Operative

Bone / Joint:
Arthrodesis
Arthroplasty
Ligament Reconstruction and Tendon Interposition (LRTI)
Resection Arthroplasty
Trapeziectomy

Nerve:
Endoscopic Carpal Tunnel Release
Nerve Decompression
Ulnar Nerve Transposition

Tendon/Ligament:
Lateral Epicondyle Release (Tennis Elbow Release)
Tommy John Surgery (UCL and MCL Reconstruction)


Arthrodesis

Arthrodesis is an effective treatment used in the stabilization of degenerative joints. It is often used to treat such conditions affecting the wrist and is an alternative to arthroplasty, or total joint replacement.

The procedure is the process of fusing, either partially or completely, the bones that make up the joint into one solid bone, in order to eliminate the instability and associated chronic pain resultant of joint degeneration. While it is effective in eliminating the pain, it reduces range of motion.

The purpose of the procedure is to reduce the range of motion, as it is the movement over worn joint surfaces, articular surfaces void of protective cartilage, which permits bone to move directly across bone causing discomfort and often debilitating pain.

Limited and total arthrodesis were developed in order to decrease the pain of degenerative joint conditions such as arthritis. While initially periods of immobilization were required to ensure fusion, internal fixation with specialized fixation devices has today eliminated the need for postoperative immobilization.

Special plates and screws for the small bones and joints of the hand, wrist and elbow continue to facilitate the treatment, which is generally indicated for trauma wounds, chronic carpal instability, avascular necrosis, tumor damage, septic and rheumatoid arthritis. Arthrodesis may also be used for stabilization of the wrist when combined with tendon transfers, in the correction of deformities, as well as in the salvage of an unsuccessful wrist arthroplasty.

Arthroplasty

An alternative to the joint fusion approach of arthrodesis, arthroplasty is the reconstruction of a deteriorating joint. Its purpose is to restore joint function and relieve pain - and is commonly used on joints severely affected by osteoarthritis.

The most commonly used arthroplastic procedure may either entail a joint resection or an interpositional reconstruction. A joint resection involves the removal of a portion of the bone from the stiffened joint in order to create additional room for improved and less painful range of motion. Interpositional reconstruction is the reshaping of the joint and placement of a prosthetic disk in order to create a more stable joint.

The complete replacement of a joint is called total joint arthroplasty.

Before any joint reconstruction procedure is complete, a series of tests are performed to ensure proper range of motion and correct movement.

Total Joint Arthroplasty
Total Joint Arthroplasty is the complete replacement of a severely deteriorated joint. The joint is replaced with a prosthesis, or artificial joint, which may be made of plastic, metal, silicone and ceramic material. A new joint can also be created from body tissue such as skin, muscle or fascia. Artificial joints are generally cemented into place once soft tissue is temporarily moved aside and a space within the deteriorating joint is cleared.

The type of joint being replaced and the severity of the deterioration will depend on the type of prosthesis used. For example, silicon hinges have proven effective in the smaller joints of the finger. Though many new implants designed specifically for the small bones and joints of the hand and upper extremity have been introduced into the market over the past several years - and continue to be refined as the biomechanics of these smaller joints are better understood.

Total joint arthroplasty is indicated when the degenerative affects of arthritis make daily tasks difficult to perform, which is often the case in the small finger joints and wrist joint.

The severe contractures often associated with severe osteoarthritis of the hand can lock fingers into positions that make many daily tasks impossible. As joint deterioration continues, pain increases. In such cases, metacarpal phalangeal (MP) joint replacement can correct deformity, help restore function, and relieve pain.

Wrist arthroplasty is indicated when a severely deteriorating wrist joint is nonresponsive to other treatments, causes chronic pain and is unable to function properly. By replacing the wrist joint with an artificial one pain is eliminated and strength in the wrist is restored - improving the range of motion and stability necessary to perform daily activities.

An elbow arthroplasty is indicated when the same conditions described for a deteriorating wrist joint exist in the elbow - generally resultant from the severe degenerative affects of osteoarthritis. The new joint replaces the damaged surfaces of a deteriorated joint and eliminates the pain of bone against bone friction, while improving elbow movement. Joint replacement of the elbow is also indicated for elderly patients suffering from osteoporosis, as internal fixation is ineffective and fusion impossible on this soft bone consistency.

