Arthritis of the hand and when to consider surgery

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Today I'm discussing arthritis of the hands, whom it affects and what can be done about it, with Dr. Brian Harley. He's an orthopedic surgeon who specializes in hand surgery and trauma reconstruction at Upstate. Thank you for making time for this interview, Dr. Harley.

Brian Harley, MD: You're very welcome, Amber.

Host Amber Smith: Before we talk about treatments, I first want to ask you some basics about arthritis. Can you describe what it is?

Brian Harley, MD: Sure. It's a really common condition because we all have bones, and where the bones join together, there's things called joints.

And that's what allows us to be flexible and to move. And at the junction of these joints, there's cartilage, which is that smooth, fibrous tissue that you see when you're dissecting your turkey at Christmastime or whatever, and taking it apart. And those smooth surfaces are what allow us, our joints to move so nicely and so well for most of our lives.

And what arthritis is, is that those smooth surfaces start to get rough. And it's a little bit like some rust in our joints. And as that progresses, it starts to typically hurt, and then you start to get typically some stiffness. And then that's that arthritis that everybody starts rubbing their joints and complaining of that starts to make their lives more difficult or miserable at times.

Host Amber Smith: So is this inevitable for all of us as we age, that we're going to get some degree of this?

Brian Harley, MD: Well, yes and no. Typically, our bodies are fragile, and over time, things do wear out, but there's definitely people that are more prone to get arthritis. So there's a genetic predisposition to it.

And then on top of that, there's people that may have injured themselves or a joint got roughened or traumatized during their youth or their young adulthood. And then that can over time degenerate. So there's what we call primary arthritis, where you just genetically are predisposed to some things breaking down sooner.

And then there's post-traumatic changes, where there was some scuffing or injury that continues to deteriorate. So there's a couple of different ways to get it and not every patient's arthritis is the same.

Host Amber Smith: Well, how common is it to show up in the hands, as opposed to some other joints?

Brian Harley, MD: Hands are quite common, mostly just because there are so many joints in the hand.

You only have one, well, two, hips, one on each side, whereas in the hands, you've got five fingers and 17 joints just in those ones alone, so there are some predispositions. So we know that in the hands specifically, women get arthritis moreso than men, especially at the base of their thumb and their fingers.

And so I see a higher population of women coming in with arthritis in their hands than men, but when men get it, the pattern is a little different. Women tend to get it more in the bases of their thumbs men, get it at their, what they call their metacarpal-phalangeal joints, in their knuckles, there.

It's a variable presentation, and everybody's not predestined to get it, but we do see some trends.

Host Amber Smith: Why do you think it's different between men and women? Is it a function of how we use our hands differently?

Brian Harley, MD: No, it's probably just there's some theoretical concepts, and there's some reality.

Women tend to be a little more flexible than men. There's more laxity. And so when we examine thumb bases, especially, the way the joint is constructed, if it's really a little looser, then the cartilage can wear out over time sooner. So that's what we see. Typically, probably just some hormonal differences.

The sexes have some differences in our makeup, and then the way we use our hands, not really sure that's the case because I have people that come in and tell me they use their hands all their lives for different things, but the reality is everybody uses their hands for all their lives.

Some men are on jackhammers for 25 years, and they don't get thumb basal joint arthritis. So it's, like I said, some things are just predispositions to things. And then again, there's other genetic factors. And then just things that some we don't know.

Host Amber Smith: So is pain the only warning sign, or how would we know that we've got arthritis?

Brian Harley, MD: Everybody's presentation is a little bit different. I like to tell my patients that everybody's a snowflake, everybody's just a little bit different. Some people come in, and they have, on X-rays, really bad arthritis. I saw a gentleman yesterday in his early 70s, and his hands looked terrible on X-ray, but he tells me they feel pretty good, and he can do most things, and they don't look very good, but they still function, and they're a little stiff. Other people come in, and the X-rays don't look that bad, but they're very symptomatic, and they have a lot of soreness, and they have swelling. And so again, everybody's experience with their own pain is sometimes different, and the way their arthritis presents is different.

Host Amber Smith: So with someone who comes in with stiffness or pain or swelling, are there nonsurgical treatments that you start them on or that you recommend?

Brian Harley, MD: Sure. As a surgeon, people typically get to me after they've tried a lot of the nonoperative modalities, but mainstays, antiinflammatories, things like ibuprofen, Naprosyn, and then there are some other prescription anti-inflammatory medications. That's sort of the mainstay first treatment, and that's the things that, when we're 20 and 30 and we do too much on a weekend and things start hurting, we use those anti-inflammatories. And they're certainly the most effective, basic first treatment for arthritis.

