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Um, and he is gonna be talking about osteoarthritis of the hand and wrist, but excluding thumb base oa, which will be covered separately today. So this is a typical appearance that you will see of, um, the average hand patient that comes in to our clinics. Um, and there's not necessarily a completely symptomatic hand. So what you'll often find is somebody might appear with a, a hand looking like this and they may have thumb base away. But also they've clearly got osteoarthritis in the D IP Js throughout. Well, and that's a very common appearance. So, about half of all women and one quarter of all men will experience the stiffness and pain of osteoarthritis of the hands by the time they're 85 years old. Um, and that's from the Arthritis Foundation, but I would definitely see that even if they're not symptomatic, you see the, the, the appearances are quite widespread in this, in this a especially middle aged to elderly in both men and women. But it's certainly more common in women. The IP, thumb base and P IP OA are more frequent in women and MCP and wrist OA are more frequent in men. And that's the studies that we get here, I would say in the average hand clinics, the thumb base oa is really the most common that we see. And the, and the biggest complaint that we get, as I said, osteoarthritis is often asymptomatic and people will have these appearances as they come into clinic. And symptomatic osteoarthritis can become asymptomatic, it can burn itself out, you can get ankylosis of the joints itself. And most of these, we will manage non operative initially. And it's very important to treat the patient and not the X ray images. And what can be a bit daunting when you get somebody to come to clinic, they, they'll come in and they'll have widespread arthritis. You'll look at the x rays, most of the joints will be affected. And really what you have to do is pin down to the patients, which of these joints is problematic because you can't go and deal with everything. Um, at the same time, there's too much to deal with and you really have to pin them down and sometimes people have horrendous x rays or have really arthritic looking hands. And it's one or two particular joints that are causing the problem. And what you've got to do is then deal with them specifically. So, managed non operatively. Initially, as I said, I haven't seen the way the rest of these slides go. So you, it's the way you would normally manage arthritis, you start off with your normal simple analgesia. You may need splints for these people. You then work up to things such as steroid infections in the sort of the non operative period. And they may be guided or unguided. And that very much depends on your unit and, and how things work there. Usually the smaller joints will have to be guided because it's a little bit more tricky, but a large joint such as a wrist joint, uh an unguided injection is usually sufficient the D IP joint. So what we, when people come in with complaining of D IP joint arthritis, you'll normally see the, the large um osteophytes present. You may see angulation of the joint itself and the problem that they present with can really vary. Some people just have a stiff, painful joint. Some people complain about the sort of mucous cysts that they get around the joint themselves. Um And some people just don't like the appearance if you are tempted to remove any of the cysts that people complain about. And you might do this because people have a good range of movement and no pain. And the only thing they complain about is the cyst. You have to remember. It's not just the cyst, you're removing, these will be caused by an underlying osteophyte. So it's the osteophyte that has to be targeted underneath, if you are going to do a simple debridement for the cysts rarely fused. But sometimes we do need to fuse them, especially when people have very symptomatically painful joints. And the standard nowadays is to use a type of compression screw. Although previously, we would have used just normal simple cortical screws for this. Some people will use K wire fixation and some people who use dental wire as well, especially probably more plastic surgeons at the moment. But the standard nowadays would be to use a compression screw and the operation is simply to make an incision, which can just be a transverse incision over the joint debride. The joint, get rid of the joint surfaces, get back to nice, get rid of all that subchondral bone, get back to nice bleeding bone, um straighten out the joint and then use AAA compression screw with the usual techniques that we use with the guide wire, first check in with x-rays until we have a good alignment, then overdraw and application of the compression screws. And it says here avoid damage to nail beds. There are some of the newer screws on the market. There is one by skeletal dynamics at the moment, which has a smooth um proximal len that actually goes onto the nail bed and is