Non-surgical options for wrist osteoarthritis

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Non-surgical options for wrist osteoarthritis

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 thumbs, 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 to 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 on both hands. I am looking for options.

We also get calls or emails from 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, a 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 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 splint or brace 24/7. I have adjusted for the way I pick up things and now my elbow and shoulders are hurting.

The conservative treatment options

The story above probably sounds a bit like yours. You have been going to doctors and you have been told that you have wrist osteoarthritis. You really did not need to be told that, you knew. You have a lot of pain, reduced motion, and lack of strength and function in that hand. But you went for an MRI so a treatment plan can be mapped out for you.

Your medical history with your wrist pain may include treatment with

The path to wrist surgery usually starts with pain medications, cortisone, and other treatments that do not help long-term. Clinical and radiological results in three wrist procedures

Doctors in 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, [1] these researchers found:

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.”

Good results with surgery, bad results with surgery

As with any medical technique, there are good results and there can, unfortunately, be bad results. In surgery, this is referred to as failed surgery syndrome. Many people have very successful wrist surgeries. These are typically the people we do not see at our center. We see the people who did not have good outcomes.

Citing this research was a November 2018 study in the Journal of Wrist Surgery. (2) Here researchers compared wrist replacement to wrist fusion. Many people do benefit from these procures.

End-stage wrist arthritis has traditionally been treated with a total wrist fusion. There is a recent trend toward motion-preserving surgery in the form of total wrist replacement. Questions Is there a functional benefit to performing a total wrist replacement instead of a total wrist fusion in patients with end-stage wrist arthritis?

Is there any difference in secondary outcome measures including pain, grip strength, and range of motion?

Does the risk of adverse events and treatment failure differ between the two techniques?

For many patients, a significant improvement in functional outcome was seen with both interventions. Similar improvements were seen in pain scores, and modest improvements were seen in grip strength. Range of motion following arthroplasty improved to a functional level in two studies.

Complication rates were higher after arthroplasty (wrist replacement) than those after fusion. Fourth-generation or newer implants performed better than earlier designs. Implant revision rates ranged from 3.5 to 52.6%. Fourth-generation prostheses survival rates were 78% at 15 years (Type: Universal 2), 86% at 10 years (Type: Motec), 90% at 9 years (Type: Re-Motion), and 95% at 8 years (Type: Maestro).

The newer fourth-generation wrist implants appear to be performing better than earlier designs. Both wrist arthrodesis and wrist arthroplasty improve function, pain, and grip strength. The risk of complication following wrist replacements is higher than that after total wrist arthrodesis.

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. [3]

A failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis (fusion)

In 2011, surgeons writing in the medical journal Acta orthopaedica [4] tried to quell criticism and fears by suggesting wrist fusion surgery as a fallback plan to wrist replacement and that this second surgery could have good outcomes. “A failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis.”

Before you start saying that research is ten years old. Let’s look at a 2021 study that offers a similar suggestion. Wrist fusion can help “salvage” a failed wrist replacement. This paper was published in the Journal of the American Academy of Orthopaedic Surgeons Global Research & Reviews. (5) Here are the learning summary points:

Simply, and perhaps some of you reading this article may be in agreement with, some people would rather give up the fusion and its promise of stability and a pain-free wrist in exchange for taking a chance on a second, revision total wrist replacement so that they can have some movement in that hand.

In this paper, doctors sought to limit “taking the chance” on revision surgery by exploring the previous studies on this surgery’s outcomes. What they suggest does not favor a second total wrist replacement.

“Overall, the high rate of complications observed in this most historical (previous studies) cohort highlights the difficulty of performing a revision total wrist replacement. Given the poor bone stock, soft-tissue deficiency, and scar tissue from the primary total wrist replacement, the revision implant is prone to instability, component loosening, and other complications.

These results should serve as a valuable reference for those considering revision total wrist replacement and demonstrate the need for improved techniques and implants. Until such innovations are able to improve on our results, caution should be used when considering a revision of total wrist replacement. “

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, [6] 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:

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 preferred 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.

The reasoning for preference is fusion over replacement is that doctors are calling for forms of treatment that allow the preservation of movement.

This is discussed by University Hospital Southampton researchers publishing in the Bone and Joint Journal:[7]

“The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment that 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.

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:

In this video, Ross Hauser, MD describes Prolotherapy treatments as an alternative to wrist fusion

A summary transcript is below:

For some people, an effective alternative to wrist fusion and wrist replacement is Prolotherapy.

If you look at the anatomy of the wrist there are four bones on the proximal row (center) and then for bones on the distal (outer) row and there are many ligaments. In fact, the wrist is a group of bones within a sea of ligaments.

Think about a fusion. Following the fusion surgery, you cannot move your wrist. Limited or no wrist movement, is this how a person wants to live their life?

By definition, fusion is the ultimate stabilization. It’s like having a cast on your wrist for the rest of your life. Some patients do not find this a good option.

If you have pain and the doctor is saying “you need a wrist fusion to get rid of that pain,” then it means that the doctor saying that you have some wrist instability, and if we stabilize the wrist with a fusion, the pain will go away. By definition, fusion is the ultimate stabilization. It’s like having a cast on your wrist for the rest of your life. Some patients do not find this a good option.

