Prakash Chandran (Host): Welcome to a series segment called Hands-On, where we'll focus on different parts of the hand from fingertip to wrist. You've probably heard of a knee or hip replacement, but did you know there are replacement surgeries that are possible for smaller or complicated joints, such as the wrist? Learn more about what makes up the wrist, how replacements work and the different kinds of arthritis that can affect the wrist. We're going to talk about it today with Dr. Khurram Pervaiz, Orthopedic Surgeon, specializing in hand and upper extremity surgery for Orthopedic Associates of Central Maryland Division. Hello, I'm Prakash and I've Got a Bone to Fix With You. So doctor, my first question is what type of arthritis affects the wrist?

Khurram Pervaiz, M.D. (Guest): Hi Prakash. So, there are several different types of arthritis that can affect the wrists. So the most common that we see is osteoarthritis, which is wear and tear arthritis from old age. We also see arthritis caused by ligament injuries to the wrist. A ligament injury, to the wrist that's not fixed can cause arthritis over time. We also see post-traumatic arthritis where somebody has had a fracture or an injury that might've been treated with surgery or may not have been treated. And then over time can also lead to arthritis. And then another common type of arthritis is rheumatoid arthritis or an autoimmune disease, which tends to affect different joints in your body and can also affect the wrist and can lead to arthritis.

Host: Okay. Understood. So what exactly does arthritis feel like? And then when someone starts experiencing it, what are typically their first steps?

Dr. Pervaiz: Yeah, it's a great question. So, you know, patients who have arthritis in their wrist will have pain. They may have swelling, warmth sometimes, pain that shoots up the arm or down into the hand. So the first steps, obviously, if when folks have pain, they may want to immobilize their wrist. They may wear a wrist brace. They can, they may use over the counter medication like Tylenol or Advil or Aleve. And of course, if their pain is not getting better, then they need to come to a specialist, have it looked at, have x-rays so that we can determine what type of arthritis it is. And then, you know, more advanced treatment options.

Host: Okay. And on a percentages basis, how often is arthritis cured in a more conservative way versus the more interventional surgical method?

Dr. Pervaiz: So I would say that in most cases of arthritis inside the wrist, I would say, you know, definitely upwards of 50% and even as close to 80%, most cases of arthritis that we see will improve with non-surgical treatment because a lot of patients have early arthritis. It's not very advanced, so their pain is going to get better, maybe not completely improved, but get significantly better with simple things like, simple things that surgeons like myself will prescribe like a brace or physical therapy or medication or injections. That works most of the time and in situations where that does not work, then we take more invasive steps such as surgery.

Host: Okay. So let's talk about that. At what point do you say, you know what, nothing seems to be working, a surgical option is needed and what does that surgical option actually look like?

Dr. Pervaiz: That obviously that's sort of a mutual decision with a patient, you know. Once their pain hasn't improved with non-surgical treatment and once they feel that the pain is bad enough that it's affecting their quality of life and it's going into surgery is worth the risk benefit profile.

So that's what, that's where a mutual discussion with the patient comes in. We present the risks, we present the benefits, and once we've made that decision, then we proceed with surgery. Now, what does the surgery look like? While there's multiple treatment options for wrist arthritis. See the wrist as a fairly complex joint.

It's unlike the knee or the hip or the shoulder in that the wrist is made up of eight different bones and these bones articulate and allow three dimensional movement in the wrist from side to side, front and back flexion extension, and then also rotational movement. So it's a fairly complex joint and the treatment options are dependent on where the arthritis is. So, sometimes, the arthritis is isolated to certain parts of the wrist. In other words, all eight bones may not be affected. Some of them may be affected. So, we direct the surgery to which bones are affected by the arthritis. There are situations where we may just remove some of the bones.

There are other situations where we may fuse some of the bones. Sometimes we fuse the entire wrist and then a more recent and more cutting edge treatment option is wrist replacement surgery where we actually remove part of the bones inside the wrist and replace it with an artificial total wrist, similar to a total hip or a total knee replacement.

Host: That's absolutely fascinating. So, with this wrist replacement, you mentioned that our wrist is made up of eight bones. Does it actually replace all eight of those bones?

Dr. Pervaiz: No. So, the wrist replacement tries to replicate the anatomy of the wrist, but the wrist replacement joint itself is made up of a single articulation. So, we remove some of the bones, the articulation inside the wrist is just one surface. One is a polyethylene, which is similar to a plastic surface. And the other surface is a metal surface. So, there's the contact between a plastic and a metal piece. Now how it is fixated inside the wrist is obviously very complex. On the one side, we have a porous coating, so it bonds into the bone. And on the other side, we have screws that go up into the hand. So, it's a very special joint replacement and of course a much more recent in its origin compared to other total joint replacements.

