What is it?
Wrist fusion (arthrodesis) is performed when there is severe destruction of the wrist joint secondary to arthritis. The operation is intended to stop movement of the wrist but will not prevent rotation of the forearm. The operation involves the removal of cartilage from the bones of the wrist so as to allow these bones to heal together as one. This will be aided by packing bone graft around the joints. This can be taken from the wrist area or from the top of the hip bone. The bones are then held in place by a titanium plate and screws.

Post-operative care
The operation is performed under general anaesthetic. Your hand will be placed in a bulky dressing, which includes a plaster to protect the operation. Movement of the hand and thumb-tip should be continued and you should perform normal light activities after the operation. Hand elevation is important to prevent swelling and stiffness of the fingers. You will stay in hospital for at least one night after your operation. Taking bone from the hip region will not harm the bone or nearby joints but the area can be quite sore for a few days.

Two weeks after the operation your plaster will be changed to a lighter splint. There obviously will be some swelling and bruising. You will need to keep the wrist protected within the splint until the X-Rays show that the bones are joining together (uniting). Unprotected heavy use will ruin the surgery. However, it is permissible to remove the splint in quiet situations and for skin care/washing.

An X-Ray will be taken at 6 weeks after the operation to assess progress. Thereafter you will be able to step up your activities as guided by common sense, using the splint in circumstances where you anticipate the wrist being knocked or strained. The bones will not have joined solidly until around 12 weeks after the operation.

Scar
You will have a scar on the back of the wrist. It will be somewhat firm to touch and tender for 6-8 weeks. Massaging it firmly with the moisturizing cream can help this.

Infection
This can occur after any operation and would be treated by antibiotics.

Nerve damage
Small nerves running in the region can occasionally be damaged during the surgery and either cause numbness on the back of the hand or form a painful spot in the scar (neuroma). The latter complication may require a further operation to correct it.

Delayed or non- union
Union of the bone can sometimes be slower than expected. It cannot be predicted but over-use of the arm can contribute. If the bone fails to unite (non-union), the surgery has to be repeated.

Stiffness
About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (CRPS). This problem cannot be predicted but can be contributed to under-use of the arm and failure to do the exercises. It is treated with physiotherapy.

Nerve compression
The swelling in the region can cause pressure on local nerves resulting in pain and pins&needles in the fingers. This may need a releasing operation soon after the fusion operation.

Ulnar Nerve Entrapment is otherwise knows as Cubital Tunnel Syndrome

What is it?
The ulnar nerve provides sensation to the little and ring fingers and activates many of the small muscles in the hand. The nerve passes behind the inner aspect of the elbow where it can be felt. This area is often referred to as the “funny bone”. At the elbow, it runs through a tight tunnel, the cubital tunnel.
In some people, this tunnel is too tight for the nerve. Mild pressure causes occasional “pins and needles”, especially at night. Severe pressure causes the fingers to become numb and the muscles of the hand waste away which causes weakness and difficulty in straightening the fingers.
The nerve gradually withers if the condition is not treated. This causes permanent loss of sensation and wasting of hand muscles which cannot be relieved by surgery.

What can be done?
Often nerve tests are carried out to confirm the diagnosis, and to give an idea of how severe the compression is. This is important as it will give an indication of the chances of success with surgery.
Correction of this problem involves cutting the roof of this tunnel, to relieve the pressure on the nerve. Occasionally the nerve is transferred in-front of the funny bone at the time of surgery to avoid further nerve damage and instability.

Surgery is usually carried out with a general anaesthetic, and as a day case. You will have a small curved scar on the inside of your elbow. Sutures used are usually dissolvable. Occasionally non-dissolvable will be used.

Post-operative care
Local anaesthetic is injected around the site of surgery and therefore this area and possibly some of the fingers will remain numb for up to ten hours after surgery.
You will be discharged with a bulky dressing. Occasionally a Plaster of Paris will be used. These will be removed at 2 weeks. Sutures, if required, will be removed at 2 weeks.
Finger and hand movement should be started immediately after surgery. You should perform normal light activities after the operation, as pain allows.
Timing of your return to work is variable according to your occupation and you should discuss this. If improvement in symptoms does occur, it can take an extended period of time. This can be as much as a year post-operatively.

