Archives: Education

Welcome to First Choice Physical Therapy’s resource with respect to recovery from Trochanteric Bursitis Surgery.

The bump of bone on the outside of the hip bone is called the greater trochanter. A fluid-filled sac, called a bursa, lies next to the greater trochanter. When the bursa in this area becomes thickened and inflamed, surgery may be needed to remove the bursa and to reduce tension on the tendon that glides over it.

This guide will help you understand:

• what the surgeon hopes to achieve
• what happens during the procedure
• what to expect during your recovery

Why did my trochanteric bursa become a problem?

Where friction must occur between muscles, tendons, and bones, there is usually a bursa. A bursa is a thin sac of tissue that contains a bit of fluid to lubricate the area where the friction occurs. The bursa is a normal structure, and the body will even produce a bursa in response to friction.

Bursa

The bursa next to the greater trochanter is called the greater trochanetric bursa. The gluteus maximus is the largest of three gluteal muscles of the buttock. This muscle spans the side of the hip and joins the iliotibial band. The iliotibial band is a long tendon that passes over the bursa on the outside of the greater trochanter. It runs down the side of the thigh and attaches just below the outside edge of the knee.

Greater Trochanetric Bursa

Walking causes the gluteus maximus to pull on the tendon. If the tendon is tight, it will start to press and rub against the greater trochanteric bursa. It is unclear why the tendon becomes tight. The rubbing causes friction to build in the greater trochangeric bursa, leading to irritation and inflammation in the bursa.

Friction can also start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on banked (slanted) surfaces.

What does the surgeon hope to achieve?

The primary goal of the surgical procedure for this condition is to remove the thickened bursa, to remove any bone spurs (knobby outgrowths) that may have formed on the greater trochanter, and to relax the large tendon of the gluteus maximus. Some surgeons prefer to simply lengthen the tendon a bit, and some prefer to remove a section of the tendon that rubs directly on the greater trochanter. Both procedures give good results by taking pressure off the bursa.

Preparation

What do I need to do before surgery?

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The amount of time patients spend in the hospital varies. You will need to stay until your medical condition has stabilized and you can safely use crutches or a walker.

What happens during the operation?

Before surgery begins, you will be given anesthesia. There are two basic options: a general anesthetic (one that puts you to sleep) or a regional block (one that numbs the area to be worked on). For hip surgery the most common type of regional anesthetic available is either a spinal block or an epidural block. Both of these regional blocks numb the body from the waist down.

If you choose to have a regional anesthetic, you may also be given medication to allow you to drift off to sleep if you are anxious. Either type of anesthetic can be used to perform this procedure. Be sure to discuss this with your surgeon.

To begin the surgical procedure, an incision is made in the side of the thigh over the area of the greater trochanter. The surgeon continues the incision through the tissues that lie over the bursa.

The tendon is then split so that the trochanteric bursa and the bone of the greater trochanter can be seen. The tendon is split lengthwise. The bursa sac is removed. The bone of the greater trochanter is smoothed, and any bone spurs are removed.

At this point the tendon may be lengthened or released and not repaired. If the surgeon chooses not to repair the tendon, scar tissue will eventually heal the loose edges of the tendon. As it heals, it will be looser than before surgery, so it won’t rub on the greater trochanter quite so much. The skin is closed with stitches.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following surgery for trochanteric bursitis include:

• anesthesia complications
• thrombophlebitis (DVT)
• infection
• nerve or blood vessel injury
• failure of the operation

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Any operation carries a small risk of infection. This procedure is no different. You will probably be given antibiotics before the operation to reduce the risk of infection. If an infection occurs you will most likely need antibiotics to cure the infection. You may need additional operations to drain the infection if it involves the area around the hip.

Nerve or Blood Vessel Injury

Several smaller nerves travel in the area where the surgery is performed. It is possible to injure the nerves during surgery, but this is extremely unlikely during this type of surgery. Nerve problems may well be temporary if the nerves have been stretched by retractors holding them out of the way. It is rare to have permanent injury to the nerves, but it is possible.

Failure of the Operation

This operation may not be successful. All operations have a chance of failure, and this operation is no different. Even after going through the procedure, you may continue to have pain from trochanteric bursitis. This is clearly not the expected outcome, and the majority of patients are relieved by the procedure.

What happens after surgery?

After surgery, your hip will be covered with a padded dressing. Try to avoid a lot of activity within the first week after surgery. Support your outer hip with a pillow when you sit or recline. During this time, you may also be instructed to use crutches to keep from placing weight on your hip while you stand or walk.

Keep the dressing on your hip until you return to the surgeon. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery. If your surgeon chooses to use dissolvable stitches, these will not need to be removed.

Portions of this document copyright MMG, LLC.

What should I expect during my recovery?

Rehabilitation after surgery can be a slow process. Although time required for recovery is different for each patient, you will probably need to attend Physical Therapy sessions for several weeks at First Choice Physical Therapy, and you should expect full recovery to take several months. Getting the hip moving as soon as possible is important. However, this must be balanced with the need to protect the healing muscles and tissues.

Our Physical Therapist may use ice and electrical stimulation treatments during your first few therapy sessions to help control pain and swelling from the surgery. Our Physical Therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

Our treatments include range-of-motion exercises and gradually work into active stretching and strengthening. Active therapy usually starts two to three weeks after surgery. Our Physical Therapist may start you on light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about four weeks we may start doing more active strengthening. Exercises focus on improving the strength and control of your buttock and hip muscles. Our Physical Therapist will help you retrain these muscles to keep the ball of the femur moving smoothly in the socket.

Some of the exercises you’ll do are designed get your hip working in ways that are similar to your work tasks and sport activities. Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your hip. Before your Physical Therapy sessions at First Choice Physical Therapy end, our Physical Therapist will teach you a number of ways to avoid future problems.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

A hip arthroscopy is a procedure where a small video camera attached to a fiber-optic lens is inserted into the hip joint to allow a surgeon to see the joint and do work on the joint without making a large incision. Arthroscopy is now used to evaluate and treat orthopedic problems in many different joints of the body. While not as common as arthroscopy of the knee and shoulder, hip arthroscopy is used to evaluate and treat certain problems affecting inside the hip joint and the area just outside the hip joint.

This guide will help you understand:

• what parts of the hip are treated during hip arthroscopy
• what types of conditions are treated with hip arthroscopy
• what to expect before and after hip arthroscopy
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the hip are involved?

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone. The thighbone itself is called the femur, and the ball on the end is called the femoral head. The ball and socket arrangement gives the hip a large amount of motion needed for daily activities such as walking, squatting, and climbing stairs.

The surfaces of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. Articular cartilage is a tough, slick material that allows the surfaces to slide against one another without damage.

The gluteus maximus is the largest of three gluteal muscles of the buttocks. The gluteus maximus muscle spans the side of the hip and joins to the iliotibial band. The iliotibial band is a long tendon that passes over the bursa on the outside of the greater trochanter. It runs down the side of the thigh and attaches just below the outside edge of the knee. The other two buttocks muscles, the gluteus medius and the gluteus minimus, attach to the greater trochanter. These muscles are known as abductors because they function to pull the lower leg away from the body; a motion that is called abduction. These muscles can be torn where they attach to the greater trochanter causing pain and weakness as well as a snapping sensation. The acetabular labrum is a fibrous rim of cartilage around the hip socket that is important in normal function of the hip. It helps keep the head of the femur (thigh bone) inside the acetabulum (hip socket). It provides stability to the joint.

Wherever friction must occur between muscles, tendons, and bones, there is usually a bursa. A bursa is a thin sac of tissue that contains a bit of fluid to lubricate the area where the friction occurs. The bursa is a normal structure, and the body will even produce a bursa in response to friction in an area. The bursa next to the greater trochanter is called the greater trochanteric bursa.

The hip joint is a synovial joint.  Synovial joints are enclosed by a ligamentous capsule and contain a fluid, called synovial fluid, that lubricates the joint.  The water-tight joint capsule is formed by ligaments, connective tissue and synovial tissue.  When the joint capsule is filled with sterile saline and is distended, the surgeon can insert the arthroscope into the pocket that is formed, turn on the lights and the camera and see inside the hip joint as if looking into an aquarium. The surgeon can see nearly everything that is inside the hip joint including: (1) the joint surfaces of the femoral head and acetabulum (2) the acetabular labrum and (3) the synovial lining of the joint.

The arthroscope can also be inserted into the greater trochanteric bursa. This allows the surgeon to see the attachment of the gluteus medius muscle and the inside of the bursa.

What does my surgeon hope to accomplish?

When hip arthroscopy first became available it was used primarily to look inside the hip joint and make a diagnosis. Today, hip arthroscopy is used in performing a wide range of different types of surgical procedures on the hip joint including confirming a diagnosis, removing loose bodies, removing or repairing a torn labrum, debriding excess inflamed bursa tissue, repairing a tear in the gluteus medius tendon and fixing fractures of the joint surface.

Your surgeon’s goal is to fix or improve your problem by performing a suitable surgical procedure; the arthroscope is a tool that improves the surgeon’s ability to perform that procedure with minimal invasiveness. The arthroscope image is magnified and allows the surgeon to see better and clearer, and also allows the surgeon to perform surgery using much smaller incisions. Smaller incisions result in less tissue damage to normal tissue and can shorten the healing process.  It should be remembered, however, that the arthroscope is only a tool. The results that you can expect from a hip arthroscopy depend on what is wrong with your hip, what can be done inside your hip to improve the problem and your effort at rehabilitation after the surgery.

What do I need to know before surgery?

You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, be sure and talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You will also need to spend time prior to the surgery with a Physical Therapist at First Choice Physical Therapy. Preoperative Physical Therapy allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. Your Physical Therapist will check your current pain levels, and will measure the movement and strength of each hip. It also allows your Physical Therapist to see your natural alignment and ability to perform certain activities such as squatting and walking prior to having your surgery.

Observing these things ahead of time can greatly assist your Physical Therapist in prescribing the correct exercises post-surgically that address any alignment issues you may have. This will, in turn, help prevent a recurrence of your problem.

A second purpose of the preoperative visit is to prepare you for what you can expect after surgery. Your Physical Therapist will teach you how to walk safely using crutches or a walker and you will begin to learn some of the exercises you will use during your recovery.

On the day of your surgery, you will probably be admitted for surgery early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during hip arthroscopy?

Before surgery you will be placed under either a general anesthesia or a type of spinal anesthesia. A special operating room table called a traction table will be used.  The hip joint is very tight with little space between the ball and the socket. By applying traction, the surgeon is able to increase this space and allow the arthroscope to be inserted into that space. The end of the arthroscope will be moved about in this space to look throughout the joint. Sterile drapes will be placed to create a sterile environment for the surgeon to work. There is a great deal of equipment that surrounds the operating table including the TV screens, cameras, light sources, and surgical instruments.

The surgeon begins the operation by making two or three small openings into the hip, called portals. These portals are where the arthroscope and surgical instruments are placed inside the hip. Care is taken to protect the nearby nerves and blood vessels. A small metal or plastic tube (or cannula) will be placed through one of the portals to inflate the hip with sterile saline.

The arthroscope is a small metal fiber-optic tube.  It is about 1/4 inch in diameter (slightly smaller than a pencil) and about seven inches in length. The fiber-optics inside the metal tube of the arthroscope allow a bright light and TV camera to be connected to the outer end of the arthroscope. The light shines through the fiber-optic tube and into the hip joint. A TV camera is attached to the lens on the outer end of the arthroscope. The TV camera projects the image from inside the hip joint onto a TV screen next to the surgeon. The surgeon actually watches the TV screen (not the hip) while moving the arthroscope to different places inside the hip joint and bursa.

Over the years since the invention of the arthroscope, many very specialized instruments have been developed to perform different types of surgery using the arthroscope and to see what is going on while the instruments are being used. Today, many surgical procedures that once required large incisions for the surgeon to see and fix the problem can be done arthroscopically  with much smaller incisions. For example, simple removal of a torn labrum or a loose body can be done using two or three small 1/4 inch incisions. More extensive surgical procedures may require larger incisions. Your surgeon may decide during the procedure that the problem requires a more traditional open type operation. If this has been discussed before the operation the surgery may be performed immediately; if it has not been discussed, the arthroscopic procedure will be concluded and another operation at a later date will be planned once your surgeon has discussed with you the details of what was found at the time of the arthroscopy and what more needs to be done.