When it progresses or when you're taking that regularly, and you're starting to get some breakthrough, then yes, there are some times braces or injections can be tried. Injections are typically what we call steroid injections. And they're just an anti-inflammatory steroid that we try to inject in or around the joint to do the same thing that the ibuprofen is doing, but just more in a concentrated form and right at a joint. Because when you take an anti-inflammatory by mouth, it diffuses through your whole body, and it doesn't necessarily get always where you want it. And so that's the advantage of an injection, but of course, an injection needs a needle, and some people don't really like those. Braces are sometimes used, but the problem with braces is the way they work is they prevent that joint from moving as much, which helps that roughness of the joint from causing the inflammation. But at the same time, our joints are meant to be moving. And once you start bracing, people's hands, for example, if you can't move your thumb as well, then you're less dextrous. And then there's often less you can do, so it might help with your pain a little bit, but then you can't be as functional.

So there's always that balance between what are we doing to try and help make your symptoms less, but not get in your way of doing what you want to during the day.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Brian Harley. He's an orthopedic surgeon specializing in hand surgery and trauma reconstruction, and our topic is treatment options for arthritis of the hands.What types of surgery are options for treating arthritis of the hands or thumb or even wrist?

Brian Harley, MD: Sure. Well, all of those are kind of different sites. So I think we just would go through each one.

So, the wrist: it's a little less common to get primary arthritis in the wrist. It was often more of a post-traumatic arthritis. So people accumulate damage from some wrist sprains and falls, and just, minor trauma that over time builds up. And then, you start to see some arthritis in the wrist. And when that happens, sometimes some bracing works. And then if you start doing surgery for the wrist, then that's often some pretty big surgeries where you have to start either removing bones or fusing bones together.

And then that fundamentally changes the way the wrist works. So wrist arthritis sometimes can be a bad one just because it's going to change. I have, especially in men who are in their 50s and working and doing labor-type activities, once we start doing surgeries on that, it's time to get out of the labor pool sort of thing and get a desk job sort of thing. So wrist arthritis can be a bad one.

In the hand, the thumb, as we talked about, very common for women, and so we do have some surgeries for that, where we can really restore motion and just take out the little bones that have worn out and give them a pretty functional thumb, and they can maintain a lot of things that they do.

Brian Harley, MD: So the thumb is a really common surgical site, and we have some really reliable surgeries for that, that have really been time tested.

And then as you move into the hand, then out into the fingers, there's a variety of different options for that. Sometimes you can just clean a joint out and do a fusion.

So out at the distal end, at the fingertips, if the arthritis was really bad there, you don't have a lot of motion if we just fuse the joint together, which is just to scrape those surfaces out and put it together, then that takes care of the pain and the hand can be very functional.

As we get into the first and second knuckles of the finger, those have a lot of motion. And so those are sometimes challenging because sometimes people have some pain, but their motion looks really good. And then you don't want to go in and do fusions or joint replacements because they'd actually be better off with what they've got. So, especially in that central part of the hand, spend a lot of time just doing value judgment, and really pressing the patients to decide: Is this bad enough that we start having to remove parts of them or can they live with it longer? Because often living with it longer is actually the best thing.

Host Amber Smith: So it sounds like you need to really talk with the patient about what their goals are and what they want to be able to do with their hands.

Brian Harley, MD: It absolutely is. The most frustrating arthritis for most patients is the ones where they have pain, but they have still a lot of motion left because that's the challenging ones. Some of the easiest arthritis patients are the ones where the pain is significant, but the joint's gotten really stiff on them. Because then when you either do a fusion, which takes away their pain, or you offer them a joint replacement, which restores some motion, then that's a real bonus for them.

So the patients that just come in with: It's sore and it's swollen, it really slows them down, but really their hand looks and functions pretty well, those are the most challenging patients.

Host Amber Smith: Is there ever concern about whether a person is actually a candidate for surgery, or would most patients be candidates for this type of surgery?

Brian Harley, MD: Yeah, again, it depends. The risk is more major surgery out in the fingertips. Sometimes it's just the last knuckle; those can be done under almost local anesthesia, if there's little surgeries for that. So yes, and especially we do see more elderly patients, that often have more health problems, and so you do have to obviously take that into consideration, but the good news is, especially operating on people's extremities, even if I need a general anesthetic, because you're operating on their hands, there's not as much risk even with a general anesthetic. So in most cases, there's low risk from surgery.