Scar
You will have a scar on the inside of the elbow. This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with the moisturizing cream.

Infection
This can occur after any operation and would be treated by antibiotics.

Neuroma
A small nerve running in the region can be damaged during the surgery and form a painful spot in the scar (neuroma). This complication is very rare but may require a further operation to correct.

Stiffness
About 5% of people are sensitive to hand/elbow surgery and their arm may become swollen, painful and stiff after an operation (Complex regional pain syndrome). This problem cannot be predicted but will be watched for afterwards and treated.

Outcome
Improvement after surgery can be modest, particularly in patients who have more severe compression. Muscles that have wasted rarely recover. Recovery of feeling is slow and often incomplete. The operation is mainly intended to prevent further deterioration.

What is it?
A common cause of wrist pain is damage or degeneration of the Triangular Fibrocartilagenous Complex (TFCC). The TFCC sits on the end of the ulna bone at the wrist and has two roles. It helps to hold the radius and ulna bones together. It also transmits about one third of force passing across the wrist from the hand to forearm. TFCC problems can occur independently or in combination with those affecting the distal radio-ulnar joint (DRUJ). Combinations may result from wrist fractures.

When the TFCC is torn or damaged, it is usual to get pain in the wrist. This occurs particularly during twisting movements. Patients also may experience clicking or popping sensations during movement. Often a MRI scan will be performed to help with the diagnosis.

What can be done?
Arthroscopy involves placing a small telescope into the wrist joint. The telescope is inserted into two to four areas on the back of the wrist. The procedure is primarily for diagnosis. Often it can be combined with the removal of loose fragments or trimming of cartilage tears. If an abnormality is found which requires more extensive surgery, I will not proceed to this “open” operation unless this has previously been discussed with you.

The operation is performed under general anaesthetic but you can usually be discharged on the day of surgery. Return to your normal activities after the operation can be variable, especially if additional procedures have been performed. This will all be discussed with you.

Occasionally the cause of the damage to the TFCC is due to the ulna bone being too long, thus leading to squashing of the TFCC against the wrist during movement. If this is the case, then shortening the ulna bone is a good option in order to take the pressure off the TFCC. This will be discussed in further detail if relevant.

Majority of tears to the TFCC occur in the area where there is no blood supply, and so the only option is to remove the torn area. Less commonly the tear occurs in the area of the TFCC where there is a blood supply. This can therefore be repaired. This can be done either through the arthroscope or done as an open procedure. You will almost certainly be placed in a above elbow Plaster of Paris for a period of time after surgery, and rehabilitation can take up to 6 months.

Scar
You will have 2-3 small scars on the back of the wrist. These will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

Nerve damage
Nerves running in the region can be damaged during the surgery. This would cause the formation of a painful spot in the scar (neuroma) or a small area of loss of sensitivity on the dorsum of the hand. This complication is rare (4%) but may require a further operation to correct.

Infection
Superficial infection can occur after any operation and would be treated with antibiotics. Deeper infection, involving the joint is very rare.

Tendon damage
Tendons running to the fingers can be damaged or cut. This is very rare (1%) but would require further surgery to correct.

Stiffness
About 5% of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (complex regional pain syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

As noted above rehabilitation can take 6 months to reach a plateau after surgery to this area.

What is it?
The tendons that bend your fingers run through a tunnel or sheath. Trigger finger is caused by a thickening on the tendon, which causes it to catch as it runs in and out of the sheath. You can often feel this swelling in the palm as you move the finger. Patients complain of pain in the palm at the base of the affected finger and episodes of the finger being stuck, bent down. This can be relieved by pushing the finger out straight, causing a snap which can be painful. Patients often wake in the morning with the finger stuck down.

What can be done?
There are two ways of treating the problem.

