Replacement surgery and tendon-repair surgery is best performed by a surgical team skilled in hand function, with a special emphasis in the reconstruction stemming from arthritis. Such a team can maximize benefits and minimize risks. The operations are usually outpatient, meaning that the patient can go home the same day.
Three major classifications of treatments can be performed:
- Synovectomy is the removal of diseased tissue. This is usually done at the wrist. Portions of bones destroyed by arthritis may also need to be removed.
Occasionally these procedures are combined with tendon-transfer surgery, if wrist tendons have ruptured. Using a tendon whose function is to some extent redundant, the surgeon physically transfers that tendon to the site of the ruptured tendon.
- Joint replacements are done by removing the painful joint surfaces and replacing them with an artificial joint, usually made of a soft synthetic material. These joints typically have a stem on either end with a spacer in the middle. The stems are placed in the ends of the bone – re-creating the joint that has been removed.
- Joint fusions mean removing the joint and stimulating the bones to grow across the site of the joint surface to create a solid segment of bone. This is usually done by adding bone graft material with tissue from another site of the body, such as the pelvis or wrist, and using metal plates or pins to stabilize the bones as they fuse over time.
Patients can have a regional anesthetic in which the arm is numbed with a local anesthetic injected near the shoulder. A general anesthetic also can be used so the patient is unconscious during surgery.
Length of hand surgery
Surgery typically lasts one to two hours, depending on the number and complexity of procedures performed.
Most outpatient surgeries enable the patient to go home after the procedure is completed. While in the surgical setting, patients typically receive intravenous fluids, to stay hydrated, and analgesic medication adjusted to their pain level. In most cases, therapy is delayed until the post-op swelling subsides, which takes one to two weeks.
Recovery and rehabilitation in the hospital
Rehabilitation typically does not begin until the patient is evaluated post-operatively in clinic, usually about one to two weeks after the surgery. Patient recoveries vary greatly and depend on the procedure(s) performed.
Most patients are discharged with a plaster splint that limits their motion. For most patients, keeping the hand elevated is important to decrease swelling. When the patient is discharged, he or she should receive oral pain medication. It’s also important to make an appointment for follow-up.
The patient should expect to work with the doctor to create an outpatient therapy plan since this is essential to successful rehabilitation. We typically recommend about six weeks of therapy for joint replacements, joint fusions or synovectomies.
Most patients can be discharged to their home and do not require a convalescent facility. Because patients have limited hand function, they should plan to have assistance with cooking and cleaning for the first three to four weeks after surgery.
Pain and pain management
The level of pain is related to the severity of the deformity prior to surgery. Most patients can manage these surgeries on an outpatient basis, but some patients need to stay in the hospital overnight to receive stronger pain medication.
Most patients will require therapy at least once or twice a week for four to six weeks following surgery. After the swelling subsides and healing is sufficient to allow early motion, usually one to two weeks after the surgery, therapy can begin.
A therapist skilled in hand rehabilitation should oversee the patient’s recovery. Desired therapists will have a special certification in hand therapy. Our office maintains a list of skilled therapists throughout the Pacific Northwest to help manage patients’ needs regardless of where they live.
Although it is important to continue the exercise program at home, we recommend that patients have a program supervised by a skilled therapist. Programs can vary, depending on the surgery performed.
Returning to ordinary daily activities
We encourage patients to use their hands, even while wearing a splint, to do simple activities such as dressing and eating. Most patients are free from splints and casts within six weeks after the surgery and can perform most daily functions. It generally takes two to three months before patients regain their full hand and wrist strength.
Long-term patient limitations
In general, we try to minimize restrictions on patients. In many cases, the patient's surgery has been tapered to their expected activity level. For example, replacement joints cannot withstand heavy lifting, so we would recommend that patients avoid such activity even if they could otherwise pursue arduous physical tasks.
Overall, the goal of the surgery is to enhance the patient's lifestyle and increase the scope of activities compared to what the patient would have achieved without corrective surgery.
Treatment of inflammatory arthritis has been revolutionized by the introduction of new medications that work against the immune processes that cause the major damage. Etanercept, Infliximab and Adalumumab are three new “biologic” agents now approved to treat rheumatoid arthritis and have had a major impact in just a few years. They can effectively suppress inflammation and prevent damage to the joints.
Older drugs such as methotrexate are still widely used and are often combined with the newer agents, to excellent effect.
Most patients with rheumatoid arthritis take pain medication for only two to three days after surgery. If just one or two joints are involved, the patient can be managed on an outpatient basis with oral medication. For some of the complex joint-replacement procedures, or when multiple joints are involved, the patient will need to stay overnight and receive intravenous analgesics.
Pain-relief medication may cause drowsiness, so patients should not drive a car or operate machinery during the medication’s course.
Risks involved with hand surgery
Complications are rare but can include wound infections, particularly in patients on high doses of steroids, and delayed healing. When joint fusions are performed, delayed healing can occur in patients with marked bone loss, due to either steroid use or serious bone destruction from disease.
Treating wound infections with intravenous antibiotics can relieve most problems, and careful therapy programs can help protect the joints and prevent too much stress on the sites of the surgical incisions.
Risks of not having hand surgery
If finger deformities are not addressed quickly enough, it becomes very difficult to restore function with joint replacements. Patients with persistent swelling due to synovitis (inflammation of the membrane that lines the joints) will have tendon ruptures. Tendon ruptures result in loss of hand function including the ability to extend the fingers.