Host Amber Smith: What is recovery like?

Brian Harley, MD: Again, totally depends upon the surgery, but in most cases, it's six to 12 weeks of a typical recovery of the initial postoperative pain. And then usually there's a splinting involved. And then in most cases, especially with the hand, because you're trying to get back motion, there's a degree of physical therapy involved for a month or two.

And then most people, by two or three months, for most of these surgeries where they're either taking out little parts of their bones or putting a little joint replacement in, or even fusing it and the bone starts to heal, by two to three months, most people are usually pretty happy that they're on the road to recovery.

Host Amber Smith: So if someone undergoes a joint replacement or a fusion, how common is it for arthritis to return to that area? Do you ever see th?

Brian Harley, MD: The surgeries that we are doing, so you just take one finger joint, and whether you do a joint replacement or whether you fuse it, that permanently removes the problem, because the joint has essentially been resected, whether you fuse the two surfaces, which means you cut out the cartilage and put the two bone surfaces together, so they knit themselves into one bone. Then you can't have arthritis, because there's no motion, and there's no joint. If you do a joint replacement, similarly, the joint has now been resected in some sort of polymer or metal and plastic has been put in to replace it. The problem with the joint replacements is those are artificial materials that obviously can break down and wear out over time, but the actual arthritis is gone because the joint has been removed.

Host Amber Smith: If a person has severe arthritis in one hand, how common is it for them to also have the same problem in the other hand?

Brian Harley, MD: Again, it somewhat depends upon the underlying cause. So if somebody just has a primary osteoarthritis from a genetic predisposition, then it's very common, it's usually very symmetric. If you take an x-ray at one hand, the other hand very much looks similar, even though one side may be more symptomatic, the X-rays are often similar. If it's a post-traumatic thing, where they injured themselves at an earlier time in their life, and then over time things have deteriorated, then obviously sometimes it can be localized to one side or one area.

Host Amber Smith: As an orthopedic surgeon, specializing in hands, do you offer alternatives to joint replacement or fusion operations?

Brian Harley, MD: Not really. I mean, as a surgeon, those are our standard surgeries. There are other holistic things and other things available for people out there, but mainstream medicine and science-based medicine typically is, working with antiinflammatories and nonoperative modalities as much as we can. And then. when things have gotten to the point where they're not being controlled with those methods, then standard, time tested and scientifically proven surgical alternatives are what I focus on, more or less.

Host Amber Smith: I've read about research into using stem cells to help regenerate damaged joints. But how soon might that be a reality?

Brian Harley, MD: You know, that's really uncertain, Amber. I remember when I was a resident, which I'm starting to date myself, but that was in the mid-90s, and one of my mentors was doing some basic science research on just cartilage regeneration, and that was over 25 years ago, and they were doing it in an animal model. And so we know a lot more about cartilage than we did 25 years ago, but other than still growing it in a Petri dish and in a lab, we're not at the stage where in any sort of reliable fashion can we inject that into a joint and then have it be long-standing or any sort of a replacement. Some of that's just, the physiologic genesis of all of this, is just, typically the cartilage is wearing out, and we just don't have a solution to some things wearing out, much like our cars rust in the winter in Syracuse, there is some just natural deterioration that's going to occur.

Host Amber Smith: Before we wrap up, how do you help someone decide what treatment is best for their particular situation?

Brian Harley, MD: Again, that's just patient education as much as possible. You try and explain, and different people have different levels of understanding, and some people really want to get to the basic science understanding and some people just say, "Please, doctor, just tell me what's best, and then we'll go with that. So working with the patient, trying to educate them to where they feel comfortable and then be realistic and telling them what the outcomes can be. Because as we talked about wrist surgery, we generally don't have a perfect solution. We're trying to find something that helps them and makes them more functional, but isn't necessarily going to be a revolution and life changing.

Whereas with thumb arthritis for that 60-year-old lady, her thumb is totally burnt out a thumb arthroplasty option can be just a wonderful option that just makes them pain-free and very functional again. So just being realistic with patients, to say, Hey, this is either really, really, really good, we should really go this route, or listen, you have to make a value decision here, as I can help, I can make this better, but we're not going to make it perfect. And so that's the challenge for me, is to help people understand that decision process.

Host Amber Smith: Well, thank you so much for making time for this interview.

Brian Harley, MD: You're very welcome.

Host Amber Smith: My guest has been Dr. Brian Harley, an orthopedic surgeon, specializing in hand surgery and trauma reconstruction at Upstate. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, thanking you for listening.