Once the surgical procedure is complete, the arthroscopic portals and surgical incisions are closed with sutures or surgical staples and covered with surgical strips. A large bandage will be applied to your hip. You may be placed in compression stockings, which are like long socks. The compression stockings reduce swelling and help prevent blood clots in the leg. Many surgeons also use pumps on your lower legs over the compression stockings. The pumps perform a similar function to the stockings, but are actively moving the fluid in your lower legs. You will only wear these pumps when you are not moving around.  The stockings, however, should be worn at all times. Once all the bandages have been placed, you will be taken to the recovery room.

Hip arthroscopy is usually done on an outpatient basis meaning that patients go home the same day as the surgery. More complex reconstructions that require larger incisions and surgery that alters bone may require a short stay in the hospital to control pain more aggressively and monitor the situation carefully. In this case you will begin Physical Therapy while in the hospital.

Crutches are commonly used after hip arthroscopy and the Physical Therapist will show you how to use your crutches on both level ground and also while doing stairs. You will need to follow your surgeon’s instructions about how much weight to place on your foot while standing or walking.  How much weight your surgeon would like you to put on your surgical side depends on what your surgeon has done inside your joint. Every surgery is different. Crutches may only be needed for one to two days after simple procedures, but should be used until your surgeon says you can fully weight bear, and until you can walk virtually without a limp.  Even one crutch, used on the opposite side to your injury, can be used to provide some support and allow you to avoid walking with a compensatory gait post-surgically.

It is important to avoid doing too much, too quickly. You will be instructed to use a cold pack on the hip and to keep your leg elevated and supported while sitting or laying both in the hospital and when you go home. You will also be instructed to perform simple ankle circle exercises and ankle pumping exercises to assist with moving swelling from your leg and preventing the blood in your legs from clotting.

What might go wrong?

As with all major surgical procedures, complications can occur during hip arthroscopy. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems following hip arthroscopy which are:

• anesthesia complications
• thrombophlebitis
• infection
• equipment failure
• slow recovery

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lungs, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective way is to get you moving as soon as possible after surgery.  Moving means getting you up out of bed to sit in a chair and to walk as soon as you are able, but it also includes having you perform ankle circles and ankle pumping exercises while lying down or sitting, which also helps to keep the fluid moving in your legs. Two other commonly used preventative measures include pressure stockings, as described above, and medications that thin the blood and prevent blood clots from forming.

Infection

Following hip arthroscopy, it is possible that a postoperative infection may occur. This is very uncommon and happens in less than 1% of cases but it can happen. You may experience increased pain, swelling, fever and redness, or drainage from the incisions.

You should alert your surgeon if you think you are developing an infection.
Infections are of two types: superficial or deep. A superficial infection may occur in the skin around the incisions or portals. A superficial infection does not extend into the joint and can usually be treated with antibiotics alone. If the hip joint itself becomes infected, this is a serious complication and will require antibiotics and possibly another surgical procedure to drain the infection.

Equipment Failure

Many of the instruments used by the surgeon to perform hip arthroscopy are small and fragile. These instruments can be broken resulting in a piece of the instrument floating inside of the joint. The broken piece is usually easily located and removed, but this may cause the operation to last longer than planned.  Fortunately there is usually no damage to the hip joint due to the breakage.

Different types of surgical devices (screws, pins, and suture anchors) are used to hold tissue in place during and after arthroscopy. These devices, unfortunately, can also cause problems. If one breaks, the free-floating piece may damage other parts inside the hip joint, particularly the articular cartilage. The end of the tissue anchor may poke too far through tissue causing it to rub and irritate nearby tissues. A second surgery may be needed to remove the device or to fix problems with these devices.

Slow Recovery

Not everyone gets quickly back to routine activities after hip arthroscopy. Due to the arthroscope allowing surgeons to use smaller incisions than in the past, many patients mistakenly believe that less surgery was necessary. This is not always true. The arthroscope allows surgeons to do a great deal of reconstructive surgery inside the hip without making large incisions.  How fast you recover from hip arthroscopy depends on what type of surgery was done inside your hip, as well as on how well you do with your rehabilitation. Simple problems that require simple procedures using the arthroscope generally get better faster. Patients with extensive damage to the hip articular cartilage tend to require more complex and extensive surgical procedures that take longer to heal and require longer rehabilitation. You should discuss your individual injury with your surgeon and make sure that you have a realistic expectation of what to expect following arthroscopic hip surgery.

After hip arthroscopy rehabilitation at First Choice Physical Therapy should begin as soon as possible.  There are a few cases where your surgeon may delay a start in your therapy because they want the tissues to heal with rest before any further stress is placed on the hip.  Often therapy begins before you are even allowed to fully weight bear. In other cases, rehabilitation will not be recommended until full or nearly full weight bearing begins. Each surgeon will set his or her own specific restrictions based on what was done during the surgical procedure, their personal experience, and whether your tissues are healing as expected. Generally speaking, the more complex the surgery the more involved and prolonged your rehabilitation program will be.

If you are still using crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using the crutches safely, properly, and confidently and that you are abiding by your weight bearing restrictions. We will also ensure that you can safely use your crutches on stairs. If you are no longer using crutches, or once you no longer need them, your Physical Therapist will focus on normal gait re-education so you are putting only the necessary forces through the surgical side with each step, and are not compensating in any way. As mentioned above, until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your First Choice Physical Therapy Physical Therapist will advise you regarding the appropriate time for you to be walking without any walking aid at all.

During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving the pain and inflammation from the surgical procedure itself. We may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the extremity. In addition, your Physical Therapist may massage your leg and ankle to improve circulation and help decrease your pain.

The next part of our treatment will focus on regaining the range of motion in your hip.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of a home exercise program. Range of motion in the hip generally comes back very quickly after an arthroscopic surgery, but it still depends on what your surgeon has done inside your joint. Most often patients find their range of motion improves slightly from prior to surgery because their surgeon has cleaned up the joint. You may experience a small amount of discomfort at the end ranges of motion initially, but it is still important to perform the range of motion exercises that your therapist prescribes because moving the joint also helps to move the swelling, get fresh blood to the healing area, and provide nutrition to the surface of the joint. Only mild discomfort, however, is permissible. Any sharp or moderate discomfort should be heeded. An exercise bike at this stage is very useful to assist in gaining back the hip flexion and extension range of motion. Even if you are unable to fully rotate the pedals of the bike it is still encouraged as performing the back and forth motion forces fluid through the joint and greatly assists the healing process.

If necessary your Physical Therapist will mobilize your hip joint. This hands-on technique encourages the hip to move gradually into its normal range of motion. Mobilization of the hip may be combined with assisted stretching of any tight muscles around the surgical site.

At First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while your hip is healing.  This can begin very early post-surgically.  You can use an upper body bike if you are non-weight bearing or may even be allowed to do non-weight bearing exercises in a pool. A stationary bike is often the best cardiovascular activity once weight bearing begins and your range of motion allows it. Weights for the upper extremities and other leg are also strongly encouraged. Your Physical Therapist at First Choice Physical Therapy can provide a program for you to maintain your general fitness while you recover from your surgery.

As soon as possible your Physical Therapist will prescribe strengthening exercises. These exercises will focus on the muscles of your hip and thigh but will also include some exercises for your back as it plays a large supporting role for your hips.  Exercises that involve the entire lower limb, such as squats, will also be given. It is important for you to perform weight bearing exercises as soon as you are able to in order to build up the muscles in a functional position, such as standing.  Exercises that work the muscles while in standing most effectively assist with daily activities such as walking and stair climbing. Other exercises in sitting or lying, however, may also be prescribed. Exercises in these positions can be excellent in allowing you to target specific muscles around the hip, such as the gluteals, without causing you any discomfort from too much body weight being on the hip. Your therapist may use an electrical muscle stimulator to assist your muscles in contracting as you do your exercises; this will help you to more rapidly gain your strength back. Exercises may also include the use of Theraband or weights to provide some added resistance for your hip and lower extremity. If you have access to a pool, your therapist may suggest you go to the pool to do your exercises. The buoyancy of the water along with the warmth of the water can assist greatly in providing comfort to the hip joint and often allows your exercises to be done more easily with less discomfort.

As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. If your balance and proprioception has declined, your joints and your limb as a whole will not be as efficient in their functioning and the decline may also contribute to further injury in the future. As a final component of our treatment your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain this balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a wobbly board or a soft plastic disc. Advanced exercises will include agility type exercises such as light hopping or moving side to side.

As your range of motion, strength, and proprioception improve, your therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows. As soon as it is safe to do so, your Physical Therapist will add more aggressive exercises such as jumping, hopping, and running, or exercises that mimic the sports or recreational activities that you enjoy participating in.  During all of your exercises you therapist will pay particular attention to your technique to ensure that you are not using any compensatory patterns or are developing bad habits in regards to how you use your hip and lower extremity.
Enduring pain in your hip for years, months, or even just weeks generally causes you to use your hip and lower extremity in a pattern that avoids or limits your pain, but that is not efficient for a normal hip.  If you do not pay close attention to how you use your joint and limb post-surgically these patterns often continue to occur once the source of your pain has been eliminated by the arthroscopic surgery. Your Physical Therapist at First Choice Physical Therapy will be crucial to providing you with feedback regarding correcting these patterns and developing new, efficient patterns during your daily activities.

Today, the arthroscope is used to perform quite complicated major reconstructive surgery using very small incisions. Remember, however, that just because you have small incisions on the outside, there may be a great deal of healing tissue on the inside of the hip joint. If you have had major reconstructive surgery, you should expect full recovery to take several months.

Generally the rehabilitation after arthroscopic hip surgery responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the hip is tolerating the rehabilitation well and ensure that there are no complications that may be impeding your recovery.

A hemiarthroplasty is an operation that is used most commonly to treat a fractured hip. The operation is similar to a total hip replacement but it involves only half of the hip. (Hemi means half, and arthroplasty means joint replacement.) The hemiarthroplasty replaces only the ball portion of the hip joint, not the socket portion. In a total hip replacement the socket is also replaced.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the operation
• what to expect after the procedure
• what First Choice Physical Therapy’s approach to rehabilitation is

How does the hip joint work?

The hip joint is one of the true ball-and-socket joints of the body (the shoulder is the other.) The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone (femur,) known as the femoral head. The thick muscles of the buttock at the back, and the thick muscles of the thigh in the front surround the hip joint.

The surface of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. Articular cartilage is a tough, slick material that allows the joint surfaces to glide against one another without damage.

All of the blood supply to the femoral head (the ball portion of the hip) comes through the neck of the femur (femoral neck), which is a thinner section of the thighbone that connects the ball to the main shaft of the bone.If this blood supply is damaged, there is no backup.

One of the problems with hip fractures is that damage can occur to these blood vessels when the hip breaks and this damage can lead to the bone of the femoral head actually dying. This dying of the bone, called avascular necrosis (AVN), is always a potential complication of a hip fracture. The problem with leaving dead bone in the hip is that it may eventually collapse, causing pain in the hip, and decreased hip function.

What do surgeons hope to achieve with the operation?

Fractures of the hip often involve the femoral neck. In many cases, the risk of developing AVN is so high that your surgeon may suggest not fixing the fracture because by fixing it there is still a high chance that you will need a second operation several months later if the femoral head dies due to AVN. Instead, it is often recommended that the femoral head be removed and replaced with an artificial piece, or prosthesis.

When the hip is fractured, the socket portion (the acetabulum) is usually not injured. If the articular cartilage of the hip socket is in good condition, the metal ball of the hemiarthroplasty prosthesis can glide against the cartilage without damaging the surface. A hemiarthroplasty is easier to do than replacing both the ball and the socket (a total hip replacement), and it allows patients to move better and quicker after surgery. Early movement is particularly important in the elderly population as it helps prevent dangerous, and possibly life-threatening complications that come from being immobilized in bed, and also lets patients more quickly return to independent function.

How should I prepare for surgery?

This procedure is usually an emergency surgery so it is likely you will not have had time to plan and prepare. Ideally, a caregiver, such as a family member or friend, will help make arrangements for you while you are in the hospital.  The surgeon and care team will communicate with your caregiver to help with these preparations. Your caregiver will help coordinate your ride home, prepare your home for your arrival, obtain any needed supplies, and schedule follow-up appointments with your surgeon, general practitioner, and Physical Therapist.

What happens during the operation?

As described earlier, the hemiarthroplasty prosthesis replaces the femoral head. The prosthesis is composed of a metal stem that fits into the hollow marrow space of the thighbone (the femur). It also has a metal ball that fits into the socket of the hip joint (the acetabulum).