meant to avoid the damage. But as long as you don't penetrate the the dorsal surface of the bone as you're going through the distal phalanx, you shouldn't damage the nail bed itself. And that's your typical appearance and people may not like it because the cysts themselves keep bursting, they're painful, they get in the way or they cause compression on the nail itself and cause a deformity of the nail. And again, these are these appearances that can be called or by these ganglion cysts, commonly called mucous cysts around the D IP. So, surgery just to get rid of these cysts, digital nerve block, I would use that for effusion as well. You don't need to do anything more than, um, a ring block for a finger tourniquet. There's caveats with the tourniquet. You have to make sure that everything is noted correctly. Ideally, you would now use very specific tourniquets that you buy for this. So in Adam Brooks, we have these digital tourniquets which are quite um, long strips and use a clip to do to hold them on. You can buy tourniquets which are purpose built sort of um, little rubber rings that go in, but they also have a little label attached which you should not remove until the end of the operation. The problem that people used to get was they would have makeshift tourniquets. And a common way was to put a finger of a glove over the finger, nick the end and then roll the glove down. And that way it would squeeze the blood out and create a little tourniquet. The problem with that is that it can go unnoticed at the end of the operation and there have been case reports out there where it's been left you've dressed the finger, the finger has got a, a ring block in. So people will not feel it. And by the time there's a lot of pain and people realize what's happening, you have an ischemic finger y shape incision. This can vary slightly. Some people use at shaped incision over the ganglion itself. The important thing is to recognize the nail bed underneath, especially your germinal matrix and make sure you avoid that decompress the cyst. As I said, you've got to bribe the osteophytes cos they will be causing the cyst and respectful skin closure complications. Skin you can have a skin defect. You can end up with a reduced range of movement because you're operating around a joint and this can cause stiffness, extensor leg. If you damage that extensor tendon going into the D IP, you'll give them a um a mallet finger recurrency can come back. And I always warn people of this, you've not got rid of the arthritic process. You may have got rid of one osteophyte, but they're still underlying osteophytes and they can regrow and stiffness. It's generally an arthritic joint. And even if it was ok before, by having a period of immobilization, you may completely stiffen it up afterwards. The one type of incision, the white type there, as I say, there are some variations in this. But the main thing here really is to ensure that whatever you're doing is not going near that sterile matrix and you're respecting the sterile matrix of the nail bed and that there is a, um that's a ring avulsion injury. He did mention that he's put a ring avulsion injury in there just really to show you the anatomy of what's going on underneath. And the important thing is to look at the slide on the right and the slide underneath which has those two black lines on either side of them. And that's respecting the way the extensor comes up over the D I PJ itself. So if you're thinking about removing um any of the cysts around there, you have to respect that extensor anatomy. So you don't cause them um an iatrogenic mallet finger. OK. And these are, these are some typical appearances of arthritis um within the, the hand itself. And as you can see, this patient has got multiple sites, the M CPJ S are not congruent. He's got some in the P IP and the D I P's definitely got some arthritic problems as well. And these are some other examples I think of some arthritic D I PS. And you can see there's always angulation al always most of the times there's some slight angulation of the D IP joints themselves. And this is how we correct them. We approach in a similar way to removing the cyst. And as I mentioned earlier, get rid of the articular surfaces. The subchondral bone stick down a guide wire and stick down a nice compression screw. And then afterwards I would use absorbable sutures. They'd keep in a big finger dressing for a couple of weeks and then I would put them in mallet type splints for another, another four weeks until they've gone onto full union, which has happened here. Um, I will mention potential complications of this fingertip tenderness because obviously you're putting your drill through and your screw through the fingertip itself. Always warn people of that. The metalwork can feel a bit prominent. So you warn people that the screw may need to be removed. And then you've got generalized risk from effusion such as non union malunion and other such generalized infections in complications