Non-surgical options for wrist osteoarthritis
In this article Ross Hauser, MD discusses wrist osteoarthritis, the problems of diagnosing various forms of wrist pain and long-term non-surgical options including the use of Prolotherapy.
A phone call or an email into our office will usually describe a patient’s wrist pain like this:
I had a lot of pain in my thumb, my hands, and my wrists. I called my doctor. I was referred to a specialist and I was put on “prescription grade Aleve” (Naproxen 500 mg). I was told to take as needed but try not to exceed 1000 mg a day as it will give me stomach upset. The Naproxen was not helping that much. On the days I need to take a little more I do get stomach problems and take stuff for nausea. Regular movements are painful and I am using wrist braces, splits, and casts to try to sleep at night. I do not want to go down the road of stronger medications.
I am thinking of scheduling a cortisone injection. I was told that this could help up to 6 months but if it failed, I would need the surgery in both hands. I am looking for options.
We also get the calls or emails from the people who already had a wrist arthroscopic procedure or a TFCC or thumb procedure. Their calls or emails go something like this:
A few years back I had a fall and damaged my wrist, simple ligament tear I was told. I had an arthroscopic procedure, the doctors went in and cleaned up my wrists and I was told everything was a success. My wrist did feel better for a while. Then over the past few years my wrist started to hurt again and making loud clicking and grinding noises. The same doctor who did the arthroscopic procedure now says it is time for a wrist fusion or a wrist replacement surgery.
We also get the calls or emails from the people who need some type of non-surgical options as they are working from the computer or work at a job that is very physically demanding on their hands.
I have wrist instability to the point that my wrist occasionally dislocates and pops out of place. I am afraid to lift anything heavy and find myself need a split or brace 24/7. I have adjusted for the way I pick up things and now my elbow and shoulders are hurting.
The path to wrist surgery usually starts with pain medications, cortisone and other treatments that do not help long-term
When a patient visits their doctor for chronic wrist pain and instability, they are typically diagnosed with a problem of overuse and continuous impact from sports or demanding work.
These activities can lead to chronic injuries which often begin as acute tendonitis or ligament sprain and frequently turn into degenerative arthritis. Conservative treatments include rest, physical therapy, NSAIDs, splinting, cortisone injections, and ergonomic modification of work stations.
When these treatments don’t provide the goals of treatment the patient desires, patient is then often referred to a surgeon and options like those mentioned above are discussed – which are not designed to treat ligament instability.
They may also make an individual more susceptible to injuries. When weakened ligaments allow the wrist bones to become unstable and shift positions, wrist instability results. In addition, any one of the ligaments may be torn due to an injury and become a source of pain.
In sports there are four principle mechanisms of injury described: throwing, weight-bearing, twisting, and impact injuries.
- Throwing injuries to the wrist are associated with throwing, racquet sports, and often overuse injuries.
- Weight-bearing injuries are seen in gymnasts and weight lifters who experience high compressive forces on the wrist.
- Twisting injuries may occur in any sport, whereby the wrist undergoes a rapid rotation, which disrupts the ligaments and stability of the wrist.
- Impact injuries are the most common injury, and result from falls.
Doctors is France recently had harsh words for wrist replacement surgery in performing a five year review of 15 patients. Publishing in the French language medical journal Acta orthopaedica Belgica, these researchers found:
- Four patients had postoperative complications, three of whom required arthrodesis (wrist fusion surgery) (of the 15 patients overall this represented 26% complications 20% fusion surgery).
- While the remaining patients obtained satisfactory pain relief they noted:
- Grip strength decreased
- mobility was reduced
- Radiological assessment revealed carpal implant loosening in eight patients. (More than half).
The doctors of this study basically filed their research under this doesn’t make sense. They confirmed “the discordance generally observed between patients’ subjective satisfaction and mediocre clinical and radiological results over the medium term.”1
Mediocre clinical and radiological results in three wrist procedures
Other research has attested to the high rate of failure of the wrist replacement. Dutch research appearing in the medical journal Acta Orthopaedica documented 25% of replacements needing revision and 2/3 of the implants becoming loose.2 While other research tried to quell criticism and fears by suggesting wrist fusion surgery as a fall back plan. “A failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis.”3
Despite studies like this, despite the loss and elimination of natural wrist movement, wrist fusion surgery has been the traditional treatment for the osteoarthritic damaged wrist.