The femoral head that attaches to the stem may be a separate part. Two types are commonly used by surgeons. Some surgeons prefer a solid metal ball to replace the femoral head. This type of prosthesis is called a unipolar type. Other surgeons prefer to use a bipolar type of prosthesis. The bipolar type has a femoral head that swivels where it attaches to the stem. The bipolar prosthesis was designed to try to reduce the wear and tear on the articular cartilage inside the acetabulum. It is unclear whether the swivel offers any significant advantages; both types seem to work well.

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis bears a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone. Both methods are still widely used. The decision about whether to use a cemented or uncemented prosthesis is made by each surgeon based on your age, the condition of your bones, your lifestyle, and the surgeon’s experience.

To begin, the surgeon makes an incision to allow access to the hip joint. Different approaches can be used to make the incision. Sometimes the incision is made posterior to the joint and sometimes it is made anterior to the joint. The choice of surgical approach is usually based on the surgeon’s training and preferences.

Once the hip joint is entered, the surgeon removes the femoral head from the acetabulum.

Special rasps (coarse files) are used to shape the hollow femur to the exact shape of the metal stem of the prosthesis. Once the size and shape are satisfactory, the stem is inserted into the femoral canal. Again, in the uncemented version the stem is held in place by the tightness of the fit into the bone (similar to the friction that holds a nail driven into a hole slightly smaller than the diameter of the nail). In the cemented variety, the femoral canal is enlarged to a size slightly larger than the femoral stem, and an epoxy-type cement is used to bond the metal stem to the bone. The metal ball that makes up the femoral head is then attached.

Once the implant is in place, the new artificial hip is put back into the hip socket (also called relocating or reducing the hip).  The surgeon makes sure that the hip works properly and the joint moves easily. The surgeon then closes the incision with several layers of stitches under the skin and uses stitches or metal staples to close the skin itself. A large bandage is placed over the incision and special boots and/or compression type stockings, which help to move the fluid in your legs, are placed on your lower legs and feet to assist in preventing the formation of blood clots. A triangle-shaped cushion may be positioned between your legs to keep your legs from crossing or rolling in.  You are then returned to the recovery room.

What happens after surgery?

Due to the use of anesthesia and the associated immobility that occurs with a surgery, all surgical patients are at risk of developing pneumonia. For this reason, once you are awake you will be instructed immediately to begin deep breathing exercises. You may even be given an incentive spirometer to encourage deep breathing. An incentive spirometer is a small handheld device that allows you to visually see a small ball rise in response to taking a deep breath. At least ten deep breaths should be taken each hour, particularly while you are not moving much. As you begin to move around more, you will naturally take deep breaths so it is not as crucial to remember to do them each hour.  It is interesting to note that laughing and yawning are natural ways to take in deep breaths as well!  In addition to deep breathing exercises you will be instructed to pump your ankles up and down and do ankle circles to encourage movement of the fluid in your legs in order to avoid a deep vein thrombosis (DVT), more commonly known as a blood clot.

Inpatient Physical Therapy will be scheduled at least once a day as long as you are in the hospital.  Usually your first visit from the physiotherapist will be soon after you are settled into your room. Your therapist will review the deep breathing and ankle pumping exercises and will also instruct you on how to get the muscles of your buttocks and thigh activated by tightening them without moving the hip or knee joints.

Your Physical Therapist will also review the movements that you must avoid doing to protect your hemiarthroplasty (also called the hip precautions).  These movements are dangerous as they can cause your hip to dislocate. The risk of dislocation is greatest right after surgery. Once the tissues around the hip heal and you have built up the strength of the muscles surrounding the hip, the risk significantly decreases.  The movements most likely to cause dislocation of your hip depend on which approach to surgery, anterior or posterior, that your surgeon used. If an anterior approach was used, then extending the hip back, turning your hip and leg out, or spreading your leg outwards should be avoided. If your surgeon used a posterior approach, then crossing your legs, turning your hip and leg inward, or bending the hip more than 90 degrees are the motions that should be avoided. Your therapist will educate you on the precautionary movements pertaining to your particular surgery.

How quickly you start getting up from the bed depends on your surgeon’s protocol. Some surgeons request that you get up from your hospital bed and move to a chair on the day of your surgery. Others wait until the day after your surgery. Even this small activity of moving from your bed to a chair is extremely beneficial to your recovery from surgery, as it helps to get the fluid in your legs moving, activate your muscles, and encourage deep breathing.

By the second session, your therapist will instruct you on more advanced exercises where you are moving your hip and knee to both encourage range of motion as well as to start to strengthening your muscles.  In addition to more advanced exercises, you will begin to walk short distances with either a walker or crutches. Most patients are allowed to put as much weight as is comfortable down through their foot when standing or walking. If, however, your surgeon used a non-cemented prosthesis you may be instructed to limit the weight you put on your foot. Your therapist will clarify for you how much weight is allowed in your particular situation.

The majority of patients begin walking using a walker, and progress to crutches if they are able, and if they have stairs to negotiate at home. Crutches allow you to be much more mobile, but they do require more coordination. If you are not steady on the crutches, even with practice, a walker is recommended even for when you go home. The walker, however, cannot be used on typical stairs.  Most patients progress to using a cane (in the hand opposite to their surgical leg) in three to four weeks. Once you can walk without a limp and your muscles are strong enough, no walking aid is used. Generally this is around the 6-week mark, but can be earlier, or may be later, depending on your ability, as well as your surgeon’s restrictions.

Each day after surgery you will be expected to independently complete your exercises and go for a walk. A therapist will visit you on most, if not all days, to ensure that you are progressing well and that you are learning to do your rehabilitation program independently. If your hospital has a pool, and your surgeon allows it, hydrotherapy may be incorporated once your surgical incision stops oozing.  The buoyancy, hydrostatic properties, and warmth of the water often allow easier and less painful hip movements.

In addition to providing you with a rehabilitation program, your Physical Therapist or an occupational therapist will discuss recommendations for home modifications that will allow you to abide by the hip precautions and create a safe environment. These recommendations may include using a raised commode seat, using a bathtub bench, and raising the surfaces of couches and chairs to keep your hip from bending too far when you sit down. Bath benches and handrails can greatly improve safety in your bathroom and are highly recommended. Other suggestions may include the use of strategic lighting and the removal of loose rugs or electrical cords from the floor in order to avoid tripping or falling.

Patients can usually be discharged home after spending anywhere from three to ten days in the hospital. Factors that determine how long you will remain in the hospital are: Your surgeon’s protocol, your ability to independently get in and out of bed, your ability to properly perform your rehabilitation exercises, your ability to walk safely for a moderate distance with your crutches or walker, your ability to safely use crutches to go up and down stairs (if you have stairs at home), and your ability to consistently remember to use your hip precautions. Patients who still need extra rehabilitation care after they are medically stable in the hospital may be sent to a different hospital unit until they are independently safe to go home. Alternatively, they may go home if they have adequate family support and a Physical Therapist can visit them at their home until they are able to demonstrate the above skills.  Not all patients, however, will require Physical Therapy in their own home.

Your staples will be removed 10-14 days after surgery. Patients are usually able to drive within three weeks. Upon the approval of the physician, patients are generally able to resume sexual activity one to two months after surgery.

What should I expect during my rehabilitation after leaving the hospital?

After you are discharged from the hospital, you should continue your home rehabilitation program. If needed, a therapist may see you in your home for a few treatments, but this is generally only until you are able to safely get out of your home.  Once you are independent enough to attend Physical Therapy outside of the home, even if someone else needs to drive you, you should begin treatment at First Choice Physical Therapy to continue your rehabilitation.  The most important part of your rehabilitation after a hip hemiarthroplasty will be the exercises that you do independently at home, however, by attending First Choice Physical Therapy for Physical Therapy we will be able to ensure that you are doing your exercises well, ensure you are doing the correct exercises for your level of healing, advance your exercises as you improve, and ensure that there are no factors in your individual case that will impede your recover or your return to function.

If you are still using a walker or crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using them safely, properly, and confidently while abiding by your weight bearing restrictions. We will also ensure that you can safely use crutches on stairs. If you are no longer using a walking aid, or once you no longer need one, your Physical Therapist will focus on normal gait re-education so you are putting only the necessary forces through the surgical side with each step, and are not compensating in any way. Until you are able to walk without a significant limp, we recommend that you continue to use a walking aid, such as your crutches, or a cane/stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until virtually normal walking can be achieved. Your First Choice Physical Therapy Physical Therapist will advise you regarding the appropriate time for you to be walking without any walking aid at all.

As mentioned above, a hip hemiarthroplasty is at risk of dislocating if it is forced into certain motions, so the hip precautions you have been taught must be strictly respected, particularly in the early stages after surgery, until the incision heals and strength is regained in the muscles around the hip and in the leg. At your first appointment your Physical Therapist will again discuss the hip precautions pertaining to your surgical procedure. The length of time that hip precautions should be abided by varies in opinion. Many surgeons suggest 12 weeks, however, other surgeons or health care professionals recommend much longer, even up to 1-2 years or forever, if possible!  How long you must abide by your hip precautions depends on a number of factors. Certainly 12 weeks minimum is a must. Other factors affecting the length of time include: your surgeon’s protocol and recommendation based on your specific case, your muscle strength, your muscular control of the hip, your risk of falling, if you are obese, if you are very thin with little muscular support, and how active or inactive you are or want to be. Your Physical Therapist at First Choice Physical Therapy will be able to discuss your individual situation regarding hip precautions.

During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving any pain and/or inflammation you may still have from the surgical procedure. They may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the extremity. In addition, your Physical Therapist may massage your hip, back, leg or ankle to improve circulation and help decrease your pain.

The next part of our treatment will focus on regaining the range of motion in your hip.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching exercises that you will practice in the clinic and also add to your home exercise program. Some of these exercises may be similar to the exercises that you learned in the hospital and that you have already been doing at home.  Many of the home exercises will have become too simple for you by this stage of your rehabilitation so your therapist will ensure that you are doing the most advanced exercises for your stage of recovery in order to ensure you progress as quickly as possible. Hip precautions will need to be strictly abided by in all of your exercises so it is best not to add any exercises into your program independently, but rather to allow your therapist to shape your individual program as they see fit for your current ability.

Range of motion in the hip generally comes back very quickly after a hemiarthoplasty. You may experience a small amount of discomfort at the end ranges of motion initially, but despite this it is important to perform the range of motion exercises as prescribed because moving the joint also helps to diminish the swelling, get fresh blood to the healing areas, and provides nutrition to the joint. Only mild discomfort, however, is permissible. Any sharp or moderate discomfort should be heeded. An exercise bike at this stage of recovery can be very useful, however you must still respect your hip precautions while using the bike, therefore the advice of your therapist regarding bike set up is crucial the first few times you attempt it.

If necessary, and as time and healing allows, your Physical Therapist may mobilize your hip joint. This hands-on technique encourages the hip to move gradually into its normal range of motion. Mobilization of the hip may be combined with assisted stretching of any tight muscles around the surgical site.

Your therapist will also review and advance your strengthening exercises. Again, as you progress you will outgrow the strengthening exercises that were given to you in the hospital so it is important that your Physical Therapist at First Choice Physical Therapy advances your exercises to suit your level of progress.  These exercises will focus on the muscles of your hip and thigh but will also include some exercises for your back and core area as they play a large supporting role for your hips.  Exercises that involve the entire lower limb, such as squats (on both legs at the same time or just one leg,) will also be given.

Exercises that work the muscles while in standing most effectively assist with daily activities such as walking and stair climbing. Other exercises in sitting or lying, however may also be prescribed. Exercises in these positions can be excellent in allowing you to target specific muscles around the hip, such as the gluteals, without causing you any discomfort from too much body weight being on the hip. Your therapist may use an electrical muscle stimulator to assist your muscles in contracting as you do your exercises; this will help you to more rapidly gain your strength back. Exercises may also include the use of exercise bands or weights to provide some added resistance for your hip and lower extremity. If you have access to a pool, your therapist may suggest you go to the pool to do your exercises. As mentioned above, the buoyancy and hydrostatic properties of the water along with the warmth of the water (provided it is a heated pool) can assist greatly in providing comfort to the hip joint and often allows your exercises to be done more easily and with less discomfort.

As a result of any injury or surgery, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. When balance and proprioception is diminished, your joints and your limb as a whole will not function as efficiently and the decline may contribute to further injury in the future. Once you are able to put full weight onto your surgical side a final component of our treatment at First Choice Physical Therapy will be to prescribe exercises for you to regain this balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a soft mat, or a soft plastic disc.

Proprioceptive exercises are important for all patients who have had surgery but they are particularly important for patients who have had a hip hemiarthroplasty because often the reason for the surgery was due to a fracture of the hip resulting from a fall. By improving one’s proprioception, you can decrease your chances of another fall, which may result in damage to your surgical hip, or worse yet, a fracture of the other hip or another bone in your body.