including infections and such like now at the P IP joints. Um this uh again is more common in ladies and can have a, a number of different, a number of different ways of managing it depending on what P IP joints we're talking about. Generally the D I PS from index to middle to ring to little are all the same management. But you've got certain considerations when you come to the P IP joint because of stability issues that we have loose body is rare, will cause locking or nausea and discomfort, explore and wash out. Er, they are rare, we hardly ever see them. Um and P IP fusion is an option for arthritis here. Now, this is a tension band technique which some people still do. Other people will put a plate and screws to create fusion. And some people will use what we call the apex screws, which he hasn't got here. And that's um it's a screw with a special type of hole in it. So screw goes down one of the phalanxes and another screw interlocks through it. Um And that can create a fusion mass itself. As I say, there's a few different types of fusion devices that you can use. The general consensus is that when it's an index finger, you should try to fuse the P IP rather than going for an arthroplasty such as a Swanson's device. And the reason is when you have a pinch grip and your thumb is pinching against your index finger, arthroplasty options such as uh clastic sponsors do not give you the same stability on the P IP. Whereas in the, the little finger and the ring finger and to some degree, the middle finger, um it doesn't matter because your pinch scripts not gonna be affecting those as much, but fusion I is the common way. And as, as you can see here, tension band wiring is, is one of the more common ways of doing it. M CPJ is in association with hemochromatosis and beware of the locked M CPJ. Um I don't know how much more he's put on about the locked M CPJ. Oh There we go. Now, I, if you can notice, I think it's more apparent on the right hand side. If you look at the index metacarpal head, you can see there's a little bit of an osteophyte poking out. Um And this is what we call a Brewerton view. So you won't see it very clearly on a lateral or on an AP view. And what's happening here is they have a locked MCP and basically, the extensor hood is catching on that osteophyte. Now, this will vary from other conditions including say a dropped finger cos if somebody has a dropped finger, a sagittal band rupture, even though they will not be able to fully extend the MCP, actively, passively, you'll be able to pull it up into full extension. You will not be able to do it for a locked MCP because that extensor hood is caught onto, onto that osteophyte there and there we go, Brewton view and you can see those little osteophytes sticking up and treatment for this treatment for this. Really, in the few cases that I've seen is what we do is we insufflate the joint with a local anesthetic. So you just get a local anesthetic. You can do it in clinic, fill up the joint, give them a few minutes to, for everything to go nice and numb. And there's 22 parts of the theory. The first part is that the insufflation itself will unhook the extensor hood. But the second part is the bit that isn't unhooked as you m manipulate the joint back into full extension. You can feel a little bit of a rip and it just, it just opens the, the little bit of the extensor hood and that's absolutely fine. Cos once you've done it, they tend to be able to move their joint straight away again and it doesn't tend to be a problem. Most people, once this, once you've unlocked it by using some local anesthetic, they're free and they haven't got an issue again. If it locks a second time, you may consider exploring, um, and getting rid of the osteophyte itself. But for a first time, just local anesthetic into the joint, manipulate it back into full extension. And usually that, that works some MCP joints. Um, this is, can be a problematic joint for a number of reasons. I'm sure when you've covered your trauma term, you're all covered ulnar collateral ligament injuries, which is the most common, um, time that you'll be dealing with the MCP joints. Um, but radio collateral ligaments are also out there. Obviously, the consideration with radio collateral ligaments is most of these could be managed on operatively and you don't have to worry about the stenar lesion that you get on the UCL, but you get from MCP joint, osteoarthritis. This joint itself is not particularly amenable to an arthroplasty option, um, because of the stability issues. So the vast majority of people would just fuse these. Um, and he hasn't, I don't think we've covered the options here, but there's a couple of different ways to fuse these. Again, there's the apex screw type option where you've got a specialized screw and screw device, there's a plate and screw device. But the more standard ways to fuse this joint is either do a tension band or my preferable way would be to expose the joint, prepare the joint as a normal