1. Steroid Injection – A small amount of steroid is injected around the tendon. This flattens out the swelling on the tendon allowing it to glide freely in and out of the sheath once more. A single injection is all that is needed in 50% of cases. A further 25% will respond to another injection (i.e. three-quarters of cases can be successfully treated in this way). The steroid injection does not work immediately. It causes no general side-effects but occasionally the skin around the injection-site can be made a little thinner. Thus two injections are the maximum.
2. Surgery – This is needed if the steroid injections do not work. It involves a small procedure usually under local anaesthetic. A slit is made in the mouth of the sheath to prevent the tendon catching at this point. The condition can occur in the affected or any other finger again in the future. Surgey is more common in patients with multiple trigger fingers and in Diabetic patients.

Post-operative care
After the operation, you will be in a big bandage, but the fingers will be free to move. It is important to move all fingers and thumb straight away, as well as keep the hand raised (above the level of your heart) for at least 72 hours to help with swelling and stiffness.

This bulky dressing can be taken down at 72 hrs and a light sticky dressing applied to the wound. There will initially be some swelling and bruising, however, if you have any worries contact your G.P (i.e increasing pain, swelling, redness) The stitches are usually dissolvable. You will be reviewed in the Orthopaedic clinic at 2- 6 weeks. Timing of your return to work is variable according to your occupation and you should discuss this.

Infection
Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar on the palm. This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

Stiffness
About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex regional pain syndrome).This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Nerve
The nerves running to the fingers can be damaged during the surgery and cause numbness in part of the finger. This is very rare.

Recurrence
As mentioned above, the triggering can recur. However this is rare.

 

What is it?
The trapezium is one of the eight carpal bones and lies at the base of your thumb. Arthritis in this joint is very common. It is a progressive condition that leads to increasing stiffness and deformity in the thumb. Pain is common especially in ladies over the age of 50yrs. This arthritis often runs in families.

What can be done?
The methods for relieving discomfort in any arthritic joint, whether it is the hip, knee, shoulder or base of the thumb are the same. I call this the therapeutic ladder. Start at the bottom with the simplest treatment and work up the ladder as symptoms require:-

(i) activity modification, (ii) pain-killers, (iii) splints, (iv) steroid injections and (v) surgery.

Surgery is the only definitive treatment for persistent symptoms. The usual indication is pain and consequent functional difficulties. There are several options available and some controversy as to which is best. I will discuss all with you before a decision is made.

1. Joint stabilisation using a tendon is only suitable for a minority of patients who have an unstable joint but little damage to the joint surfaces. This would be in younger patients with little or no evidence of arthritis on an X-Ray.
2. Trapeziectomy involves the complete removal of the trapezium bone. It is mandatory if the joints both above and below the trapezium are arthritic. This is my preferred treatment in most patients. I stabilise the base of the thumb with a cuff of tissue.
3. Trapeziectomy with ligament reconstruction is performed by some surgeons. There is no evidence that this improves outcome.
4. Arthrodesis (fusion) is reserved for younger patients who are involved in heavy manual jobs, or in advanced cases with very deformed thumbs. It has the disadvantage of stiffening the thumb and is contraindicated if there is any wear beneath the trapezium.
5. Joint Replacement. This is used more rarely. The ends of the bones which are rubbing are removed. The gap is replaced with a prosthetic joint. The long-term results of this procedure is not known. It however may be of use in a younger patient with significant arthritis. If the replacement fails at a later stage there is a good salvage option of a Trapeziectomy.

Post-operative care
My standard procedure is a simple trapeziectomy and stabilisation. The operation is carried out either under a peripheral block or a general anaesthetic supplemented by local anaesthetic. You may stay in hospital for one night after the operation.

Hand elevation is important to prevent swelling and stiffness of the fingers. Your hand will be placed in a bulky dressing, which includes a plaster to protect the operation. Movement of the hand and thumb-tip should be continued and you should perform normal light activities after the operation.
Between one and two weeks after the operation your plaster will be changed to a lighter splint. Physiotherapy rehabilitation will start at this stage. Sutures are usually dissolvable. 6 weeks after surgery, you will be able to take off your splint during the day but it is worth wearing it for protection at night for a further two weeks or so.