During all of your exercises your Physical Therapist at First Choice Physical Therapy will pay particular attention to your exercise technique to ensure that you are not using any compensatory patterns or are developing bad habits in regards to how you use your hip and lower extremity.  If you do not pay close attention to how you use your joint and limb post-surgically inefficient patterns can quickly occur and compensatory pain will develop either in your hip, back, or another joint.  The acetabulum of the hip can also begin to quickly wear down, leading to the need for it to also be replaced, if your exercise technique or walking pattern is not pristine. Your Physical Therapist at First Choice Physical Therapy will be crucial for providing you with feedback regarding correcting these patterns and developing new, efficient patterns during your daily activities.

As your range of motion, strength, and proprioception improve, your therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows, and to incorporate exercises that simulate your specific everyday activities of daily living and any recreational activities that you may want to return to. Many patients undergoing this surgery are older, and are not still regularly active. However, there are also younger patients for whom this surgery is required. For these younger patients unfortunately, heavy sports that require running, jumping, quick stopping and starting, and cutting are discouraged. Patients may also need to consider alternate jobs to avoid work activities that require heavy demands of lifting, crawling, and climbing. Your surgeon will advise you which activities in your case are not at all permissible or are discouraged.

Your Physical Therapist at First Choice Physical Therapy’s goal is to help you maximize range of motion, strength and proprioception, as well as walk normally, and improve your ability to do your activities. When you are well under way, regular visits to our clinic will end. Your Physical Therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Generally the rehabilitation after a hemiarthroplasty responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should or your therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the hip is tolerating the rehabilitation well and ensure that there are no complications that may be impeding your recovery.

What might go wrong?

As with all major surgical procedures, complications can occur. A few of the potential complications have already been touched on in the information above, but are discussed in further detail below. The following is not a complete list of the possible complications, but rather some of the most common problems, which include:

• anesthesia complications
• thrombophlebitis
• infection
• dislocation
• loosening
• ongoing pain

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be used before surgery. A very small number of patients have problems with anesthesia such as a reaction to the drugs used, or a problem under anesthesia related to other medical complications. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called a deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. These clots may cause the leg to swell and become warm to the touch and painful. Even more dangerously, if the blood clots in the veins break apart, they can travel to the lungs where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but one of the most effective ways is to get you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings or pumps to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection in any surgery, such as a hip hemiarthroplasty, can be a very serious complication. The chance of getting an infection following hemiarthroplasty is approximately one percent. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. To reduce the risk of spreading germs to your joint your surgeon may ask you to take antibiotics when you have dental work or surgical procedures on your bladder or colon.

Dislocation

By opening up your hip joint to perform the hemiarthroplasty, your surgeon must cut through the soft tissues around your hip (the joint capsule and ligaments), which normally provide stabilization to your joint. Due to this, your hip after surgery is at risk of dislocating (the ball coming out of the socket.) There is a greater risk of dislocation immediately after surgery, before the tissues have healed around the joint, but there is always a risk. Your Physical Therapist will instruct you on which activities and positions to avoid that may have a tendency to cause a hip dislocation. A hip that dislocates more than once may have to be revised with another surgery to make it more stable. Patients with diseases such as Parkinson’s or Alzheimer’s are at a higher risk of dislocating their hip. With Parkinson’s this risk is increased due to the uncontrollable associated movements of the disease and

higher risk of falling. In patients with Alzheimer’s, the inability to consistently follow the hip precautions increases their risk of dislocation.

Loosening

The main reason that joint implants eventually fail continues to be loosening of the metal or cement from the bone. Great advances have been made in extending how long artificial replacement parts will last, but most will eventually loosen and require a revision.

Generally you can expect 12 to 15 years of service from replacement parts for the hip, but in some cases the hip will loosen earlier than that. A loose hip is a problem because it causes pain and affects the biomechanics of the joint, which then causes further wear and tear on the joint itself as well as other associated joints.  Once the pain becomes unbearable, another operation is often required to revise the hip.

Ongoing Pain

A hemiarthroplasty replaces the ball portion of the hip joint, but does not replace the socket of the joint. This means that the metal ball is constantly rubbing against the articular cartilage that lines the inside of your natural hip socket. The socket may become arthritic as the cartilage wears out over time. If this occurs, the hip will become painful just like any other arthritic joint. If the pain becomes unbearable, the hemiarthroplasty may need to be converted to a completely artificial joint. This means that the socket will be replaced with a new artificial socket. Fortunately the metal stem does not always need to be replaced when this occurs.

Most orthopedic surgeons recommend that you have routine checkups after undergoing a hip hemiarthroplasty. How often you need to be seen varies from every six months to every five years, according to your individual situation and what your surgeon recommends. Obviously, if at any time post surgically you feel like your hip suddenly declines in function or you are experiencing more pain that usual, a follow up with your surgeon would be prudent.

Welcome to First Choice Physical Therapy’s patient resource about Open Carpal Tunnel Release.

Carpal tunnel syndrome (CTS) occurs when the median nerve is squeezed as it courses through the wrist. The passageway through the wrist, called the carpal tunnel, is formed by the small wrist bones (carpals) on one side and a ligament on the other. In an open release for CTS, the surgeon makes an incision on the front of the wrist and hand in order to cut the ligament. The goal is to relieve pressure on the median nerve.

This guide will help you understand:

• what part of the wrist and hand are treated during surgery
• how surgeons perform the operation
• what to expect before and after the procedure

What part of the wrist is treated during surgery?

The carpal tunnel is an opening through the wrist into the hand that is formed by the carpal bones of the wrist on the bottom and the transverse carpal Ligament on the top. The transverse carpal ligament is at the base of the wrist and crosses from one side of the wrist to the other. (Transverse means across.) It is sometimes referred to as the carpal ligament.

Transverse Carpal Ligament

The opening formed by the carpal bones and the carpal ligament is the carpal tunnel. The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb.

Median Nerve

The median nerve rests on top of the flexor tendons, just below the carpal ligament. Between the skin and the carpal ligament is a thin sheet of connective tissue called the palmar fascia.

What does the surgeon hope to achieve?

The surgery releases the carpal ligament, taking pressure off the median nerve. The open procedure for releasing the carpal ligament involves a sizeable wrist incision, usually about two inches long. By creating a large incision, the surgeon is able to clearly see the wrist structures and to carefully do the operation.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

Open release for CTS is occasionally done using a general anesthetic (one that puts you to sleep). More often, it is done using a regional anesthetic. A regional anesthetic blocks the nerves going to only a portion of the body. Injections of medications similar to lidocaine are used to block the nerves for several hours. This type of anesthesia could be an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep). The surgery can also be performed by simply injecting lidocaine around the area of the incision.

Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution.

A small incision is made in the palm of the hand, usually about one inche long. In some severe cases, a slightly longer incision is extended into the forearm.

Incision

The incision makes the palmar fascia visible. This is a sheet of connective tissue in the palm and forearm right under the skin. The surgeon makes an incision through this material and exposes the carpal ligament.

Palmar Fascia

View animation of palmar fascia exposed

Once in view, the carpal ligament is released using a scalpel or scissors.

Carpal Ligament Released

View animation of ligament exposed

Care is taken to make sure that the median nerve and flexor tendons are out of the way and protected. By cutting the carpal ligament, pressure is taken off the median nerve.

Median Nerve

Upon dividing the carpal ligament, the surgeon stitches just the skin together and leaves the loose ends of the carpal ligament separated. The loose ends are left apart to keep pressure off the median nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue.

Dividing Carpal Ligament

After the skin is stitched together, your hand will be wrapped in a bulky dressing. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

Bulky Dressing

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following open carpal tunnel release are

• anesthesia
• infection
• incision pain
• scar tissue formation
• nerve damage
• hand weakness

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection is a possible complication after surgery, especially infection of the incision. Therefore, check your incision every day as instructed by your surgeon. If you think you have a fever take your temperature. If you have signs of infection or other complications, call your surgeon right away.

These are warning signs of infection or other complications:

• pain in your hand that is not relieved by your medicine
• discharge with an unpleasant odor coming from your incision
• swelling, heat, and redness along your incision
• chills or fever over 100.4 degrees Fahrenheit
• bright red blood coming from your incision

Incision Pain

Some patients continue to have pain along their incision. The area often stays sensitive long after the surgery. However, symptoms of incision sensitivity tend to get better within four to six months after surgery.

Scar Tissue Formation

A common problem after carpal tunnel release is excessive scar tissue buildup. The body attempts to heal the area but goes too far in the process of supplying new cells. Too much scar tissue forms. When this happens the nearby soft tissues can become bound together. The incision may appear raised. The nearby skin may feel tight. You may even feel a bump beneath the incision. Wrist and hand movement may feel restricted. Scar tissue can also bind the flexor tendons and median nerve, preventing them from gliding smoothly within the carpal tunnel. Pain and a loss of range of motion may occur. In severe cases, a second surgery may be needed to remove the extra scar tissue.

Nerve Symptoms

Sometimes people still feel some numbness and tingling after surgery, especially if they had severe pressure on the median nerve prior to surgery. When the thenar muscles (mentioned earlier) are notably shrunken (atrophied) from prolonged pressure on the median nerve, full strength and normal sensation may not fully return even after having the surgery.

Hand Weakness

Muscles that are used to squeeze and grip may seem weak after surgery. During normal gripping, the tendons of the wrist press outward against the carpal ligament. This allows the carpal ligament to work like a pulley to improve grip strength. People used to think that the tendons lose this mechanical advantage after the carpal ligament has been released. However, recent studies indicate that hand weakness is more likely from pain or swelling that occurs in the early weeks after the procedure. With the exception of patients who have severe thenar atrophy at the time of surgery, most people achieve normal hand strength within two to four months of surgery. Those with severe atrophy commonly see improvements in hand strength, but they rarely regain normal size of the thenar muscles.

What happens immediately after surgery?

At first, take time during the day to support your healing arm with your hand elevated above the level of your heart. You may be instructed to put an ice pack on your wrist several times a day to keep swelling down. At various times during the day, move your thumb and fingers five to 10 times. Also, bend and straighten your elbow and lift and lower your shoulder occasionally to keep these joints limber. Keep the dressing on your hand until you return to the surgeon. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery.

Heavy gripping and pinching should be avoided for up to six weeks. These actions need to be avoided to keep the tendons from pushing out against the healing carpal ligament After six weeks, you should be safe to resume gripping and pinching without irritating the wrist.

It generally takes longer to recover after open carpal tunnel release. Pain and symptoms usually begin to improve, but you may have tenderness in the area of the incision for several months after surgery.

Patients who wait too long to seek medical advice sometimes have difficulty adjusting after surgery. Poor coping skills in the presence of persistent pain and numbness may result in disappointment or dissatisfaction with the results of surgery. Recovery may take longer than expected when nerve damage is severe. In some cases, symptoms are not entirely alleviated.

What should I expect after surgery?

Once the stitches are removed, many surgeons prefer to have their patients attend occupational or Physical Therapy sessions, such as those offered at First Choice Physical Therapy. After this procedure, our patients are usually treated two to three times each week for four to six weeks, although the time required for recovery does vary. As mentioned, however, it may take several months for the incision pain to go away and for maximum hand strength to return.

At first, our Physical Therapist will attempt to reduce pain and swelling. We may apply hot or cold packs, electrical stimulation, and ultrasound. Massage strokes directed from the fingers toward the elbow help move swelling away from the hand and wrist.

Our Physical Therapist will use hands-on stretching and active hand and wrist exercises to encourage range of motion. We’ll show you how to carefully strengthen your hand by squeezing and stretching special putty. Our therapist may also provide you with home exercises to improve hand and finger movement and strength.

Some of our Physical Therapy treatments are used to reduce sensitivity in the incision. The methods are applied gently at first. One method is for our Physical Therapist to massage the incision for several minutes. We will teach you this massage technique so that you can do it on your own five to six times each day. Another way to desensitize the incision is to grip materials of various textures or to rub them over the incision. These treatments are gradually done with more vigor as the sensitivity of the incision eases.

Another of our therapy goals is to prevent scar tissue formation. Our Physical Therapist will use scar massage to reduce scar tissue formation in the incision and in the nearby skin and soft tissues. To prevent scar tissue from forming between the flexor tendons and median nerve, we also instruct patients in a series of fist positions. These specialized exercises encourage the normal gliding action of the structures within the carpal tunnel.