fusion. I'd bend the plate to about 30 degrees and I'd just use a normal, er, compact handset plate um across the top and just apply compression. As I say, we're gonna be covering CM CJO a er for another day, but actually later on today. But that's, that is the most common form of arthritis that we see. Um I mention for S TT OA um not too much, I don't know how much maybe Lucy might be covering a bit more of this later. Um But this really goes hand in hand with your base of thumb oa. And the vast majority of people who have these that we see in clinic have a form of pantrapezial oa. So they'll have first CMC G AOA and we do manage these um all at the same time again for this joint as well as the other joints. Our first step will be simple analgesia and then move on to steroid injections. It can become a bit of a tricky customer to deal with and I'm not sure how much Lucy's covered. So I won't try and go too far into it at the moment. But basically, there are a couple of options. There are some implants that you could put in called Pyrocarbon. They've mostly been withdrawn from the market themselves. You can fuse the S TT, but it's notoriously difficult to get fusion in this joint. Um, and you can do a distal pole of scaphoid excision. The problem is if you do that, when they've already gone onto slight carpal instabilities, you'll completely destabilize the carpus. Um So that's the only one to use if you've got a normal alignment. Otherwise, the, the standard answer for this, if you want it for an exam is S TT fusion snack is something you will commonly see. Um in hand clinics that scaphoid non union advanced collapse, closely related to scapholunate, advanced collapse. And basically, this is a carpal instability that causes a malalignment because of the previous injury and that there's a number of different ways to deal with this. This includes a four corner fusion. I would say if, if your snack is actually lo looking like this. So there's an established nonunion, but there's not much degenerative change around the wrist, you can go and try and do a, a scaphoid nonunion repair. So use a bit of iliac crest. And I'd say looking at the appearances of this x-ray itself, that's probably the option you'd want to try maybe with a radial styloidectomy because you can see there's a little bit of arthritis on that area, but it's probably worth someone like this going in and trying, trying a salvage sort of a a more minor salvage procedure in in the form of um a non union fixation with iliac crest graft. But some people are beyond that and they could require this, which is a four corner effusion always mentioned with a four corner effusion, they need a scaphoid ectomy at the same time. The other option is a proximal row carpectomy. So that's removing the entire proximal row. The big difference is between the two. The big theory between the two is that proximal row carpectomy will give you a greater bit range of movement. But a four corner fusion cos it keeps the carpal height will give you a greater grip strength in the hand. So for a lot of these conditions, this is your first stage of salvage, either APR C or a four corner fusion. And if you've got both of these as an option, then you have to give the option to the patient, whether they want to improve range of movement or improve grip strength. And that can vary from patient to patient and what their activities in normal job are. It is worth mentioning that a proximal row carpectomy is only possible if that proximal pole of capitate is in a reasonable condition because otherwise you're gonna be loading an arthritic surface onto the lunate fossa. Whereas in the four corner fusion, the midcarpal joint doesn't really matter so much you just have to ensure that your radiolunate joint itself is in a reasonable condition. If your lunate fossa itself is arthritic, then you are limiting your options. You might be able to try something like a radio scape and lunate fusion or you might have to consider if the arthritis is pancarpal and very bad a total risk fusion, slack wrist much the same when you're looking at a slack wrist like that and that's scapholunate, advanced collapse. You can see there's quite a bit of arthritis in the radio scaphoid joint. They've also got evidence of mid carpal arthritis here. So this is someone I you probably wouldn't want to consider a uh proximal row carpectomy because you can already see the, the the arthritic changes at the proximal pole that capitate there. They're already going into a malalignment. You can see the dizzy deformity on the lateral view. Um But actually, if you look at the radiolunate uh fossa that looks like that's probably reasonably cons conserved. So I would imagine in this patient that you may want to consider a four corner fusion, I would say in all these ones, when you're considering to go between APR C and A four corner, it's probably worth either getting an MRI scan or if your institution scopes wrist and scope a wrist just to have a look at the