderly
 Results related to severity AND
 Degree of cervical disease
 Often some degree of both
 Start with cubital tunnel surgery
 Always get a nerve test

24.  Conservative, conservative, conservative
 80 percent better at a year
 Refer after prolonged conservative treatment
 No bridges burned by living with it
 Pain issue
 Surgery removes diseased tissue

25.  Results generally good but not entirely
predictable
 Multiple techniques available
 Open
 Arthroscopic
 Experimental
 Resume light activities immediately
 Full use in 6-12 weeks

26.  Joints spared vs. pan carpal arthritis
 Post traumatic/ osteoarthritis vs inflammatory
arthritis
 Occupational/ avocational needs of patient
 Physiologic age

27.  Total wrist arthroplasty
 Total wrist fusion
 Limited wrist fusion (LWF)
 Proximal row carpectomy (PRC)

28.  Higher risk, higher reward
 High complication, revision rate
 Few indications
 Low demand patient with bilateral disease
 Inflammatory arthritis
 Failure can be salvaged to fusion

29. Conclusions: The results for the Universal wrist
prosthesis at a minimum of five years of follow-up
include a high rate of failure, most often because of
carpal component loosening, resulting in revision of
ten (50%) of twenty wrists at the time of the latest
follow-up (with the inclusion of one revision in a
patient who died before five years). Patients with a
stable prosthesis maintained a functional range of
motion and had improvement in patient-reported
outcome measures.
JBJS 2011: Adams et al.

31. Long-Term Functional Outcomes After
Bilateral Total Wrist Arthrodesis
Conclusions Bilateral total wrist arthrodesis
improved pain while enabling patients with
severe carpal arthrosis to maintain a satisfactory
level of extremity function and quality of life. In
general, patients adapted and were satisfied with
functional capabilities. This is a viable salvage
option for patients with severe bilateral disease. (J
Hand Surg Am. 2015, Wagner et al.)

35.  Functional range of motion
 Good pain relief
 Good strength
 Limited wrist fusion holds up better over time
but….
 Higher complication rate
 Longer recovery
 Patient selection

37.  Extremely common
 Conservative options
 Refer when patient chooses not to live with
pain and functional loss
 Burn no bridges by waiting
 Surgical options depend on stage
 X-ray findings do not correlate well with sx

38.  Pain
 Deformity
 Loss of function

39.  I am worried it is going to get worse
 I will be too old to have surgery
 It will be too bad to fix

40.  I am worried it is going to get worse
 I will be too old to have surgery
 It will be too bad to fix

41. Normal or widening
CMC joint
Normal STT joint

42.  Stabilization
 Unloading procedure
 Arthrodesis
 Arthroplasty

44. Treatment of Eaton Stage I Trapeziometacarpal
Disease With Thumb Metacarpal Extension
Osteotomy. Tomaino, JHS 2000
Results: 11/12 satisfied
Long-Term Outcomes of First Metacarpal
Extension Osteotomy in the Treatment of Carpal-
Metacarpal Osteoarthritis. Parker et al, JHS 2008
Results: Excellent 6/8 at 9 years

45. Early CMC narrowing
vs. severe
Normal STT joint

46. Scar and tendon

47. Severe pantrapezial arthritis

48. Scar and tendon

49.  Generally very good results
 Average about 70 percent of normal strength
 Takes 1 year to reach maximal improvement
 Cast 1 month, then splint 1 month

50.  Extremely common
 Conservative treatment effective early
 Surgery extremely effective
 Refer on earlier side
 Surgical options
 Poor results
 Not CTS
 Severe

51.  Patient tired of symptoms
 Numbness constant
 Hands feel like sandpaper
 Drop things
 Can’t button buttons
 Weakness
 Thenar atrophy

52.  Traditional open
 Open
 Mini open
 Endoscopic

53.  Ligament safely cut, all effective
 Recovery, return to activities/ work
 Light use immediately (typing, eating, ADLs)
 Unrestricted use at 3 weeks

56. Not all the same

57.  Inflammatory vs. Degenerative Arthritis
 Multiple vs single digits
 Very good results in OA, single digit
 Mixed results in multiple digits, inflammatory

58.  Synovectomy
 Arthroplasty
 Arthrodesis

63. Conclusions: The outcome after silicone
metacarpophalangeal joint arthroplasty in patients
with rheumatoid arthritis worsens with long-term
follow-up. Given these findings, the indications for
and long-term expectations of silicone
metacarpophalangeal arthroplasty must be
carefully examined in light of the improvements in
the medical management of rheumatoid disease.
JBJS Oct 2003 Goldfarb and Stern

65.  Generally improved cosmesis
 Function perceived as improved
 Multiple studies show no significant objective
improvement in function

66.  Single digit osteoarthritis or well controlled RA
 Soft tissues preserved
 Less deformity
 Much better outcome

68.  Results are more favorable
 Refer early before significant deformity
 Good pain relief and motion

69.  Inflammatory vs. Degenerative Arthritis
 Doesn’t matter
 Severity/ deformity
 Doesn’t matter
 Arthrodesis
 Excellent results
 Thumb needs stable post for pinch

70. Osteoarthritis PIP and DIP joints

71.  Osteoarthritis vs. inflammatory arthritis
 Deformity (boutonniere, swan neck)
 Single vs multiple digits
 MPs and DIPs involved
 Which digit is involved
 Technical issues

72.  Synovectomy
 Arthroplasty
 Silastic implants
 Pyrocarbon
 Metal poly implants
 Arthrodesis

74. Pre op Post op

75.  Stable long term results
 Loss of PIP motion less well tolerated
 Improved cosmesis and function but …

76.  Fusion is best option when patient ready
 Predictable pain relief, deformity correction
 Motion loss usually well tolerated

77. Questions?