As you progress, your First Choice Physical Therapy Physical Therapist will also give you exercises to help strengthen and stabilize the muscles and joints in your hand. We will use other exercises to improve fine motor control and dexterity. Some of the exercises that we’ll teach you are designed to get your hand working in ways that are similar to your work tasks and sport activities.

Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your hand and wrist. Before your therapy sessions end, we will teach you a number of ways to avoid future problems.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s patient resource about Excision Arthroplasty of the Thumb.

Thumb arthritis may be surgically treated with a procedure called excision arthroplasty. The term excision means to take out. In this surgery, the surgeon takes out a small bone at the base of the thumb and fills in the space with a rolled up section of tendon. The soft tissue forms a false joint that keeps the thumb somewhat mobile and stops pain by preventing the joint surfaces from rubbing together.

This guide will help you understand:

• which parts of the thumb are involved
• why this type of surgery is used
• what happens during the procedure
• what to expect before and after surgery

Which parts of the thumb are involved?

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is this joint that allows you to move your thumb into your palm, a motion called opposition.

Carpometacarpal Joint

Several ligaments (strong bands of tissue) hold the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful.

What does the surgeon hope to achieve?

The main goal of this surgery is to ease pain where the surfaces of the thumb joint are rubbing together. The surgeon uses a piece of tendon to form a spacer that separates the surfaces of the CMC joint. Unlike a fusion surgery that simply binds the joint together, excision arthroplasty can help take away pain while allowing the thumb joint to retain some movement.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during surgery?

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution. An incision will be made that angles along the back of the thumb to the edge of the wrist. Special care is taken not to damage the nearby nerve going to the thumb.

The CMC joint and surrounding tissues are exposed.

Next, the joint capsule surrounding the CMC joint is opened. The surgeon takes out (excises) the trapezium bone at the base of the thumb.

Then the doctor removes a small section of one of the tendons near the thumb. The piece of tendon is sewn into a small ball and placed into the space where the trapezium bone was removed. The remaining portion of the tendon is sewn to the thumb metacarpal to stabilize the joint. The surgeon may also insert a surgical pin to connect and hold the metacarpal bones of the thumb and index finger. The pin protects the reconstructed joint and is usually removed three weeks after the surgery.

The soft tissues over the joint are sewn back together. The thumb is placed in a splint, and the hand is wrapped in a bulky dressing.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following excision arthroplasty are:

• anesthesia
• infection
• nerve damage

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Excision arthroplasty of the thumb is no different. You will probably be given antibiotics before the operation to reduce the risk of infection. If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the arthroplasty.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the CMC joint. Because the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.

What happens after surgery?

After surgery, your thumb will be bandaged with a well-padded dressing and a splint for support. The splint will keep the thumb in a natural position during healing. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. If a surgical pin was used, it will be removed three weeks after surgery. You may have some discomfort after exicision arthroplasty. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

What should I expect during my recovery period?

After surgery, you’ll wear a thumb brace for up to six weeks to give the repair time to heal. Then you will be able to begin your Physical Therapy recovery program. Although the time required for recovery varies, it is likely that you will need to attend therapy sessions for one to two months, and you should expect full recovery to take up to four months.

Our first few Physical Therapy treatments will focus on controlling the pain and swelling from surgery. We may use heat treatments, gentle massage and other hands-on therapies to ease muscle spasm and pain.

Our Physical Therapist will have you begin gentle range-of-motion exercise. Then we will use strengthening exercises to provide added stability around your thumb joint. We will also instruct you in ways to grip and support items in order to do your tasks safely and with the least amount of stress on your thumb joint. As with any surgery, you need to avoid doing too much, too quickly.

Some of the exercises you’ll do are designed get your hand and thumb working in ways that are similar to your work tasks and daily activities. Our Physical Therapist will help you find ways for you to do your tasks that don’t put too much stress on your thumb joint. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s guide to artificial replacement of the thumb.

If nonsurgical treatments are not successful in easing problems of thumb arthritis, your doctor may recommend replacing the surfaces of the joint. Joint replacement surgery is called arthroplasty.

This guide will help you understand:

• which parts of the thumb are involved
• how surgeons perform this surgery
• what to expect before and after surgery
• First Choice Physical Therapy’s guide to rehabilitation after surgery

Which parts of the thumb are involved?

The carpometacarpal joint of the thumb (CMC joint) is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb as it is the joint closest to the bottom of the hand. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition.

Several ligaments (bands of strong tissue) hold the bones of the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful. Osteoarthritis is the most common form of arthritis occurring at this joint.

What does the surgeon hope to achieve?

Arthritic joint surfaces can be a source of stiffness, pain, and swelling. The artificial joint is used to replace the damaged joint surfaces so patients can do their activities with less pain. Unlike a fusion surgery that simply binds the joint together, arthroplasty can help take away pain while allowing the thumb joint to retain movement.

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. Your Physical Therapist may also liaise with your surgeon to confirm the types of therapy techniques trialed and confirm the ineffectiveness of conservative therapy. You need to understand as much about the procedure as possible. Any concerns or questions you have should be brought up to your surgeon.

Once you decide to go ahead with the surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

A preoperative visit to one of our Physical Therapists at First Choice Physical Therapy will also help to prepare you for your surgery. We will start to teach you some of the rehabilitation exercises you will use during your recovery. It is often easier to try these exercises prior to the surgery, when there is no surgical pain and you are feeling well.  Your Physical Therapist at this time can also help you anticipate any special needs or problems you might have at home, once you are released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The length of time you spend in the hospital depends on a variety of factors including the ease of the surgery, your body’s reaction to the surgery, as well as any complications that can, but rarely occur.

What happens during surgery?

Before we describe the procedure, let’s look first at the artificial thumb joint itself.

The Artificial Thumb Joint

Surgeons have several ways to replace the thumb joint surfaces. One way is to attach the ends of a prosthesis implant into the bones of the thumb joint. A newer method uses a small, marble-shaped implant to form the new joint surfaces. This spherical implant works like a ball bearing to give the joint a smooth arc of movement.

The Operation

The procedure to put in the prosthesis implant takes about two hours to complete. The newer method using the ball implant takes 30 to 60 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution.

Prosthesis Implant

In this procedure, an incision is made across the base of the thumb. The soft tissues are spread apart with a retractor. Special care is taken not to damage the nearby nerves going to the thumb. The joint capsule is opened, exposing the CMC joint. The ends of the bones that form the CMC joint surfaces are taken off, forming flat surfaces.

A burr (a small cutting tool) is used to make a canal into the bones that form the thumb joint. The surgeon sizes the stem of the prosthesis to ensure a snug fit into the canal and inserts it. When the new joint is in place, the surgeon wraps the joint with a strip of nearby tendon. This gives the new implant some added protection and stability.

The skin is stitched together and a splint applied.

Spherical Implant

A new method for replacing the thumb joint is to use a spherical implant that looks much like a marble. The surgeon makes a small, one-inch incision at the base of the thumb joint. The ends of the bones that form the CMC joint surfaces are removed, forming flat surfaces.

A burr is used to make a small notch, or canal, in the ends of the two bones. The surgeon shapes the notch so the ball-shaped implant will fit snugly in the joint. The implant is placed between the ends of the shaped bones.

The soft tissues are sewn together, and the thumb is splinted and bandaged.

What happens after surgery?

After surgery, your thumb will be bandaged with a well-padded dressing and a splint for support. The splint will keep the thumb in a natural position during healing. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medication to control the discomfort.
You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. Ice may also be used at this stage for pain relief.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications with an artificial joint replacement of the thumb are highlighted below:

• reaction to the anesthesia
• infection
• nerve damage
• prosthesis failure

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs that the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss these risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Replacing the thumb joint is no different. You will probably be given antibiotics before the operation to reduce the risk of infection.  If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the hardware. In these cases, the hardware may need to be removed.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the thumb joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerve injury has come from the nerve being stretched by retractors during the surgery holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels during this surgery, but it is possible.

Prosthesis Failure

Unfortunately artificial replacement prosthesis can fail. The older silicon-type prosthesis has been shown to break apart and fragment. Most types of prostheses have the potential to displace, or move out of the correct position, causing problems. Most of these problems will require a second operation to remove and replace the prosthesis.

Welcome to First Choice Physical Therapy’s guide to Finger Fusion.

Arthritis of the finger joints may be surgically treated with a fusion procedure. A fusion keeps the problem joints from moving so that pain is eliminated.

This guide will help you understand:

• what parts make up the finger joint
• why this type of surgery is used
• how the operation is performed
• what to expect before and after surgery
• First Choice Physical Therapy’s guide to rehabilitation after surgery

What parts of the finger are involved?

The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand with the finger bone, or phalange. Each finger (the thumb is not termed a finger) has three phalanges, separated by two interphalangeal joints (IP joints. The closest phalange to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).
Ligaments are tough bands of tissue that connect bones together. Several ligaments hold the joints together in the finger. These ligaments join to form the joint capsule of the finger joint, a watertight sac around the joint.  The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful. Rheumatic arthritis is a different form of arthritis (which is more widespread in the body and develops due to an autoimmune disorder) but can also cause wearing out of the joint surfaces and deformity of the joints.

Why is a finger joint fused?

Arthritic finger joints cause pain and make it difficult to perform normal movements, such as grasping and pinching. Advanced arthritis can also loosen the joint and may begin to cause finger joint deformity. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. Fusing the two joint surfaces together relieves pain, makes the joint stable, and prevents additional joint deformity. It is used when all other potential forms of treatment, including finger joint replacement, have been exhausted.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made together by you and your surgeon. Your Physical Therapist may also liaise with your surgeon to confirm the types of therapy techniques trialed and confirm the ineffectiveness of conservative therapy. You need to understand as much about the procedure as possible. Any concerns or questions you have should be brought up to your surgeon.

Once you decide to go ahead with the surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.
On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The length of time you spend in the hospital depends on a variety of factors including the ease of the surgery, your body’s reaction to the surgery, as well as any complications that can, but rarely occur.

What happens during the operation?

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.
Once you have had the anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution.

An incision is made on the back part of the finger over the surface of the joint that is to be fused. Special care is taken not to damage the nearby nerves going to the finger. The joint capsule surrounding the finger joint is then opened so that the surgeon can see the joint surfaces. The articular cartilage is removed from both joint surfaces to leave two surfaces of raw bone. The bottom of the phalange is hollowed with a special tool to form a socket. The other surface is shaped into a rounded cone that fits inside the socket.
The surgeon places a metal pin through the center of both bones and then connects the cone and socket snugly together. The metal pin allows the surgeon to hold the two bones in the correct alignment and prevents the bones from moving too much as they grow together, or fuse.

The soft tissues over the joint are sewn back together. The forearm and hand are then placed in a cast until the bones completely fuse together. This takes about six weeks.

What happens immediately after surgery?

After surgery, you will wear an elbow-length cast for about six weeks. This gives the ends of the bones time to fuse together. Your surgeon will want to check your hand in five to seven days. Stitches may need to be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medication by your doctor to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. Ice may also be used at this stage for pain relief.

What should I expect during my rehabilitation period?

As mentioned above, you will wear a cast on your arm and hand for about six weeks to give the fusion time to heal. When the cast is removed, you may have stiffness or pain in the joints closest to the fused joint or pain around the surgical incision.  Physical Therapy at First Choice Physical Therapy will help relieve your pain and decrease the stiffness in the surrounding joints.

In order to decrease pain we may use modalities such as heat, ice, or electrical current.

These will assist with managing pain and any ongoing swelling you have around the surgical site, anywhere along the arm, or into the hand. Massage to these areas may also be done in order to improve circulation and assist with easing any discomfort. Some of the muscles of the neck may also be painful from having the arm in a cast for an extended period. These muscles may also benefit from massage treatment, which will make movement of your entire surgical side easier.

The next part of our treatment will focus on regaining the range of motion, strength, and dexterity in the joints on either side of your fused finger as well as your other fingers, wrist, hand, elbow, and even shoulder. As the motion of your fused joint will be permanently lost, it is of paramount importance to maintain the range of motion, strength, and dexterity in the joints surrounding the fusion in order to be able to continue to use your hand functionally.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of range of motion and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of rehabilitation equipment such as mini pulleys, putty, elastics or balls for strengthening and gripping resistance. In addition to strengthening your grip we will educate you on ways to grip and support items in order to do your daily tasks by compensating for your surgical finger but without putting too much stress on your healing fusion or the other joints.

If necessary, your Physical Therapist will mobilize the joints above and below your fused joint or any other joint in the area that is stiff and impeding movement of your hand and limb. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion.

