Mr Prash Jesudason MB, ChB, MSc., FRCSEd (Trauma & Orth), Dip. Hand Surg (Br)
Small joint arthritis in the hand
What are the causes of arthritis?
The small joints of the hand commonly become arthritic. There are many causes. Primary osteoarthritis has a genetic cause and this tends to develop as we age. Osteoarthritis can also be secondary to disorders such as infection, previous trauma, gout and other causes of inflammation. Many years of manual labour can also predispose to arthritis.
What are the symptoms?
These vary in severity, but generally patients complain of stiffness, loss of function and pain. The pain is usually aggravated by activity.
What are the treatment options?
The treatment is tailored to the severity of symptoms:
What are the surgical options?
This is most predictable operation in terms of alleviating pain. The joint in question is permanently fused in a position of function. This converts a stiff, painful joint into a stiffened painless joint. In some respects we are “robbing Peter to pay Paul” as the surgeon sacrifices what movement is left to improve pain. Generally the results are excellent in terms of pain relief. Fusion is the treatment of choice in young patients and manual workers (as a joint replacement would wear out too quickly); and patients with painful, unstable joints.
The metacarpo-phalangeal joints (MCP joints) and proximal interphalangeal joints (PIP joints) and occasionally even the distal interphalangeal joints (DIP joints) can potentially be replaced with artificial joints. The two options are generally a hinged silicone implant, or in certain circumstances a metallic or pyrolytic carbon joint replacement. Pyrolytic carbon is a man-made material of pure carbon, with material properties similar to bone and very low friction, hence is a good bearing surface for a joint replacement.
What are the expected outcomes and possible complications?
Fusion of a finger joint almost always gives a pain free joint, wiith improved, but not normal function. The position of fusion of the joint is critical, and must be carefully decided on prior to surgery, often with a trial of joint splint to mimic the position of fusion. There is around a 5% chance that the bones don’t fuse (non-union), and around a 1% risk of infection, nerve or artery injury and an abnormal pain response. Sometimes the plates, screws or wires used to do the fusion need to be removed as a second procedure.
The results of finger joint replacements are also good, but in some respects less predictable than with a fusion. The patient satisfaction is generally very high, but the risks are loosening of the implant over time and need for further surgery; infection; stiffness; nerve / arterial injury; joint dislocation and fracture
What is the recovery period?
Theses operations need a careful period of rehabilitation. After a joint fusion, the joint must be splinted until the bones have fused together, usually around 6 weeks. However, motion of the neighbouring joints and the rest of the hand must be promoted with specific exercises. This usually requires a time off work and driving.
For a joint replacement, the joint also needs to be protected with a custom splint, but an intense and carefully tailored hand therapy regime is critical to obtain good motion and function.
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