state of the articular surfaces just so you don't get any surprises when you go in for your main operation. And then we've got someone who's, who's got this. Um, and this is severe wrist osteoarthritis. Occasionally you will get people who come into clinic. You'll see x-rays very similar to this and you'll be all ready to go fusing their whole wrist. And actually, the arthritis isn't too bad in terms of their clinical movement, they may be a bit stiff, they may have a range of movement, but their pain may be reasonably well controlled or they might not have that much pain. So really, even though you see an X ray like this, it's very important to go on how people are clinically because you may not do need to do too much more for a patient like this, then give him some simple analgesia and a splint. And if someone presents to you the first time and things are not too bad, it's always worth trying a steroid injection as well. Same goes for someone like this pancarpal arthritis, which is gonna be quite severe for them. And ultimately, in these patients, if your steroid doesn't work or they've already gone through the process and they've had steroids before and they just want a definitive solution. We move on to a wrist arthrodesis and this is pretty much the standard type of arthrodesis plate that you will see. I think this looks like a synthase plate and that's what we usually use. It's got a little um dip in the middle of a little curve and that can be either slightly longer or slightly shorter, depending on whether you do a PR C to the patient. So it depends on the carpal height. You'd also use a shorter curve in the neuromuscular patients that you're operating on because you end up with a reduction in carpal height. There are another or there are numerous other devices that you can get, you can get devices that spare the third CMC J. Um And even when preparing for a uh an arthrodesis subsidy, some people prepare the CMC J and some people don't. I personally would cos I think once you deal with it, it's one less problem you're likely to have later on. It's important to tell patients that although they will lose all flexion extension and radio ulnar deviation because the Droge is OK. Here you'd expect them to keep um for arm rotation. Of course, a real problem comes when you've got distal radia on the joint, that's problematic as well. And you may find that this is something that can be dealt with separately again. What you need to be doing is your clinical examination working out. What is exactly the problem that this patient has? And I think probably what they may be getting out here is a Vaughan Jackson lesion. No, the Vaughan Jackson lesion initially was attributed to rheumatoid arthritis. I think most of us when we see him quite commonly now tend to be the osteo. And what is happening is you end up around your Dr UJ. As the arrow is pointing, you end up with sharp bits of osteophytes that are there. Now, if you were to get us an axial view of this area of the wrist, you'll see this is exactly where your extensor tendons are coming over. So for those who haven't heard of the vaugh and Jackson lesion before what happens is you end up with dropped fingers because what's happening is you're getting an atr rupture of the extensor tendons starting from the little and working their way radially. It's important to recognize this feature because when you want to deal with it, you're talking about tendon transfers to deal with the tendons themselves. But if you don't deal with this, then what will happen is you just end up with more attrition ruptures and you end up in the worst place. So when you, when you counsel patients about this, you have to tell them not only that we have to deal with the tendons, but we have to deal with the source and that can take various different forms. I'll, I'll go along the slides here. OK. So different forms, different ways that we can deal with this. Now, in your sort of common age group, which tends to be, they tend to be ladies, they tend to be older in their maybe eighties, nineties, low function, they start to get dropped fingers. A common procedure here would be a dry. So that would be an excision of the ulnar head and clearing out any of the osteophytes there. Once you do that, you repair the capsule over the area of where, where you've done the operation. So you've got a nice smooth bed, do your tendon transfers afterwards. And that should clear your problem and allows you to, to restore function in a younger age group, which we see probably more common. Now, they don't do very well with the dares procedure because by removing the ulnar head and doing nothing else to it, you end up destabilizing the articulation between the radius and the ulnar and you end up with impingement where your ulnar stump ends up impinging onto the radius. So for them, commonly, what we would do is a, a an ulnar head replacement and you only replace the ulnar head itself. There is a total dr UJ replacement that you can get, that's