In the July 2017 issue of the medical journal Hand, doctors from New York University Hospital for Joint Diseases, the Mayo Clinic, and Emory University examined national trends in the utilization and complication rates of total wrist arthroplasty (replacement) and total wrist fusion.
What they found was that doctors:
- Performed significantly less total wrist replacements than wrist fusions.
- The patients who did get a wrist replacement were significantly older, more likely female, and more likely to have a diagnosis of osteoarthritis than patients undergoing wrist fusion.
- There were no significant differences in complication rates, including postoperative infection, nerve palsy, or rate of secondary surgery, between the two procedures.
The point of this study was actually to determine what the “new wave,” of emerging career orthopedic surgeons thought about these wrist procedures by way of measuring their choice of prefered surgery. The study found that the new surgeons followed the path of the old surgeons and chose to continue wrist fusions as the treatment of choice.6
The reasoning for preference is fusion over replacement is that doctors are calling for forms of treatment which allow the preservation of movement.
This is discussed by University Hospital Southampton researchers publishing in the Bone and Joint Journal:
“The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Modern arthroplasties of the wrist are still not sufficiently robust to meet the demands of many patients, nor do they restore normal kinematics of the wrist.” The study suggests at this point partial fusions may be an answer.4
Yet, despite the concern of researchers and a desire to provide treatments that can rebuild and restore normal function of the wrist, three wrist surgeries are favored for the following problems of the wrist:
- Total wrist fusion: The procedure is performed in young patients who have arthritis in one wrist and high physical demands on the wrist. The operation will lead to good pain relief but loss of movement of the wrist.
- Total wrist replacement: Performed in patients with arthritis in both wrists but with relatively low manual demands. The operation results in good pain relief and a functional range of movement.
- Wrist denervation: In this procedure, nerve branches that take sensations from the wrist to the brain are cut, which will reduce pain perception and improve symptoms temporarily.5
Prolotherapy for Wrist Pain – In search of an alternative to wrist surgery
Since wrist fusion after wrist replacement do not treat ligament instability and in fact can cause it (see again above mediocre results), we have to disagree with surgical treatment except in rare cases where wrist replacement is needed.
In research conducted, Prolotherapy showed itself to be very effective in eliminating pain, stiffness and improving the quality of life in this group of patients with unresolved wrist pain.
Prolotherapy is the injection of a solution for the purpose of tightening and strengthening weak tendons, ligaments, or joint capsules. Prolotherapy works by stimulating the body to repair these soft tissue structures.
As we discussed above, one explanation for the lack of response of chronic wrist pain sufferers to traditional conservative therapies is that their underlying problem, ligament laxity, is not being addressed. Typically in the early stages of wrist arthritis, the problems are mainly caused by carpal instability from ligament injury. Prolotherapy has been shown to decrease pain by stimulating tissue repair in degenerated tissues such as ligaments and tendons.
Research: Please refer to our study on patients using Dextrose Prolotherapy for Unresolved Wrist Pain, published in the journal Practical Pain Management.
In this research, thirty-one patients with an average pain duration of 52 months, were treated quarterly with Prolotherapy.
Included in this group were:
- nineteen patients (61%) who were told by their medical doctor(s) that no other treatment options for their pain were available or that surgery was their only option.
Patients were contacted an average of 22 months following their final prolotherapy session and asked questions via telephone interview regarding levels of pain, stiffness, other physical and psychological symptoms, as well as questions related to activities of daily living, before and after their last prolotherapy treatment.
Improvements in many quality of life parameters were achieved in this patient population who received the Prolotherapy for their wrist pain.
- Ninety percent of patients had 50% or more pain relief and 88% felt improvement in their stiffness levels. All patients who were taking pain medications prior to receiving prolotherapy were able to reduce the frequency of required medications after receiving prolotherapy.
Do you have a questions wrist pain and instability? Get help and information from our Caring Medical staff
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