Possible complications are as follows:

Scar
You will have a scar on the back of the thumb. This will be somewhat firm to touch and tender for 6-8 weeks. Massaging it firmly with moisturizing cream can help this.

Infection
This can occur after any operation and would be treated by antibiotics.

Stiffness
All patients will have some stiffness after surgery. This will be treated by the therapists during your rehabilitation. About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex Regional Pain Syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Neuroma
A small nerve running in the region can occasionally be damaged during the surgery and either cause numbness on the back of the thumb or form a painful spot in the scar (neuroma). The latter complication may require a further operation to correct it.

Pain
Pain is not uncommon after surgery, but would normally settle over the first week or two. Occasionally this can be prolonged and can be due to inflammation around a tendon in the wrist. This will usually settle, a steroid injection may help.

Function Recovery from this operation can be slow and it can often be 6 months before you can resume heavy activities. You will probably be able to drive a car after 8-12 weeks as long as you are comfortable and you have regained full finger movements. Timing of your return to work is variable according to your occupation and you should discuss this. Success rate from a Trapeziectomy is in the order of 70-80%.

What is it?
Tennis elbow (lateral epicondylitis) is present in 1% to 3% of people. It is most frequent between 40 and 50 years of age and in the dominant arm. The cause is poorly understood but it is thought to be due to a micro-injury at the origin of the extensor muscles (common extensor origin) on the outer side of the elbow. These muscles normal actions are to lift up the wrist and fingers. Whilst some regard overexertion as a causative factor, there is little evidence that it is commoner among manual workers (or tennis players !).

Tennis elbow causes pain on the outside of the elbow that often radiates to the forearm. The pain is usually aggravated by use of the arm, particularly lifting. A positive test is pain when resisting wrist and middle finger extension.

What can be done ?

Many treatments have been described; many are a waste of time!

Steroid injections can result in short-term relief of symptoms but studies have questioned the success in the long term. A maximum of 2 injections is my limit over a treatment period (6 months to a year). Risks of injection include pain, infection, skin discolouration and thinning of the fat and skin over the area.

Other treatments include anti-inflammatory drugs, physiotherapy, acupuncture, splints/clasps, and increasing the size of the handle on sports rackets. It is my opinion that it is worth trying all these modalities during a treatment course if the symptoms are not settling. Studies have not shown any clear benefit from any particular type of treatment.

The natural history of tennis elbow is a slow (12-18 months) resolution of the problem for the majority of people. Treatments discussed above probably do not change the natural course of the problem, but may help in offering some relief of symptoms for a period of time.

Stem Cell is a technique where blood (bone marrow) is taken from the pelvic bone and injected around the site of pain. It is thought to work as an anti-inflammatory. This is a newish technique and the longterm results are not fully known, however success rates appear to be 60-70%.

Shockwave therapy is a non-invasive technique, which stimulates the bodies’ own healing process. Success appears to be at around 60-80%. This procedure is useful in selected patients. Further information can be sought at www.shockwavesouth.co.uk

Surgery is considered in patients with severe or chronic tennis elbow and little or no response to treatment. This involves release of the common extensor origin through a short incision on the side of the elbow. This does not cause a long-term weakening of the arm once the muscle has healed. Success rates appear to be about 80%, however post operative rehabilitation can be prolonged.

Post-operative care
The operation is usually performed under general anaesthetic as a day-case. The elbow will be dressed with a supportive dressing that permits movement and light hand use. Occasionally you will be put in a Plaster of Paris for 2 weeks.Your stitches will usually be dissolvable. Timing of your return to work is variable according to your occupation and you should discuss this.

Nerve damage
Nerves running in the region can be bruised or damaged during the surgery and form a painful spot in the scar (neuroma) or numbness down the side of the forearm.

Infection
Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar on the elbow. This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

Function
The symptoms and your function will recover slowly and it will probably be six months before you will get your final result. Success rates for surgery are in the order of 60-80%.

What is it?
The scaphoid bone is the most common of all the small bones of the wrist to be fractured. Fractures are usually caused by falls onto the outstretched hand.

