Non-surgical options for wrist osteoarthritis

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida
David N. Woznica, MD. Caring Medical Regenerative Medicine Clinics, Oak Park, IL

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 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, the patient is 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.

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:

  • 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
    • Radiologic 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.”

Good results with surgery, bad results with surgery

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

While other research tried to quell criticism and fears by suggesting wrist fusion surgery as a fallback plan. “A failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis.” [4]

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, [5] 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 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:[6]

“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.

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 also a loss of wrist movement.
  • 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

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.

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.

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

Since wrist fusion after 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.

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 questions about wrist pain and instability? Get help and information from our Caring Medical staff

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 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]
6 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]

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