called a chequer and that's not, it's not a common implant, it is available. And for most people in the region who I know would probably use that if there's a failure of the total ulnar head replacement. And we tend to send them off to a specialist center to have that done. So it's not commonly done, but you can be aware that it is there as a as the back up. So commonly older patient group, you do a dares procedure. Some people who do a suave a Kanji which is where they fuse the ulnar head into the radius itself and then create a gap underneath. Um So take out the section just below the ulnar head after doing the fusion, but generally, it's accepted that tends to cause the same sort of issues as the dares procedure. So if you've got a younger age group, you go for a total ulnar head replacement. And that's the paper of the Vaughan Jackson lesion, which you don't need to uh read, but you do need to recognize and going back to the metac the locked metacarpals that we mentioned earlier. The difference is in the Vaughan and Jackson lesion. When you rupture the tendon, you will be able to passively extend that joint even though people will not be able to hold it up actively and they won't be able to actively move it. They'll, you, you can passively extend that joint questions. OK. Are we off screen sharing now? Yeah, I think you are, we're off screen sharing. Good. OK. Fine. Um Yeah, it's a bit of a whiz through and obviously that wasn't my presentation. So I hope I've covered most of the things there. Um um So yeah, it's a, it's a lot to go through on, on the arthritis of the hand. But I think it is worth recognizing the different conditions. And I'd say I'd say the main thing when you're, you're assessing your patients in clinic is really focus down on what joint is causing the problem because they will come in and their are, the wrists will be arthritic. The basal thumb will be arthritic. They'll have arthritis throughout the P I PS and D PS M CPS. You don't tend to see as often. Um And I don't think we covered a huge amount of the treatments there, but M CPS as well. You can either fuse them or you can use clastic arth arthroplasties in them as well. A a but I don't know, it's pretty, I don't know whether it's worth just maybe mentioning a couple of indications when you might consider um, wrist arthroplasty. I know we don't really offer it, but just because obviously it's offered in some regions, whether we're going to cover our wrist arthroplasty in a couple of weeks, that's fine. So I'll go through it a little bit, a little bit more then. But yeah, wrist arthroplasty is not that often. We tend to just fuse them. Yeah, I'll go into the reasons then. That's why. Yeah. Uh Shimon your mic is muted. I can you hear me now? Are you still running? Hi. Um, do we, um, what's the, um, workload distribution between us and plastics on this stuff? Um, I was chatting to a plastic surgeon a couple of weeks ago who was actually doing, um, well, more in the thumb way, but actually doing joint replacements, which I sort of assumed was an orthopedic only sport. No, it's quite mixed and it, it really depends. Hands are one of those interface ones where some orthopedic surgeons stay quite orthopedic, some do a bit more plasticky stuff. So some will do more tendon and nerve things. Um And then from the plastics as well, it really depends on what their interests are. So, a lot of plastics won't come down and do the basal thumb arthritis. It, it really depends institute to institute. So what we do in Cambridge, the workload distributions different to how knowledge is. So the bump, basal thumb replacements all stay under Ortho there. But then some of theirs will do Silastic replacements. It, it kind of depends on what fellowships people have done as well, whether they're more Ortho or more plastics. Cool. Thank you, Aaron. There's a, there's a question from the chat as well. Um When would you do a bowler versus a Derek's procedure? Um, in a younger patient? You don't do them that often? I did one last year. Um But it tends to be a younger patient when you're basically the, the problem with the dares is you, you, you destabilize, um, the Jews in a way that doesn't really matter in a 90 year old because functionally they, they kind of get on with it. A Bowers procedure is worth trying if you've got someone young and you don't wanna start subjecting them to arthroplasty on the head replacements just yet. So you can do that as a first stage. Um, whereas they know that it, it may keep the stability of the wrist, get rid of some of the problems that they've got. Um, but if that doesn't work, then you can then move on to things such such as on the head replacements afterwards. But um it, it basically comes down to function, low function. They get a dares if they're higher function and you start thinking about other things, but depending on the pattern of arthritis and, and um after sort of patient consultations. Ok. Fine. I'll hand you over to one of my colleagues.