Being able to move your hand and finger so that you can complete your work tasks and daily activities is the goal for our therapy at First Choice Physical Therapy. Maximizing dexterity can greatly improve the functional use of your hand. For this reason, we will also incorporate functional activities like picking up items from a table or twisting items into place using your surgical hand. These functional activities encourage the joints and the muscles of the hand and arm to work in unison, which is critical to maximizing the use of your overall upper limb. Exercises where weight is put through your fused joint, such as pressing the pad of your finger into something, will also be added when appropriate to encourage the fusion to tolerate weight in a controlled fashion.

When you are well underway, regular visits to First Choice Physical Therapy will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. Generally, the majority of your gains from Physical Therapy will occur within the first 1-2 months after the joint is fused.  Since the fused joint does not move and therefore does not need any therapy to gain range of motion itself, improvements with therapy at First Choice Physical Therapyafter a finger joint fusion are noticed very quickly.

Generally the Physical Therapy we provide at First Choice Physical Therapy after finger joint fusion occurs without any complications.  If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the joint fusion is tolerating the rehabilitation well and to ensure that there are no hardware issues that may be impeding your recovery.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications with a fusion of the finger are highlighted below:

• reaction to the anesthesia
• infection
• nerve damage
• nonunion

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs that the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss these risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Fusing the finger joint is no different. You will probably be given antibiotics before the operation to reduce the risk of infection.  If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the hardware. In these cases, the hardware may need to be removed.

Nerve Damage

All of the nerves and blood vessels that go to the finger travel across, or near, the finger joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerve injury has come from the nerve being stretched by retractors during the surgery holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels during this surgery, but it is possible.

Nonunion

Sometimes the finger bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (Pseud means false, and arthro means joint; a pseudarthrosis refers to the motion at a false joint.) If the motion from a nonunion continues to cause pain, you may need a second operation to try to get the bones to completely fuse. This may mean adding a bone graft and making sure that any metal pins that have been used are holding the bones still to allow the fusion to occur.

Welcome to First Choice Physical Therapy’s resource on thumb fusion surgery.

Thumb arthritis may be surgically treated with a fusion procedure. The bones that form the thumb joint are set so they can grow together, or fuse. A fusion keeps the problem joint from moving so that pain is eliminated.

This guide will help you understand:

• which parts of the thumb are involved
• why this type of surgery is used
• how the operation is performed
• what to expect before and after surgery
• First Choice Physical Therapy’s guide to rehabilitation after surgery

Which parts of the thumb are involved?

The carpometacarpal joint of the thumb (CMC joint) is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb as it is the joint closest to the bottom of the hand. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition.

Several ligaments (bands of strong tissue) hold the bones of the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful. Osteoarthritis is the most common form of arthritis occurring at this joint.

What does the surgeon hope to achieve?

When the articular cartilage wears out, the CMC joint becomes arthritic. The joint becomes painful when the thumb is used for gripping and pinching.

Joint fusion is a procedure that joins the surfaces of the thumb metacarpal and the trapezium bone so that they don’t move or cause pain. This surgery is usually done on younger patients who need a lot of thumb strength for their job, such as carpenters who need to use a hammer all day. Once the CMC joint is fused, the pain goes away. They lose joint movement, but they still have a good ability to grip and pinch. Joint fusion of this joint is used when all other potential forms of treatment, including a joint replacement, have been exhausted.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made together by you and your surgeon. Your Physical Therapist may also liaise with your surgeon to confirm the types of therapy techniques trialed and confirm the ineffectiveness of conservative therapy. You need to understand as much about the procedure as possible. Any concerns or questions you have should be brought up to your surgeon.

Once you decide to go ahead with surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The length of time you spend in the hospital depends on a variety of factors including the ease of the surgery, your body’s reaction to the surgery, as well as any complications that can, but rarely occur.

What happens during the operation?

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution.

An incision is made on the side of the thumb just over the CMC joint. Special care is taken not to damage the nearby nerves going to the thumb.  The joint capsule surrounding the CMC joint is then opened so that the surgeon can see the joint surfaces. The articular cartilage is removed from both joint surfaces to leave two surfaces of raw bone. A special tool is used to hollow the end of the thumb metacarpal to form a socket. The surface of the trapezium is shaped into a rounded cone that fits into the socket inside the thumb metacarpal.

The surgeon places a metal pin through the center of both bones and then connects the cone and socket snugly together. The metal pin allows the surgeon to hold the two bones in the correct alignment and prevents the bones from moving too much as they grow together, or fuse.

The soft tissues over the joint are then sewn back together. The forearm and hand are placed in a cast until the bones completely fuse together. This takes about six weeks.

What happens after surgery?

After surgery, you will be fitted with an elbow-length cast for about 6 weeks. This gives the ends of the bones the opportunity to fuse together. Your surgeon will want to check your hand within five to seven days. Stitches may need to be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medication to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. Ice may also be used at this stage for pain relief.

What should I expect during my rehabilitation period?

As mentioned above, you will wear a cast on your arm and hand for about six weeks to give the fusion time to heal. When the cast is removed, you may have stiffness or pain in the joints closest to the fused joint or pain around the surgical incision.  Physical Therapy at First Choice Physical Therapy will help relieve your pain and decrease the stiffness in the surrounding joints.

In order to decrease pain we may use modalities such as heat, ice, or electrical current.  These will assist with managing pain and any ongoing swelling you have around the surgical site, anywhere along the arm, or into the hand. Massage to these areas may also be done in order to improve circulation and assist with easing any discomfort. Some of the muscles of the neck may also be painful from having the arm in a cast for an extended period. These muscles may also benefit from massage treatment, which will make movement of your entire surgical side easier.

The next part of our treatment will focus on regaining the range of motion, strength, and dexterity in the joints on either side of your fused thumb as well as your other fingers, wrist, hand, elbow, and even shoulder. As the motion of your fused thumb joint will be permanently lost, it is of paramount importance to maintain the range of motion, strength, and dexterity in the joints surrounding the fusion in order to be able to continue to use your hand functionally.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of rehabilitation equipment such as mini pulleys, putty, elastics or balls for strengthening and gripping resistance. In addition to strengthening your grip we will educate you on ways to grip and support items in order to do your daily tasks by compensating for your surgical joint but without putting too much stress on your healing fusion or the other joints.

If necessary, your Physical Therapist will mobilize the joints above and below your fused CMC joint or any other joint in the area that is stiff and impeding movement of your hand and limb. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion.

Being able to move your hand and thumb so that you can complete your work tasks and daily activities is the goal for our therapy at First Choice Physical Therapy. Maximizing dexterity can greatly improve the functional use of your hand. For this reason, we will also incorporate functional activities like picking up items from a table or twisting items into place using your surgical hand. These functional activities encourage the joints and the muscles of the hand and arm to work in unison, which is critical to maximizing the use of your overall upper limb. Exercises where weight is put through your fused joint, such as pressing the pad of your thumb into something, will also be added when appropriate to encourage the fusion to tolerate weight in a controlled fashion.

When you are well underway, regular visits to First Choice Physical Therapy will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. Generally, the majority of your gains from Physical Therapy will occur within the first 1-2 months after the joint is fused.  Since the fused joint does not move and therefore does not need any therapy to gain range of motion itself, improvements with therapy at First Choice Physical Therapyafter a CMC joint fusion are noticed very quickly.

Generally the Physical Therapy we provide at First Choice Physical Therapy after CMC joint fusion occurs without any complications. If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the joint fusion is tolerating the rehabilitation well and to ensure that there are no hardware issues that may be impeding your recovery.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications with a fusion of the CMC joint of the thumb are highlighted below:

• reaction to the anesthesia
• infection
• nerve damage
• nonunion

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs that the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss these risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Fusing the CMC joint of the thumb is no different. You will probably be given antibiotics before the operation to reduce the risk of infection.  If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the hardware. In these cases, the hardware may need to be removed.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the thumb joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerve injury has come from the nerve being stretched by retractors during the surgery holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels during this surgery, but it is possible.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (Pseud means false, and arthro means joint; a pseudarthrosis refers to the motion at a false joint.) If the motion from a nonunion continues to cause pain, you may need a second operation to try to get the bones to completely fuse. This may mean adding a bone graft and making sure that any metal pins that have been used are holding the bones still to allow the fusion to occur.

Welcome to First Choice Physical Therapy’s resource about artificial joint replacement of the finger.

If nonsurgical treatments are not successful in easing problems of finger arthritis, your doctor may recommend replacing the surfaces of the joint. Joint replacement surgery is called joint arthroplasty.

This guide will help you understand:

• what parts make up the finger joint
• how the operation is performed
• what to expect before and after surgery
• First Choice Physical Therapy’s guide to rehabilitation after surgery

What parts of the finger are involved?

The finger joints work like hinges when they bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand to the finger bone, or phalange. Each finger (the thumb is not termed a finger) has three phalanges, separated by two interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).

Ligaments are tough bands of tissue that connect bones together. Several ligaments hold the joints together in the finger. These ligaments join to form the joint capsule of the finger joint. The joint capsule is a watertight sac around the joint. The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy material that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful. Rheumatic arthritis is a different form of arthritis (which develops due to an autoimmune disorder and is more widespread in the body) but can also cause wearing out of the joint surfaces and also deformity of the joints.

Why is an artificial joint replacement done for a finger?

Arthritic joint surfaces can be a source of stiffness, pain, and swelling. Many of these symptoms will respond to Physical Therapy at First Choice Physical Therapy but when the symptoms don’t respond or become too much to bear, a joint replacement may be suggested. The artificial joint is used to replace the damaged joint surfaces so patients can do their activities with freedom of movement and less pain.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. Your Physical Therapist may also liaise with your surgeon to confirm the types of therapy techniques trialed and confirm the ineffectiveness of conservative therapy. You need to understand as much about the joint replacement procedure as possible. Any concerns or questions you have should be brought up to your surgeon.

Once you decide to go ahead with the joint replacement surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor.

This exam helps ensure that you are in the best possible condition to undergo the operation.

A preoperative visit to one of our Physical Therapists at First Choice Physical Therapy will also help to prepare you for your surgery. We will start to teach you some of the rehabilitation exercises you will use during your recovery. It is often easier to try these exercises prior to the surgery, when there is no surgical pain and you are feeling well. Your Physical Therapist at this time can also help you anticipate any special needs or problems you might have at home, once you are released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. If a general anesthesia is used then the length of time you spend in the hospital depends a lot on your recovery from the anesthesia after surgery. In general, finger joint surgery can be done on an outpatient basis, meaning you can leave the hospital the same day.

What happens during the operation?

The Artificial Finger Joint

Surgeons use silicon plastic implants to replace the original joint surfaces. The artificial joint functions the same way a hinge on a door does.

The Operation

The procedure takes about two hours to complete. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have had the anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution.

An incision is made across the back of the finger joints that are to be replaced. The soft tissues are spread apart with a retractor. Special care is taken not to damage the nearby nerve that passes by the joint. The joint is exposed. The ends of the bones that form the finger joint surfaces are taken off, forming flat surfaces.

A burr (a small cutting tool) is used to make a canal into the bones that form the finger joint.

The surgeon then sizes the stem of the prosthesis to ensure a snug fit into the hollow bone marrow space of the bone. The prosthesis is inserted into the ends of both finger bones.

When the new joint is in place, the surgeon wraps the joint with a strip of nearby ligament to form a tight sac. This gives the new implant some added protection and stability.

The soft tissues are sewn together, and the finger is splinted and bandaged.

What happens immediately after surgery?

As mentioned above, after surgery, your finger will be bandaged with a well-padded dressing and a splint for support. The splint will keep the finger in a straightened position during healing. Some patients are placed in an arm-length cast with the finger in a straightened position for about three weeks after the prosthesis is implanted. Some only have the splint extend up to the wrist.  Your surgeon will want to check your hand in five to seven days. Stitches may need to be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medication to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. Ice may also be used at this stage for pain relief.

What should I expect during my rehabilitation?

Physical Therapy will begin once your surgeon allows it. The time frame regarding when you can move your finger after surgery will depend on several factors including your surgeon’s opinion, the type of replacement used, and potentially other factors that are specific to your injury or recovery. Many patients will be able to start doing general finger range of motion exercises a few days after surgery whereas others will be asked to wait 2-3 weeks before beginning any motion to allow further healing time. Generally, once therapy begins, you will be fitted with a removable supportive finger splint that can be taken off to do your exercises but should be worn at all other times including at night.

As your rehabilitation progresses your surgeon or Physical Therapist will determine when it is no longer necessary to wear this splint. Generally it is removed during daytime activities before it is removed completely at night. It may even be needed for up to 3 months post surgically.