Most fractures (around 90%) will heal if immobilized in a Plaster for a sufficient period (6-12 weeks on average). This is lower if the fracture is displaced. However, some fractures do not unite (heal). Generally, the nearer the bottom of the scaphoid (proximal pole), the poorer the blood supply and the less likely it is to heal. Some proximal pole fractures only have a 20-30% union rate. If you are a smoker, then the risk of non-union is much higher due to the negative affect of smoking on the blood supply to the scaphoid.

Although some patients with a scaphoid non-union have few symptoms, most experience some discomfort and stiffness. If left untreated, the natural history is the almost certain development of wrist osteoarthritis causing increasing symptoms and disability of pain and stiffness.

What can be done?
First confirmation will be needed that the scaphoid has not heald. This will be done with X-rays and usually a CT and/or a MRI scan. These scans give a better idea of the situation in the scaphoid bone with regards to the position, blood supply, and whether any healing has taken place or not.

The only real treatment is surgery. This will usually be done under a general anaesthetic and may require a one night stay in hospital.You will have a scar either over the front or back of the wrist, depending where in the scaphoid the non-union is. You may well have a scar over the pelvis for the harvesting of bone graft. This will all be discussed with you before surgery.

The aim of the treatment of the non-united scaphoid is to heal the bone and restore its shape. Surgery therefore involves (i) freshening of boneends with removal of scar tissue and bone fragments (ii) correction of any displacement and collapse, (iii) insertion of a bone graft from the hip or wrist, to maintain the correction and (iv) stabilisation of the bone and graft with a screw. When the cause of non-union is poor blood supply, a vascularised bone graft (connected to its blood supply) can be transferred from the radius. This may give a slightly higher chance of union occuring, but this is debatable.

After the operation, your hand will be placed in a bulky dressing, which includes a plaster to protect the operation. Hand elevation is important to prevent swelling and stiffness of the fingers. Movement of the hand and thumb-tip should be continued and you should perform normal light activities after the operation. If a graft has been taken from the pelvis, this can be quite uncomfortable for a period of time ( a day or two).

Six weeks after the operation your wrist will be X-Rayed. If all is well, you can begin to take off your splint during the day for initially light use. However, it is worth wearing it for protection or at night for at least another six weeks after the operation. Physiotherapy will now be started and aimed at recovering wrist movements.

If all goes well, your fracture should unite over a 6-8 week period but it can often be 3 months before you can resume heavy activities. The fracture can, however, take longer to heal and your progress will be judged by examination and X-Ray. You may need to be patient. Also the above times are only a rough estimate.

Non-union
There is about a 20 – 30 % chance of the fracture failing again to unite. This is significantly higher if you are a smoker.

Arthritis
Surgery attempts to prevent the development of arthritis. However, damage may have occurred during the time the fracture was ununited. Therefore it cannot be guaranteed that arthritis will not occur later even if the operation succeeds in healing the fracture.

Scar
You will have a scar on the wrist, which will be somewhat firm to touch and tender for 6-8 weeks. You can ease the tenderness by massaging the area firmly with moisturizing cream.

Infection
This can occur after any operation and would be treated by antibiotics.

Stiffness
You are likely to lose some movement at the wrist if you have not already done so. About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex Regional Pain Syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Neuroma
A small nerve running in the region can occasionally be damaged during the surgery and either cause numbness in the palm or form a painful spot in the scar (neuroma). The latter complication may require a further operation to correct it.

What is it?
Golfer’s elbow (medial epicondylitis) is most frequent between 30 and 50 years of age. It is more common in men.The cause is poorly understood but it is thought to be due to micro-tears or degeneration at the origin of the flexor muscles (common flexor origin) on the inner side of the elbow. The damage is typically related to excess or repetitive stress, especially forceful wrist and finger motions (only 10% patients are golfers!).

Golfer’s elbow causes pain on the inner aspect of the elbow that often radiates down the forearm.There can be associated numbness in the hand (little and ring finger) due to irritability of the ulna (funny bone) nerve behind the epicondyle. A positive provocative test to help diagnose this, is pain on the inner aspect of the elbow when trying to flex the wrist against resistance. This is due to the usual function of these affected flexor muscles being to flex the wrist and fingers.