Host: Wow. That is so fascinating. Talk to us a little bit about the recovery from a surgery like this.

Dr. Pervaiz: So this surgery amazingly, it's typically done on an outpatient basis. Patients go home the same day. We immobilize them in a splint. I typically will immobilize patients for about two weeks before switching them into a removable brace and starting physical therapy. We have them just early on, just do range of motion, which is, you know, working with a therapist.

And then about after a couple of months, we have them do strengthening exercises then typically anywhere from three to six months, we allow patients to return to full function. And I typically will ask these patients to limit their activities long-term to some degree, to avoid early wear of the total wrists. So in other words, you know, I may ask them to limit the amount of weight that they may lift with their wrists, ask them to avoid heavy weight lifting because the total wrist is not designed for excessive weight lifting. It's typically, you know, a pain relief operation. So you know, in other words if somebody is a heavy laborer, let's say somebody does heavy labor, that person is gonna have a much better outcome with a wrist fusion than a total wrist replacement.

Host: I see. So a wrist replacement really is there to minimize pain. Talk to us a little bit about the mobility of that wrist after a surgery like this, and maybe just generally, what are the main outcomes that you see?

Dr. Pervaiz: The mobility is obviously, it's never going to be similar to a normal wrist, but it's going to be better than a fusion. So, when we fuse the wrist now, depending on what type of fusion we do, which is the other option for wrist arthritis. If we do a partial. You will have some mobility, maybe half or a third of normal mobility of the wrist. If you do a full total wrist fusion, then they'll be, there will be no mobility. So, the interesting thing with the wrist is that the lack of complete mobility can be quite disabling. Because your non-dominant wrist is fused. It can even be sometimes difficult to go to the bathroom if you know what I mean, because you need a little bit of wrist flexion to be able to go to the bathroom, to clean yourself.

So those are things that hand surgeons consider, you know, if somebody has wrist arthritis in both of their wrists. We may on the,one wrist, do a replacement so that they maintain some mobility. And on the other wrist, maybe we do a fusion so that they use their one wrist for heavyweight lifting.

And the other wrist is just used for mobility and not so much heavy. These are obviously fairly complex decisions that come into play depending on, you know, where the patient's arthritis is and if they have bilateral disease. Now going back to the wrist replacement, a total wrist replacement, patients unfortunately, even with a total wrist replacement, patients will never have full mobility. So, I typically will tell patients that they'll have anywhere from a third to half of normal wrist motion, enough range of motion to be functional, to be able to do everything that they want to, all activities of daily living, hygiene, driving, typing on a computer, just living a normal life. But they're never going to be able to obviously do gymnastics, you know, extreme sports that require hypermobility. They're not going to be able to do that.

Host: But to be clear, it seems like so many go for the surgery to reduce or get rid of the pain. And it seems like a total wrist replacement does accomplish that goal. Is that correct?

Dr. Pervaiz: Absolutely. A hundred percent. And you know, these procedures are designed for older patients, right? And older patients are generally lower demand patients. And all they're looking for is pain relief. And in terms of pain relief, it works beautifully. Patients have pain relief. They have to still maintain some mobility and they're very happy.

Host: Well, this has been such an interesting conversation. Is there anything else that you'd like to share with our audience today before we close?

Dr. Pervaiz: I think it's important to, you know, if your pain is not improving and issues in the upper extremity or just orthopedic issues in general, don't sit on it. Don't you know, don't wait, don't think it's going to get better if you've given it some time. Definitely have it looked at by a physician, maybe a specialist, come to our practice, come and see us, and then we can give you, we can make you better.

Host: Yeah, it definitely does seem like time is of the essence. So, as soon as you start experiencing the signs of arthritis, it's important to go and get a consultation to really figure out how you can either be proactive to prevent, you know, more invasive options or how you can really work with someone like yourself, an orthopedic surgeon to really figure out the right options for you. Is that correct?

Dr. Pervaiz: Exactly. Yes.

Host: Well, perfect. Well, Dr. Pervaiz, thank you so much for your time.

Dr. Pervaiz: Thank you for Prakash.

Host: That's Dr. Khurram Pervaiz, Orthopedic Surgeon, specializing in hand and upper extremity surgery for Orthopedic Associates of Central Maryland Division. For more information, you can head to MDbonedocs.com. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

That's all for today, I'm Prakash Chandran and that Was A Bone That's Fixed.