Your first Physical Therapy sessions at First Choice Physical Therapy will focus on relieving the pain associated with the surgical process as well as the immobilization. We may use modalities such as heat, ice, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere along the arm, or into the shoulder or hand. Massage to these areas may also be done in order to improve circulation and assist with the pain.  Depending on how extensive the splint was some of the muscles of the neck may also initially be painful and therefore may also benefit from some massage treatment to make movement of your entire surgical side easier.
The next part of our treatment will focus on regaining the range of motion, strength, and dexterity in your finger, wrist, hand, elbow, and even shoulder. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of range of motion and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of rehabilitation equipment such as mini pulleys, putty, elastics or balls for strengthening and gripping resistance. In addition to strengthening your grip we will educate you on ways to grip and support items in order to do your tasks without putting too much stress on your new finger joint.

If necessary, your Physical Therapist will mobilize your finger joint or any other joint in the area that is stiff and impeding normal movement of your hand and limb. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion.

Being able to move your hand and finger so that you can complete your work tasks and daily activities is the goal for our therapy at First Choice Physical Therapy. Maximizing dexterity can greatly improve the functional use of your hand.  For this reason, we will also incorporate activities like picking up items from a table or twisting items into place using your surgical hand. These functional activities encourage the joints and the muscles of the hand and arm to work in unison, which is critical to maximizing the use of your entire upper limb. Exercises where weight is put through your new joint, such as pressing the pad of your finger into something, will also be added, when appropriate, to encourage the joint to tolerate weight in a controlled fashion.

When you are well underway, regular visits to First Choice Physical Therapy will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. Generally, the majority of your gains from Physical Therapy will occur within the first 2-3 months after the joint is replaced, but ongoing tissue remodeling will occur even up to 12 months post-surgery.

In the majority of cases the Physical Therapy we provide at First Choice Physical Therapy after finger joint replacement surgery occurs without any complications.  If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the joint replacement is tolerating the rehabilitation well and to ensure that there are no hardware issues that may be impeding your recovery.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications with an artificial joint replacement of the finger are highlighted below:

• reaction to the anesthesia
• infection
• nerve damage
• prosthesis failure

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs that the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss these risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Replacing the finger joint is no different. You will probably be given antibiotics before the operation to reduce the risk of infection.  If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the hardware. In these cases, the hardware may need to be removed.

Nerve Damage

All of the nerves and blood vessels that go to the finger travel across, or near, the finger joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerve injury has come from the nerve being stretched by retractors during the surgery holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels during this surgery, but it is possible.

Prosthesis Failure

Unfortunately artificial replacement prosthesis can fail. The older silicon-type prosthesis has been shown to break apart and fragment. Most types of prostheses have the potential to displace, or move out of the correct position, causing problems. Most of these problems will require a second operation to remove and replace the prosthesis.

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families. This condition is seven times more common in men than women. It is more common in men of Scandinavian, Irish, or Eastern European ancestry. Interestingly, the spread of the disease seems to follow the same pattern as the spread of Viking culture in ancient times. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

Both non-surgical and surgical treatment options are available for Duputryen’s contracture, but this guide will focus on the surgical option. For more information on the non-surgical options, refer to A Patient’s Guide to Dupuytren’s Contracture.

In regards to surgical procedures a partial palmar fasciectomy remains the “gold standard” procedure, although at earlier stages of this disease a less invasive surgical procedure called a needle aponeurectomy may be done.

It should be noted that surgical treatment does not always stop or cure this disease process, so recurrence can occur.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the operation
• what to expect after the procedure
• First Choice Physical Therapy’s approach to rehabilitation after surgery

What part of the hand is affected?

The palmar fascia lies under the skin on the palm of the hands and fingers. This fascia is a thin sheet of connective tissue shaped somewhat like a triangle. It covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against the front of the fingers. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture forms when the palmar fascia begins to thicken and tighten, causing the fingers to bend.

This condition commonly first shows up as a thick nodule (knob), or a short cord in the palm of the hand, just below the ring finger. More nodules form and the tissues thicken and shorten until the finger cannot be fully straightened.

What is the goal of surgery?

Many cases of Dupuytren’s contracture progress to the point where surgery is needed. The goal of surgery is to remove the diseased fascia, allowing the finger to straighten out again. By removing the tight cords and fascia, the tension on the finger is released. Once the fibrous tissue is removed, the skin is sewn back together with fine stitches.

In some cases, grafting extra skin is necessary in the area close to the incision to give the finger more flexibility to straighten. Skin grafting is more commonly necessary in severe Dupuytren’s contractures that have been present for many years. Over this lengthy time the skin itself also contracts. When the contracture or the cord is released, the skin cannot stretch enough to allow the finger to straighten. Skin is added, or grafted into place to allow the finger to straighten without being held back by the tight skin of the palm.

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. Your Physical Therapist may also provide input regarding failed conservative (non-surgical) treatment, which may lead you to the option of surgical treatment. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

Surgery for Dupuytren’s Disease is commonly performed as an outpatient, meaning that you will probably go home the same day. The surgical procedure may be performed in an operating room in a surgery center or hospital. The needle aponeurotomy may be performed in the office setting. On the day of your surgery, you will arrive at the location chosen by the surgeon and the staff will register and prepare you for the procedure. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Needle Aponeurotomy (Percutaneous Fasciotomy)

The needle aponeurotomy is available when the disease is at an early stage. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough so that when the surgeon straightens the finger the cord will snap or rupture and this allows the finger to straighten. The diseased tissue is not removed. This type of procedure can be done in an office setting.

Needle aponeurotomy may be used when a patient has a contracture that’s due to a palpable cord lying beneath the skin. It does not work for non-Dupuytren’s related contractures. The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is there can be a high recurrence rate because the diseased tissue remains and can continue to contract. There is also the potential for nerve injury, infection, and hematoma (pocket of blood) formation. These complications are similarto the open procedure.

Palmar Fascia Removal (palmar fasciectomy)

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic (one that puts you to sleep during surgery), or a local anesthetic (one that only numbs the hand). With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution. An incision will be made in the skin. Several types of incisions can be made, but yours will most likely be made along the natural creases and lines in the hand. This will help make the scar less noticeable once the hand is healed.

Once the palmar fascia is exposed, it will be carefully separated from nerves, arteries, and tendons. Special care is taken not to damage the nearby nerves and blood vessels.
Next your surgeon will remove enough of the diseased palmar fascia to allow you to straighten your finger(s). If the problem has been ignored for a long time, the joint capsule or the ligaments of the joint may also be stiff or contracted. The surgeon may therefore also need to release these tissues in order to allow the finger to straighten normally. Once the fibrous tissue is removed, the skin is sewn back together with fine stitches.

A skin graft may be needed if the skin surface has contracted so much that the finger cannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following surgery for Dupuytren’s contracture are:

• anesthesia related issues
• infection
• nerve and blood vessel damage

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection of the incision is one possible complication after surgery. Therefore, check your incision every day as instructed by your surgeon. If you think you have a fever, take your temperature, as this is a sign of infection. If you have a fever or other signs of infection or other complications, call your surgeon right away.

Nerve or Blood Vessel Damage

There are many nerves and blood vessels in the hand. It is possible, though uncommon, that these structures can be injured during surgery. If an injury occurs, it can be a serious complication. Injury to nerves can cause numbness or weakness of the hand. Repairing an injury to the blood vessels may require additional surgery.

What happens after surgery?

After a needle aponeurotomy, small adhesive bandages may be applied, or a light gauze wrap. Elevation and ice are recommended for several days following the procedure. Rehabilitation will begin once these bandages are removed.

After a partial palmar fasciectomy, your hand will be bandaged with a well-padded dressing and a splint for support. The splint will keep the hand open and the fingers straight during healing. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. Due to the many nerves found in the hand, you may have some discomfort after surgery. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation will generally begin after your stitches are removed, or as soon as your surgeon feels it is appropriate.

What should I expect during my recovery?

Extensive Physical Therapy is not required after a needle aponeurotomy, however a few sessions at First Choice Physical Therapy will start your recovery on the right track.  Your Physical Therapist will do some gentle stretching with you and provide you will home exercise regime that you will do independently. You should not be doing any strenuous gripping for one week after your aponeurotomy.  After this time you will be able to return to activities as tolerated. Occasionally a splint is prescribed for night use.

Rehabilitation after a palmar fasciectomy is considerably more extensive. Although the time required for recovery varies, as a guideline, you may expect to attend Physical Therapy sessions for up to six weeks. Our Physical Therapist may apply heat treatments, soft tissue massage, and a program of vigorous stretching. Our Physical Therapist at First Choice Physical Therapy will provide you with a personalized program to speed your recovery.

Attending the recommended Physical Therapy sessions can make the difference to a successful result after fasciectomy surgery. These sessions are important in limiting the buildup of scar tissue, preventing the return of contractures, and getting the most benefit from surgery.

Our Physical Therapist may recommend that your wear a splint at night for up to six months after surgery. It is used to keep the joints straight, and prevent new contractures from forming. You will gradually be able to put your hand to use, and should be able to straighten all joints within about four to eight weeks or sometimes slightly longer.

At First Choice Physical Therapy, our goal for Physical Therapy is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of independently doing your exercises as part of an ongoing home program.

Generally Physical Therapy at First Choice Physical Therapy occurs without any issues, and full recovery occurs provided our advice is closely followed. If, however, your recovery is not progressing as your Physical Therapist feels it should, we will ask you to return to your surgeon for a follow-up visit to ensure there are no complications, which are impeding your recovery.

Carpal Tunnel Syndrome (CTS) is a condition affecting the wrist and hand. While the most common surgical procedure for carpal tunnel syndrome is still the open-incision technique, some surgeons are using a new procedure, called endoscopic carpal tunnel release.

This procedure is done using an endoscope (a small, fiber-optic TV camera) to look into the carpal tunnel through a small incision just below the wrist. Using the camera allows the surgeon to release the problematic tissue without disturbing the overlying tissues.

This guide will help you understand:

• what part of the wrist is treated during surgery
• how surgeons perform the operation
• what to expect before and after the procedure
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the wrist is treated during surgery?

The carpal tunnel is an opening through the wrist into the hand that is formed by the bones of the wrist (carpal bones) on one side and a ligament, the transverse carpal ligament, on the other (ligaments connect bones together.) The transverse carpal ligament is at the base of the wrist and crosses from one side of the wrist to the other (transverse means across). It is sometimes referred to as the carpal ligament.

The median nerve, as well as the flexor tendons of the fingers pass through the carpal tunnel. The median nerve rests on top of the tendons, just below the carpal ligament. Between the skin and the carpal ligament is a thin sheet of connective tissue called the palmar fascia.

CTS is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment or compressive neuropathy. The carpal tunnel cannot expand so any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of CTS. Any increase in pressure within the carpal tunnel can reduce blood flow to the median nerve, leading to symptoms and loss of nerve function.

What does the surgeon hope to achieve?

Endoscopic carpal tunnel release surgery releases the carpal ligament, taking pressure off the median nerve. By using the endoscope, surgeons can accomplish this without disrupting the nearby tissues.

Proponents of the procedure feel that patients heal quicker than with an open surgery, are able to use their hand faster, and have fewer problems regarding tenderness of the palmar incision. Other physicians, however, are not convinced that this procedure for releasing the carpal ligament is better than the open-incision technique.

On the negative side, the endoscopic method is more technically demanding and can be more expensive in most hospitals. There may be a higher complication rate with this procedure involving incomplete release of the carpal ligament or injury to the median nerve inside the carpal tunnel. As more and more surgeons choose to use this method, these questions will likely be resolved.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. This surgery can usually be done as an outpatient procedure, meaning that you can leave the hospital the same day.

What happens during the operation?

The surgery is occasionally done using a general anesthetic (one that puts you to sleep). More often, however, a regional anesthetic is used. A regional anesthetic blocks the nerves going to only a portion of the body. Injection of medications similar to lidocaine are used to block the nerves for several hours. This type of anesthesia could be used for an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep). The surgery can also be performed by simply injecting lidocaine around the area of the incision.

Once anesthesia is achieved, your surgeon will make sure the skin of your wrist area is free of infection by cleaning the skin with a germ-killing solution.

The surgeon nicks the skin to create a small opening just below the crease in the wrist where the palm starts. This opening allows the surgeon to place the endoscope into the carpal tunnel. Some surgeons make a second small incision within the palm of the hand, however the procedure using a single incision is becoming more popular. The incision allows the surgeon to open the carpal tunnel just below the carpal ligament.

