When Is Wrist Surgery Needed for Arthritis?

If wrist pain and stiffness from arthritis can no longer be managed with conservative treatment, surgery may be an option. Just like for hips and knees, there’s joint replacement for the wrist. But other surgeries are actually more common.

The wrist is made up of eight small bones (carpal bones) arranged in two rows. “It’s like a pyramid of ball bearings, lined up perfectly,” explains orthopaedic surgeon David Shapiro, MD.

“If you injure the ball bearings or change their alignment, the rest of the pile will shift, and then they start to rub against each other in ways that cause them to wear down — that’s arthritis.

Arthritis in the wrist can have different causes:

• Osteoarthritis is degeneration of the impact-absorbing cartilage at the ends of the bone.
• Inflammatory arthritis, including rheumatoid arthritis, psoriatic arthritis and others, are systemic diseases that can damage cartilage.
• Pseudogout is a type of arthritis that can lead to wrist arthritis.
• Trauma, infection and congenital abnormalities are some other causes.

Partial procedures

There are several surgical options to stop arthritic bones from rubbing together.

“One is to remove the arthritic bones and another is to fuse them together so they don’t move and don’t hurt,” Dr. Shaprio says.

Which operation is better depends on which bones are involved. “You can remove the whole bottom row and the rest of the stack of bones will stay up,” he says. But if you take out just one bone from the middle, the whole pile of bones will collapse.

A partial fusion stabilizes the wrist and removes the arthritic joint. Both of these options provide good pain relief, although patients typically lose some portion of their wrist motion.

Whole-wrist procedures

Some people have arthritis in most or all of the joints in the wrist. This can occur in advanced osteoarthritis or rheumatoid arthritis. In these cases, the choice is between fusing all of the bones (total fusion) and joint replacement.

With total fusion, the wrist will no longer bend, but you can still rotate it, turning palm up and palm down since this motion comes from the elbow joint. Fusion sounds debilitating, but it does give great pain relief.

“Patients almost always find they can do more things more comfortably after surgery than before,” Dr. Shapiro says.

Joint replacement seems appealing because it retains, and may even improve, range of motion in the wrist. “The problem is durability of the implant,” Dr. Shapiro says. With wrist replacement, bones are removed and an implant made up of metal parts and a plastic spacer is inserted. These implants aren’t as predictably long-lasting as implants for other joints, such as hips and knees. And complications can be particularly challenging to treat.

Joint replacement generally is reserved for older adults who don’t put too much stress on the wrist. Surgeons may also consider replacement for people who have had one wrist fusion and need surgery on the other side, so they retain movement in one of their wrists.

What to expect from surgery

The surgeries usually are done as same-day procedures under regional anesthesia (which blocks sensation to the arm) and sedation. With fusion and joint replacement, the wrist will be in a cast for three to eight weeks. Most people require physical therapy to work on regaining strength and motion. Complete recovery takes a few months.

Like all surgeries, there are potential complications, including bleeding and infection. “Fusions do not heal as well in smokers, so I try to get people to stop smoking well before the surgery,” Dr. Shapiro says.

“Future developments will hopefully lead to ways to longer-lasting and more durable implants to increase the indication for and success of wrist replacement.”

This article originally appeared in Cleveland Clinic Arthritis Advisor.