In my opinion, a much better alternative is Prolotherapy. Prolotherapy strengthens the ligaments of your wrist. This stabilizes your wrist without fusion. You may not however get all of your motion back with Prolotherapy, the reality is by the time most patients consider Prolotherapy is when they have already been told that they need surgery and motion has already been lost. However, Prolotherapy can help keep that motion, not lose it to fusion.

What are we seeing in this image?

In this illustration, we can demonstrate that the wrist is held together by a “sea of ligaments,” in which the bones of the wrist and base of the thumb float in. The symptoms of wrist ligament weakness are seen in instability, a popping and cracking noise from the wrist, loss of range of motion, muscle spasms in the arm and hand, loss of strength, especially grip strength, and numbness.

In this illustration, we can demonstrate that the wrist is held together by a "sea of ligaments," in which the bones of the wrist and base of the thumb float in. The symptoms of wrist ligament weakness is seen in instability, a popping and cracking noise from the wrist, loss of range of motion, muscle spasms in the arm and hand, loss of strength, especially grip strength and numbness.

Prolotherapy for Wrist Pain – In search of an alternative to wrist surgery

If you are like many patients we see, you share a common history that many wrist pain patients share: A visit to the doctor for chronic wrist pain and instability, a diagnosis of a problem of overuse and continuous impact from sports or demanding work. Following many months and possibly years of the treatments already outlined here and their continued failure to provide the goals of treatment the patient desires, the patient is often referred to a surgeon.

Weakened ligaments commonly cause chronic wrist pain.

Weakened ligaments commonly cause chronic wrist pain. The weakened ligaments allow one of the eight wrist bones to become unstable and shift positions, leading to wrist instability.  The wrist is actually eight oddly shaped bones in a sea of ligaments. The most common wrist bones that become unstable because of loose ligaments are the capitate, scaphoid, and lunate. Thus, the most common ligaments treated with Prolotherapy for chronic wrist pain are the dorsal capitate-trapezoid, hamate-capitate, scaphoid-triquetral, and scapholunate ligaments. Again, the diagnosis is easily made by direct palpation of these ligaments, as the wrist bones are very superficial to the skin. The weakened ligament can be palpated and a positive “jump sign” elicited. Several Prolotherapy sessions in this area resolve the problem.

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.

Since wrist fusion after a wrist replacement does 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.

Research on Prolotherapy injections

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 a 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.

Prolotherapy treatment Outcomes

In the patients we saw in this study, an average of 3.6 prolotherapy treatments per wrist was given. The avergae time of the follow up to assess the success or failure of treatment was 22 months after the last treatment session.

Ninety-seven percent of patients reported improvement in pain, with 88% showing improvement in stiffness after prolotherapy.

Medication usage

In regard to pain medication usage,

Range of motion

Quality of life issues

In regard to quality of life issues prior to receiving prolotherapy:

Exercise

Depression

Sleep

Pain/disability

To a simple yes or no question, “Has prolotherapy changed your life for the better?” All of the patients treated answered “yes.” Seventy-seven percent of the patients reported that, overall, greater than 75% of their improvements resulting from prolotherapy remained positive after prolotherapy treatments ended. Of those whose pain/disability had increased since stopping the prolotherapy, 81% noted reasons for this occurrence. Fifty-five percent claimed the prolotherapy was stopped too soon (before 100% pain relief was achieved). Twenty-two percent reported a re-injury to the area. One hundred percent of patients knew someone who had received prolotherapy.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your wrist pain challenges.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

 

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References

1 Chevrollier J, Strugarek-Lecoanet C, Dap F, Dautel G. Results of a unicentric series of 15 wrist prosthesis implantations at a 5.2-year follow-up. Acta Orthop Belg. 2016 Mar;82(1):31-42. PubMed PMID: 26984652. [Google Scholar]
2 Berber O, Garagnani L, Gidwani S. Systematic review of total wrist arthroplasty and arthrodesis in wrist arthritis. Journal of wrist surgery. 2018 Nov;7(5):424. [Google Scholar]
3 Harlingen D, Heesterbeek PJ, J de Vos M. High rate of complications and radiographic loosening of the biaxial total wrist arthroplasty in rheumatoid arthritis: 32 wrists followed for 6 (5–8) years. Acta Orthop. 2011 Dec;82(6):721-6. Epub 2011 Nov 9.[Google Scholar]
4 Krukhaug Y, Lie SA, Havelin LI, Furnes O, Hove LM. Results of 189 wrist replacements. A report from the Norwegian Arthroplasty Register. Acta Orthop. 2011 Aug;82(4):405-9.[Google Scholar]
5 Wagner ER, Srnec JJ, Fort MW, Barras LA, Rizzo M. Outcomes of Revision Total Wrist Arthroplasty. JAAOS Global Research & Reviews. 2021 Mar;5(3). [Google Scholar]
6 Hinds RM, Capo JT, Rizzo M, Roberson JR, Gottschalk MB. Total Wrist Arthroplasty Versus Wrist Fusion: Utilization and Complication Rates as Reported by ABOS Part II Candidates. HAND. 2016 Sep 12:1558944716668846. [Google Scholar]
7 Logan JS, Warwick D. The treatment of arthritis of the wrist. Bone Joint J. 2015 Oct;97-B(10):1303-8. doi: 10.1302/0301-620X.97B10.35717. [Google Scholar]

This article was updated May 21, 2021

 

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