Ligament Reconstruction and Tendon Interposition (LRTI)

A ligament reconstruction and tendon interposition is generally performed on patients suffering from the degenerative affects of basilar joint arthritis, or arthritis of the thumb. It is also used to treat some carpal metacarpal (CMC) instability cases.

The procedure entails either a partial or complete resection of the trapezium, one of the eight carpal bones. The palmar oblique ligament is then recreated using the distally based radial half of the flexor carpus radialis (FCR) tendon, in order to reconstruct ligamentous support for the metacarpal - preventing radial subluxation. The remaining tendon is arranged in the empty area of the trapezium.

The long-term effect of the procedure results in increased grip and pinch strength.

Resection Arthroplasty

Resection arthroplasty is a surgical procedure that involves the removal of a portion of bone within the joint, prompting the development of scar tissue. This scar tissue then serves as the cushioning agent of cartilage, reducing the painful friction caused by the ends of arthritic bones and providing some mobility. Resection arthroplasty may also entail the use of an implant to further improve range of motion - flexible hinge implants particularly effective in the small finger joints.

The procedure can be done as open surgery with a small one-inch long incision, or arthroscopically. Recovery is similar with both procedures.

Patients usually return home wearing an arm sling. Stitches are removed approximately one week later and movement becomes easier each day thereafter. Rehabilitation and strengthening exercises are key in recovery and resumption of range of motion.

Trapeziectomy

A trapeziectomy is indicated when the joints around the trapezium become stiff and severely affected by arthritis. It entails complete removal of the trapezium bone, which is one of the eight carpal bones of the wrist - located at the base of the thumb.

The large range of motion that the thumb is able to attain predisposes the joints at its base to instability and increased wear, which frequently leads to arthritis. The joint instability also leads to increased joint stiffness, pain, and ultimately deformity at the thumb. A trapeziectomy is performed when symptoms become nonresponsive to conservative treatment such as activity changes, anti-inflammatory medication, splints and steroid injections.

Increasingly a simple trapeziectomy with a small modification, also known as hematoma and distraction arthroplasty, is used. This combination is producing a high rate of success. In this procedure, the trapezium is removed in small sections and stabilized with internal fixation at the first metacarpal. There is then a short period of postoperative immobilization.

The procedure successfully eliminates pain and dramatically improves range of motion and grip and pinch strength.

Endoscopic Carpal Tunnel Release

Endoscopic surgery is a minimally invasive procedure similar to arthroscopy. It uses a slender, flexible tube called an endoscope, with a small fiber-optic camera attached. The endoscope is inserted into a small incision, or portal, and allows the surgeon to clearly see within the wrist via a small monitor, without having to open it completely and risk disturbing surrounding tissue.

An endoscopic carpal tunnel release is a very technical procedure designed to release the tight, or compressed, transverse carpal ligament over the median nerve, which is responsible for causing the pain and numbness associated with carpal tunnel syndrome. The median nerve, which supplies sensation to the thumb, index, middle and portion of the ring finger, as well as supplying the thumb muscle, becomes compressed at the wrist - because the transverse carpal ligament is contracted from swelling and inflammation prompted by repetitive activities, or age.

Endoscopic carpal tunnel release is indicated when symptoms persist despite several months of conservative treatment, or the severity of the symptoms affect work and everyday activities. The procedure may also be indicated if there is loss of hand or finger function and a nerve test reveals possible damage to the median nerve.

About the Procedure
Endoscopic carpal tunnel release is an outpatient procedure that is generally performed under regional anesthesia and lasts approximately 30 minutes.

Once the anesthesia has taken affect the hand is marked to indicate where the incision will be made. The skin is then cleaned and a small incision, or portal, is made just under the crease of the wrist, below the palm. The endoscope, along with a metal or plastic cannula (a tube with a slot on the side), is inserted under the transverse carpal ligament and the fiber optic images are viewed on a monitor. Once it is determined that the nearby nerves and arteries are safely out of the way, a special knife is inserted through the cannula and the transverse carpal ligament is cut to relieve the pressure from the median nerve. Careful attention is given to the surrounding area, in order to ensure that all other soft tissue remains undisturbed. The small incisions, or portals, are then closed with stitches and the hand is carefully wrapped with a soft dressing.

Following Surgery
Patients are able to move their hand and wrist immediately after surgery though instructed to avoid heavy grasping or pinching with the hand for five to six weeks. This helps to prevent the tendons from pushing against the healing transverse ligament.