What can be done?
Many treatments have been described;

Steroid injections can result in short-term relief of symptoms but studies have questioned the success in the long term. A maximum of 2 injections is my limit as more can cause skin problems.Other treatments include anti-inflammatory drugs, physiotherapy techniques, and splints. Probably the most effective treatment is to stop/cut back on the activities which cause the symptoms. The natural history of golfer’s elbow is a slow (12-18 months) resolution of the problem.

Stem Cell is a technique where blood (bone marrow) is taken from the pelvic bone and injected around the site of pain. It is thought to work as an anti-inflammatory. This is a newish technique and the longterm results are not fully known, however success rates appear to be 60-70%.

Shockwave therapy is a non-invasive technique, which stimulates the bodies’ own healing process. Success appears to be at around 60-80%. This procedure is useful in selected patients. Further information can be sought at www.shockwavesouth.co.uk 

Surgery is considered in patients with severe or chronic golfer’s elbow and little or no response to treatment. This involves release of the common flexor origin through a short incision on the side of the elbow, removal of damaged tissue and the prominent epicondyle bone. Occasionally the ulna nerve will also be released. This does not cause a long-term weakening of the arm once the muscle has healed.

Post-operative care
The operation is usually performed under general anaesthetic as a day-case. The elbow will be dressed with a supportive dressing that permits movement and light hand use. Occasionally you will be put in a Plaster of Paris for 2 weeks.Your stitches will usually be dissolvable. Timing of your return to work is variable according to your occupation and you should discuss this.

Nerve damage
Nerves running in the region can be bruised or damaged during the surgery and form a painful spot in the scar (neuroma) or numbness down the side of the forearm.

Infection
Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar on the elbow. This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with the moisturizing cream.

Function
The symptoms and your function will recover slowly and it will probably be six months before you will get your final result. Success rate of surgery is in the order of 60-80%.

Stiffness
About 5% of people are sensitive to upper limb surgery and their arm may become swollen, painful and stiff after an operation (Complex regional pain syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

What is it?
Ganglions represent 50-70% of all soft tissue lumps in the hand. These cysts contain thick clear fluid and are usually attached to the lining of an underlying joint (capsule) or tendon (sheath) by a tail. A good analogy is a blown-up party ballon, full of gelatinous goo, not tied at the bottom but attached to the joint or tendon. They are most common in women (up to 3 times more than in men) and 70% occur in the late teens and young adulthood.

The most common sites are (i) the back of the wrist, (ii) the back of the finger-tip (mucous cyst), (iii) the tendon sheath on the base of the finger and (iv) the front of the wrist.

The cause of ganglions remains unknown. The majority can be left alone if they are causing no pain or functional problem, as they are harmless. They can sometimes disappear by themselves (some reports quote up to 50%). It is only rarely obligatory to treat a ganglion, for example if it is pressing on a nerve.

What can be done ?
A number of methods are used for treating ganglions including (i) rupture by pressure or hitting them (not recommended), (ii) aspiration – drawing the fluid off with a needle, followed by an injection with substances such as steroids, (iii) surgery. Surgery involves removal of both the ganglion and the tail. This can be done under a general or local anaesthetic. The site and size of the ganglion will influence which type of anaesthetic we advise. In some instances ganglions on the back of the wrist can be removed with an arthroscope (key-hole surgery). I will discuss with you the most relevant treatment for your ganglion.

Post-operative care
After the operation, you will be in a big bandage, but the fingers will be free to move. It is important to move all fingers and thumb straight away, as well as keep the hand raised (above the level of your heart) for at least 72 hours to help with swelling and stiffness. This bulky dressing can be taken down at 3-5 days after surgery and a light sticky dressing applied to the wound. There will initially be some swelling and bruising, however, if you have any worries contact your G.P (i.e increasing pain, swelling, redness). Occasionally a Plaster of Paris or thick dressing will be used and left on for a full 2 weeks.