Once the surgeon is sure that the instruments can be passed into the carpal tunnel, a metal or plastic cannula (a tube with a slot on the side) is placed alongside the median nerve. The endoscope can be placed into the tube to look at the underside of the carpal ligament, making sure that the nerves and arteries are safely out of the way.

A special knife is inserted through the cannula. This knife has a hook on the end that cuts backwards when the knife is pulled back out of the cannula. Once the knife is pulled all the way back, the carpal ligament is divided, without cutting the palmar fascia or the skin of the palm.

Once the carpal ligament is divided there is more space available in the carpal tunnel, which means the median nerve is no longer compressed.

After the carpal ligament is released, the surgeon stitches just the skin openings and leaves the loose ends of the carpal ligament separated to keep pressure off the median nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue.

What happens immediately after surgery?

After surgery, the incision is wrapped in a soft dressing or simply covered with a bandage. Your surgeon may splint and wrap the wrist.

You’ll be scheduled to see your doctor in 10 to 12 days for a follow-up. Your surgeon may need to take out one or two of the stitches if they haven’t already been absorbed into your body.

Call your surgeon’s office if you feel your hand is not healing as it should.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems, which are:

• anesthesia complications
• infection
• incision pain
• persistent symptoms
• incomplete ligament release
• hand weakness

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection is a possible complication after surgery, especially infection of the incision. The warning signs of infection (or possibly other complications) are:

• pain in your hand that is not relieved by your medication
• discharge with an unpleasant odor coming from your incision
• swelling, heat, and redness along your incision
• chills or fever over 100.4 degrees Fahrenheit or 38 degree Celsius
• bright red blood coming from your incision

To monitor for an infection check your incision every day as instructed by your surgeon. If you think you have a fever monitor your temperature. If you have signs of infection or other complications, call your surgeon right away.

Incision Pain

Some patients report having pain along the palmar incision, but this complication occurs less than when people have an open release procedure. Sometimes people still feel some numbness and tingling after surgery, especially if they had severe pressure on the median nerve prior to surgery. If the thenar (thumb) muscles prior to surgery have notably shrunken (atrophied) from prolonged pressure on the median nerve, strength and sensation may not fully return even after having this type of surgery.

Persistent Symptoms

There is a small chance that problems of CTS don’t go away completely. Sometimes symptoms come back after having the endoscopic release surgery. A return of symptoms is rare, but the likelihood is greatest in workers who go back to a job where they hold on to vibrating tools for long hours.

Incomplete Ligament Release

Releasing the carpal ligament using an endoscope requires skill and experience. One drawback of this procedure is incomplete release of the carpal ligament. When this occurs, symptoms may not go away completely. Some patients end up needing a second surgery to completely release the carpal ligament.

Hand Weakness

Muscles that are used to squeeze and grip may seem weak after surgery. During normal gripping, the tendons of the wrist press outward against the carpal ligament. This allows the carpal ligament to work like a pulley to improve grip strength. People used to think that the tendons lose this mechanical advantage after the carpal ligament has been released causing hand weakness. Recent studies, however, indicate that hand weakness is more likely from pain or swelling that occurs in the early weeks after the procedure rather than from lost mechanical advantage. With the exception of patients who have severe atrophy at the time of surgery, most people achieve normal hand strength within two to four months of surgery with the assistance of Physical Therapy. Those with severe atrophy commonly see improvements in hand strength, but they rarely regain normal size of the thenar muscles.

What should I expect after surgery?

Physical Therapy at First Choice Physical Therapy will begin once your surgeon allows it. Often therapy can begin nearly immediately after your initial follow up visit with your surgeon. Even before that time your surgeon may have suggested you do some gentle finger motion exercises to start moving the tendons and tissues at the surgical site.
Your first few Physical Therapy sessions at First Choice Physical Therapy will focus on relieving the pain associated with the surgical procedure itself. Your therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere along the arm or into the hand. Massage to these areas may also be done in order to improve circulation and assist with the pain.

The next part of our treatment will focus on regaining the range of motion and strength in your wrist and hand, and if restricted also in your elbow, and shoulder. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of range of motion and strengthening exercises that you will practice in the clinic and also learn to do as part of a home exercise program. If scar tissue builds up and impedes the motion of the tendons or nerves at the surgical site, similar symptoms to those you experienced before the surgery can occur.  For this reason your therapist will teach you special range of motion exercises for your hand, wrist, elbow and shoulder that help to glide the tendons and nerves of the wrist through the surgical site.

Strengthening exercises may include the use of rehabilitation equipment such as putty, elastics, as well as small weights or balls in order to add strengthening and gripping resistance. Strengthening of the muscles that bend your wrist up as well as those that move the thumb will be specifically focused on since these muscles are supplied by the median nerve so they may have specifically lost strength due to the CTS.  Most light exercises can be started fairly quickly but heavy grasping or pinching will not be encouraged until about 6 weeks post surgery in order to avoid the tendons pushing out against the healing carpal ligament. In addition to strengthening your wrist muscles and grip strength we will educate you on ways to hold items and use your wrist and hand such that you don’t put unnecessary stress on your healing tissues and to avoid any future pain.

If necessary, your Physical Therapist will mobilize the joints of your wrist or hand if they are particularly stiff after the surgery. This hands-on technique encourages the stiff joints to move gradually back into their normal range of motion.

Being able to use your wrist fully so that you can complete your work tasks and daily activities is the goal of our therapy at First Choice Physical Therapy. Maximizing dexterity and fine motor control of the hand can greatly improve the functional use of your hand and wrist.  For this reason, as part of your rehabilitation we will also include activities such as picking up items from a table, twisting items into place, or doing tasks with your hand that are similar to your regular work or sporting activities. These functional activities encourage the joints and the muscles of the hand and wrist to work in unison, which is critical to maximizing the use of your entire upper limb.

A final, but extremely important part of our treatment for you at First Choice Physical Therapy following endoscopic carpal tunnel release is to discuss your overall posture and alignment. Pressure in your wrist can stem not only from direct pressure at the wrist but also from compensatory posturing patterns that start even as high up as the neck!  If you are required to sit for long periods at the computer you can easily develop poor posture which puts pressure on the nerves that run from the neck through the shoulder and elbow, and down into the wrist and hand. Poor elbow or wrist posturing as they rest on your chair or desk can also heavily contribute to an injury in the area.  Desk workers, however, are not the only sufferers from poor posturing. Anyone can be affected the same way if their posture is poor over a long period of time.  Correcting your posturing and doing exercises to strengthen the muscles that help to keep you in a proper posture position is crucial in avoiding further symptoms in the future. Your Physical Therapist will advise you on proper posturing while standing, sitting, and during other functional tasks, and if you are an office worker, they can also help you to adjust your workstation to ensure there is the least amount of strain on your body as possible.

When you are well underway, regular visits to First Choice Physical Therapy will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

In the majority of cases the Physical Therapy we provide at First Choice Physical Therapy after endoscopic carpal tunnel release surgery occurs without any complications.  If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that your wrist is tolerating the rehabilitation well and to ensure that there are no complications that may be impeding your recovery.

Thumb arthritis may be surgically treated with a procedure called resection arthroplasty or sometimes called excision arthroplasty. The term excision means to take out. In this surgery, the surgeon takes out a small bone at the base of the thumb and fills in the space with a rolled up section of tendon. The soft tissue forms a false joint that keeps the thumb somewhat mobile and stops pain by preventing the joint surfaces from rubbing together.

This guide will help you understand:

• which parts of the thumb are involved
• why this type of surgery is used
• what happens during the procedure
• what to expect before and after surgery
• what First Choice Physical Therapy’s approach to rehabilitation is

Which parts of the thumb are involved?

The carpometacarpal joint (or CMC joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC joint is the one that allows you to move your thumb into your palm, a motion called opposition.

Several ligaments (strong bands of tissue) hold the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful.

What does the surgeon hope to achieve?

The main goal of this surgery is to ease pain where the surfaces of the thumb joint are rubbing together. The surgeon uses a piece of tendon to form a spacer that separates the surfaces of the CMC joint. Unlike a fusion surgery that simply binds the joint together, excision arthroplasty can help take away pain while allowing the thumb joint to retain some movement.

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps to ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during surgery?

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution. An incision will be made which angles along the back of the thumb to the edge of the wrist. Special care is taken not to damage the nearby nerve going to the thumb.

The CMC joint and surrounding tissues are exposed. Next, the joint capsule surrounding the CMC joint is opened. The surgeon takes out (excises) the trapezium bone at the base of the thumb.

Next the surgeon removes a small section of one of the tendons near the thumb. The piece of tendon is sewn into a small ball and placed into the space where the trapezium bone was removed. The remaining portion of the tendon is sewn to the thumb metacarpal to stabilize the joint. The surgeon may also insert a surgical pin to connect and hold the metacarpal bones of the thumb and index finger. The pin protects the reconstructed joint and is usually removed three weeks after the surgery.

The soft tissues over the joint are sewn back together. The thumb is placed in a splint, and the hand is wrapped in a bulky dressing.

What happens after surgery?

After surgery, your thumb will be bandaged with a well-padded dressing and a splint for support. The splint will keep the thumb in a natural position during healing. You will be required to wear a thumb brace for up to six weeks to give the repair time to heal. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. If a surgical pin was used, it will be removed three weeks after surgery.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

You may have some discomfort after excision arthroplasty. You will be given pain medicine to control the discomfort.

What should I expect during my recovery period?

Physical Therapy treatment at First Choice Physical Therapy can begin as soon as you are no longer required to wear your thumb brace, and once your surgeon has given approval for you to begin your rehabilitation.  If some minimal support for your thumb continues to be required after wearing the rigid brace your Physical Therapist may tape your thumb or prescribe a small soft flexible brace that you can wear as needed while you begin your rehabilitation.

Your initial few Physical Therapy treatments will focus on relieving any lingering pain associated with the surgical process as well as the period of immobilization. Your Physical Therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere into your hand or along your arm. Massage to these areas may also be done in order to improve circulation and assist with the pain.

The next part of treatment will focus on regaining the range of motion, strength, and dexterity in your thumb, wrist, hand, elbow, and even shoulder. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of range of motion and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program.  Full motion of your thumb, including opposition, as well as motions enabling your thumb to extend fully away from your palm will be encouraged. The prescribed range of motion and strength exercises may include the use of rehabilitation equipment such as mini pulleys, putty, elastics or balls for strengthening and gripping resistance. In addition to strengthening your grip we will educate you on ways to grip and support items in order to do your tasks without putting too much stress on your new thumb joint.

If necessary, your Physical Therapist will mobilize your thumb joint or any other joint in the area that is stiff and impeding normal movement of your hand and limb. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion.

Minimizing or eliminating your pain as well as being able to move your hand and thumb so that you can complete your work tasks and daily activities is the goal of our therapy at First Choice Physical Therapy. Maximizing dexterity of your thumb and its fine motor abilities post surgically can greatly improve the functional use of your hand.  For this reason, we will also incorporate specific activities into your rehabilitation program like picking up items from a table or twisting items into place using your surgical hand. Other exercises might include activities that are specific to the tasks you personally need to complete on a regular daily basis, such as typing or picking up papers or dishes. These functional activities encourage the joints and the muscles of the hand and arm to work in unison, which is critical to maximizing the use of your entire upper limb. Exercises where weight is put through your new joint, such as pressing the pad of your thumb into different surfaces, will also be added when the thumb is ready.  These exercises encourage your surgical joint to tolerate weight in a controlled fashion.  Finally, your Physical Therapist will discuss ways that you can modify some of your regular activities in order to decrease the overall stress put on your thumb and to avoid problems with your thumb and hand in the future.

When you are well underway, regular visits to First Choice Physical Therapy will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. In most cases you will need to attend regular therapy sessions for one to two months, but you should expect full recovery to take up to four months.  Ongoing tissue remodeling will occur even up to 12 months post-surgery.

In the majority of cases the Physical Therapy we provide at First Choice Physical Therapy after resection arthroplasty of the thumb occurs without any complications.  If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the joint is tolerating the rehabilitation well and to ensure that there are no hardware issues that may be impeding your recovery.

What might go wrong due to surgery?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following resection arthroplasty are:

• anesthesia problems
• infection
• nerve damage

Anesthesia

Problems can arise when the anesthesia given during surgery, which causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Resection arthroplasty of the thumb is no different. You will probably be given antibiotics before the operation to reduce the risk of infection. If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the arthroplasty.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the CMC joint. Being that the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may only be temporary if the damage has been caused due to the nerve being stretched by surgical retractors, which hold the nerves out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.