Instructions for rehabilitation are discussed and a schedule to begin rehabilitative exercises is created. Some patients may work with a physical or occupational therapist for several weeks following surgery and begin doing active hand movements and range of motion exercises. Ice packs, soft-tissue massages and hands-on stretching to help with range of motion may also be used. A follow-up visit is scheduled approximately two weeks following the procedure.

Rehabilitation
Rehabilitation exercises designed specifically for carpal tunnel patients are demonstrated by a physical therapist and then continued independently at home. These exercises are key to a rapid and successful recovery. Therapists may also discuss ways in which a patient can alter the activity or activities that initially prompted the condition.

Nerve Decompression

Nerve decompression is performed in order to surgically release compressed nerves, which are nonresponsive to conservative treatment. It helps relieve the pressure and painful affects of nerve compression.

Most often performed as an outpatient procedure, patients are given either a general or regional anesthetic depending on the location of the nerve. Nerve decompression procedures involving the hand and arm utilize an axillary block.

The procedure begins with an incision over the area of compression - delicately moving aside the surrounding soft tissue in order to examine all potential causes of compression or pinching affecting the nerve. Once identified, the compression is relieved. The particular technique used to decompress the nerve depends on the source of the pinching or compression. The soft tissue is then placed back in its original position and the skin is sutured closed. Rehabilitative exercises begin once the surgical site has healed sufficiently.

Ulnar Nerve Transposition

A surgical procedure called Ulnar Nerve Transposition is performed in order to relieve the pressure on the ulnar nerve often associated with cubital tunnel syndrome nonresponsive to conservative treatment.

The procedure entails moving the ulnar nerve to the front of the elbow and beneath a muscle layer. Here it is protected from the bony groove of the elbow when it is bent. Beneath the muscle, the nerve is also protected from injury. During the procedure, adjustments are made in order to ensure that the ulnar nerve does not become compressed in its new location.

An incision along the back of the elbow is carefully made in order to preserve the integrity of the nerves in the area. The bands of pressure entrapping the ulnar nerve are then identified and released. Muscle is then lifted from the bone and a protected area void of future nerve compression is created. Scar tissue or other damage that may be evident within the area is addressed and the area is closed with sutures.

A key part of the recovery for this as with all other procedures is rehabilitative and strengthening exercises, in order to rebuild muscle function and promote nerve regeneration.

Lateral Epicondyle Release (Tennis Elbow Release)

Lateral Epicondyle (Tennis Elbow) Release is a procedure designed to relieve tension from the extensor tendon at the elbow joint, generally caused by overstressing the joint. It is indicated when symptoms become nonresponsive to conservative treatment.

Most often performed as outpatient treatment, the procedure entails the use of an axillary block to numb the arm. An incision is then made to the outside of the elbow over the lateral epicondyle. The surrounding soft tissue is gently moved aside permitting visibility of the tendons. Damaged tissue and any visible bone spurs may be removed as the tendons are explored.

The extensor tendon is then cut and split at the point that it connects to the lateral epicondyle, facilitating the removal of any existing scar tissue. It may also be necessary to cut the tendon at its attachment to the bone and remove a small portion of the bone, in order to improve the blood supply to the area.

The key to a successful recovery is an effective rehabilitation program, which begins once the wound has shown sufficient signs of healing.

Tommy John Surgery (MCL & UCL Reconstruction)

The Ulnar Collateral Ligament (UCL) Reconstruction procedure was made popular by Los Angeles Dodgers player, Tommy John, following his successful treatment of what was once a career-ending UCL injury.

The procedure, most commonly called the Tommy John Surgery in honor of the first professional athlete to undergo the surgery for an elbow injury and return to a professional pitching career, is today changing the way athletes view elbow injuries. What were once devastating injuries for an athlete, UCL tears are now managed with this surgical procedure developed to restore strength to the damaged limb and return athletes to their sport in top form. Nearly 90 percent of those undergoing the surgery today make a complete recovery.

The goal of the procedure, which takes approximately one hour, is to replace the damaged ligament of the medial elbow and replace it with a tendon from the patient's forearm, hamstring or foot. The rehabilitation program that follows is ex an essential part of the overall treatment for athletes.

The surgery is also used in some cases to treat medial epicondylitis (Golfer's Elbow) and lateral epicondylitis (Tennis Elbow)