If nonsurgical treatments are not successful in easing problems of finger arthritis, you may be need replacing the surfaces of the joint
Anatomy of small joints of hand
The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the MCP joint. It is formed by the connection of the metacarpal bone in the palm of the hand to the finger bone, or phalanx. Each 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 each finger joint together. 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.
Joint Replacement Surgery of the Hand At A Glance
Joint replacement surgery involves replacing a destroyed joint with an artificial joint.
This procedure is typically employed in treating severe arthritis involving certain joints.
Surgical options for treatment of arthritis of the hand include cleaning of the abnormal cartilage and bone, fusion, and replacement surgery.
Surgical options with the different joints of the hands and wrists.
Hand joint replacement surgery options differ according to the specific joint(s) involved.
DIP joint (joint closest to the fingertip) : This joint is not a good candidate for joint replacement. The bones are very small and do not hold the implant very well. The best treatment option for advanced arthritis at this joint is fusion. Hand function is only minimally compromised by lack of motion at this joint after a fusion procedure, while pain is relieved.
PIP joint (second joint from the fingertip) : Joint replacement is commonly performed in the PIP joint. Hand function, especially power grasp, can be hindered by fusion of this joint. The small and ring fingers are the best candidates for joint replacement as they are the most important for power grasp. The index finger is not a good candidate for a PIP joint replacement, as it must withstand sideways forces which accompany movements such as key turning and fine manipulation of objects. These forces cause excess stress on the joint implant and can lead to early implant breakage. The best results with PIP joint replacement are in patients with rheumatoid arthritis and in older, lower-activity patients.
MCP joint (third joint from the fingertip) : Osteoarthritis rarely affects the MCP joints. The most common need for joint replacement in this joint is destruction from rheumatoid arthritis.
Thumb basal joint (where the thumb meets the wrist): This joint is exposed to very high stresses with normal activities. Forces felt at the tip of the thumb are multiplied 12 times in their effect to the thumb base, thus predisposing this joint to wear. Arthritis of this joint is very common, especially in women, and frequently requires joint replacement. Attempts at silicone replacement of this joint have not been as successful as hoped due to implant failure and bone destruction. Thus, the most common joint replacement procedure for the thumb base is done with natural material. The procedure is termed the ligament reconstruction-tendon interposition procedure (LRTI). This procedure uses the patient's own tendon to stabilize the thumb and resurface the joint. LRTI provides stability and pain relief. Long-term results have been excellent. This has also been called the tendon roll or "anchovy" procedure because the tendon used is curled to form the new joint cushion.
Wrist joint : Most patients with wrist arthritis are best treated with surgical joint cleaning or fusion and not joint replacement. Most wrist-joint prostheses on the market are currently investigational and for use in extremely low activity patients with osteoarthritis or rheumatoid arthritis.
The risks are low, but include :
Infection - risk is low around 1%, but it occurs is a serious problem as control of infection can be difficult, due to the implant
Pain - This usually settles over the first week and is usually moderate.
Stiffness - Often the joint that is being replaced is very stiff. If this is the case the resultant movement after the operation will be limited. This is the most common complication in small joint replacements.
Swelling - The finger will remain swollen for 3 to 6 months
Nerve injury - Localised numbness around the wound may occur. It usually resolves with time.
Dislocation - This is a risk in the short term, before the tissues tighten. The risk is low, but if it does occur, a short anaesthetic is required to relocate the joint.
Loosening - This is the long term complication of the joint replacement and is almost inevitable. Once the joint is loose, it may become painful and swollen again. At that stage the majority of patients would have their replacement converted to a fusion. Hopefully though there have been many years of benefit!
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 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.
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. surgeon will want to check your hand in five to seven days. Stitches will be removed after 10 to 14 days, You may have some discomfort after surgery. You will be given pain medicine to control the discomfort you have.
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.
A physical or occupational therapist will direct your recovery program. Recovery takes up to three months after prosthesis is implanted.
The first few therapy treatments will focus on controlling the pain and swelling from surgery. Heat treatments may be used. Your therapist may also use gentle massage and other hands-on treatments to ease muscle spasm and pain.
Then you'll begin gentle range-of-motion exercise. Strengthening exercises are used to give added stability around the finger joint. You'll learn ways to grip and support items in order to do your tasks safely and with the least amount of stress on your new finger joint. As with any surgery, you need to avoid doing too much, too quickly.
Some of the exercises you'll do are designed to get your hand and fingers working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your finger joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.
The therapist's goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and fingers.