Stitches are usually dissolvable. You will be reviewed in the Orthopaedic clinic at 2-6 weeks. Timing of your return to work is variable according to your occupation and you should discuss this.

Infection
Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar that will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

Stiffness
About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex regional pain syndrome).This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Recurrence
Between 20 and 30% of ganglions return after being removed surgically. The recurrence after aspiration and injection is higher and reported as between 40 and 80%.

Nerves
Nerve damage can occur during your surgery which results in either a painful spot in the scar (neuroma) or some loss of feeling in the hand. This complication is very rare but may require a further operation to correct.

Artery
Ganglions on the front of the wrist are close to major arteries, which can be damaged.

Nail
Ganglions on the tip of the finger often cause a groove in the nail. It usually settles after the operation but occasionally it can persist after or result from the surgery.

What is it?
Loss of the cartilage in the joints of the hand leads to pain, deformity and functional loss. The cause of this loss and subsequent arthritis can be due to:-

• Trauma – where the smooth joint surfaces have been damaged by injury or infection, and then have worn.
• Osteoarthritis – where the joint surfaces have decayed through natural wear and tear.
• Inflammatory arthritis – where the cartilage is attacked by cells that line the joint in “auto-immune” conditions such as rheumatoid arthritis.

What can be done?
The methods for relieving pain in any arthritic joint, whether it’s the hip, knee, spine or hand, is always the same. This is the therapeutic ladder.

1. Activity modification
2. Pain killers
3. Splints
4. Physiotherapy
5. Steroid injections
6. Surgery

Treatment will commence at some point on the therapeutic ladder depending on the severity of the symptoms.

Surgery is the only definitive treatment for persistent problems but no operation restores normal function. There are a number of operations available to your surgeon but the choice is complex.

Cheilectomy: The bony lumps around the joint are smoothed off, and the joint washed out.

Synovectomy: Applicable only to early cases of inflammatory arthritis where there is considerable swelling (synovitis). It is suitable only if the joint is reasonably mobile and if the joint surfaces have not been badly damaged.

Arthroplasty: Involves removal of the joint and its replacement by one of a number of implants. It is most suited to a reasonably stable and mobile but painful joint in patients who do not need high power levels for work or play. There are two types of implants available and these will be discussed with you by the surgeon.

Arthrodesis (fusion): Involves removal of the joint and joining of the two bones together by either metal wires or screws and plates. The joint is generally set in a slightly bent position for best function. Although the operation abolishes movement at this (and only this) joint, the resulting fusion is very tough. This option is chosen when (i) joints are badly damaged (ii) there is already little movement, (iii) there is damage to nearby ligaments and tendons (iv) a previous arthroplasty has failed and (v) when heavy manual use is anticipated.

Rehabilitation
Activity will be restricted for a minimum of twelve weeks after most of these operations at which time bones have usually united and soft tissues have recovered normal strength. Your surgeon or therapist will, however, modify splinting and exercises depending on your progress.

Splints are made to rest and protect the operation as well as to maintain alignment and position. These should be removed to allow wound care and for exercise of the joint after surgery. Arthrodesed joints are not intended to be moved and will be protected until united. The splint can generally be removed when sitting quietly but should always be worn at night or when the hand is liable to be knocked or strained.

Exercise is necessary to maintain mobility in neighbouring joints and to recover movement in joints after synovectomy or arthroplasty. You will be advised by a Hand Therapist.

There are a number of potential complications of surgery:

Scar
You will have a scar. This will be somewhat firm to touch and tender for 6-8 weeks. Massaging it firmly with moisturizing cream can help this.

Infection
This can occur after any operation and would be treated by antibiotics. Very rarely the metal or prosthesis will have to be removed if deep infection is noted.

Stiffness
Generalised joint stiffness is common after surgery, and will be reviewed and treated by the Hand Therapist. About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex Regional Pain Syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Neuroma
A small nerve running in the region can occasionally be damaged during the surgery and either cause numbness or form a painful spot in the scar (neuroma). The latter complication may require a further operation to correct it.

Function Recovery from this operation can take time. Return to work is variable according to your occupation and you should discuss this.