1 FINGER JOINT ARTHRITIS & JOINT REPLACEMENT
Introduction In a joint replacement, the abnormal bone and lining structures of the joint are removed surgically, and new parts are inserted in their places. These new parts may be made of special metal or plastic or specific kinds of carbon-coated implants. The new parts allow the joints to move again with little or no pain. Finger joints (called Proximal Inter- Phalangeal or PIP joints), knuckle joints (called Metacarpal-Phalangeal or MCP joints), thumb joints (Carpometacarpal or CMC joints), and wrist joints can all be replaced. Artificial joints in the hand may help: Reduce joint pain Restore or maintain joint motion Improve the look and alignment of the joint(s) Improve overall hand function
Causes In a normal joint, bones have a smooth surface made of a substance called articular cartilage on their ends that allows one bone to glide easily against another. Joints are lubricated by a thin layer of fluid (synovial fluid) that acts like oil in an engine to keep parts gliding smoothly. When the articular cartilage wears out, is damaged, or the joint fluid is abnormal, problems develop, and joints often become stiff and painful. This is arthritis, which may be possible to treat with the joint replacement procedure.
How does arthritis affect the hand? A common osteoarthritic pattern of joint involvement in the hand is the thumb base and some of the DIPJs. Inflammatory arthritis more commonly affects the MCPJs of both hands rather evenly. Despite this both types of arthritis can affect any of the small joints of the hand.
What are the symptoms of arthritis in the fingers? Affected joints can be painful, swollen, misshapen (lumpy) and stiff. With inflammatory arthritis the supporting soft tissue structures can stretch out allowing the fingers to drift out of position from side to side.
How is the diagnosis of finger arthritis made? A characteristic story and examination suggest the diagnosis. X-rays usually confirm the diagnosis although these can be normal early on. Blood tests and more detailed scans can sometimes be useful. Certain other conditions may need to be excluded.
What treatments are available for finger arthritis? Most patients with this condition do not need surgery but manage with various combinations of painkillers, splints and activity modification. If an inflammatory cause is suspected medical treatment with drugs can be very useful and this might need to be discussed with a Rheumatology Consultant. Local anaesthetic and steroid injections into the repair the arthritis but does reduce the inflammation within the joint secondary to the arthritis. jointSometimes can dramatically the joint is more relieve painful symptoms, for a couple sometimes of days forafter prolonged these injections. periods. The The beneficial injection effects doesn’t of the steroid may take up to a week to become apparent. There is also a small risk of infection with these injections.
BMI Three Shires Hospital, Northampton Ramsay Woodland Hospital, Kettering BMI Saxon Clinic, Milton Keynes 01604 633730 [email protected] www.upperlimb.co.uk
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For persistent, severe symptoms surgery might need to be considered. This must be carefully considered for each joint and each patient to balance the risks of surgery against the potential functional benefits. Persistent, intrusive pain is a common indication for surgery as well as instability causing functional difficulties. Available options include ligament reconstruction, joint re-alignment, joint fusion and joint replacement. Your surgeon can advise you further.
Types of replacement At present there are three types of joint replacements used. Rubber (silicone), a metal/plastic combination, and pyrocarbon (a material almost as hard as diamond). In general soft replacements are used for patients with rheumatoid arthritis and hard replacements for those with osteoarthritis but this is not a rigid rule.
How is the operation performed? This is a day case operation. The choice of anaesthetic will be discussed by the anaesthetist, but may be a general anaesthetic, where you are asleep, or a nerve block where your arm is numb, supplemented with sedation if required. During the procedure arthritic diseased bone is removed and an artificial joint is inserted, often using X-ray help the alignment of the replacement.
What can I expect after surgery? Afterwards you will have a bulky dressing, with a plaster splint. The stability of the replacement at the end of the operation will determine the speed at which you can start to regain movement and strength. Local anaesthetic will be injected into the wound at the end of the operation. This area and the fingers will remain numb for up to six hours after surgery. Before the effect wears off, you should take painkillers which have been prescribed on a regular basis. Your hand will initially be placed in a plaster splint. Swelling causes stiffness and pain which is made worse by hanging the arm down at your side or resting it on your lap. Swelling is best prevented by keeping the hand above the level of the heart for the first 48 hours. You will be seen within a few days by the Hand Therapist. The dressings will be removed and the wound will be checked. You will be fitted for a bespoke splint, given advice and exercises to start immediately. Hand elevation remains important to prevent swelling and stiffness of the fingers. Please remember not to walk with your hand dangling, or sit with your hand held in your lap. If the hand becomes red, hot and very swollen you must go to your GP or the Emergency Department. An appointment will be made for the following week to check your exercises. You will be given a splint to wear at night which will rest the fingers in a safe position. You will also be given a day splint to help you start bending the fingers. The surgeon will see you in the outpatient clinic around 2 weeks. Any stitches present will be removed then. At this stage it is safe to get the hand wet. The wound and the surrounding skin often become very dry and will be more comfortable if a moisturiser is applied, including on the wound itself. Initially the scar will be thickened and tender to touch. This must be massaged firmly with a moisturising cream to reduce sensitivity and swelling.
BMI Three Shires Hospital, Northampton Ramsay Woodland Hospital, Kettering BMI Saxon Clinic, Milton Keynes 01604 633730 [email protected] www.upperlimb.co.uk
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After two weeks you can usually drive a car as long as you are comfortable and have regained full finger movements. Timing of your return to work varies with your occupation and this should be discussed with your therapist. It will take 3-6 months for the swelling to completely settle.
What are the main risks of this operation? The risks are low, but include: Pain - this usually settles over the first week and is usually moderate. Infection - this is unusual in the hand (less than 1% of cases). Local wound infections can often be treated with oral antibiotics. Rare, deep seated infections may require re-admission to hospital, antibiotics into the vein and occasionally more surgery. Nerve Damage - the nerves most at risk with these operations are the small skin branches supplying sensation around the scar on the back of the finger. The lost patch of skin sensation from these injuries might be irritating initially but will settle and it should not affect how your hand works. Swelling - in most people the general swelling reduces dramatically in the first week after the operation; this can be reduced by keeping the arm elevated and moving all the free joints as soon as possible. Local swelling can be helped by massaging the tissues and by using compressive tape (under the guidance of the Hand Therapist). Local swelling around the surgical site can persist for several months. 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. Chronic Regional Pain Syndrome (CRPS) - occasionally patients are troubled by more swelling and stiffness than average. In this case complex regional pain syndrome (CRPS) is sometimes the cause. Severe CRPS occurs in less than 1% of cases. 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 or failure of the replacement - this is the long term complication of the joint replacement and is almost inevitable Soft replacements can break over time and hard replacements can work loose in the bone. Either problem may require further surgery. Dislocation of the components - hard replacements have a separate part for each bone. These components can dislocate occasionally. Sometimes this can be sorted out with a simple manipulation of the joint (with an anaesthetic) and further splinting. Sometimes this is not enough and further surgery is necessary. Failure of Tendon Repair - this risk mainly relates to how your surgeon opened up your finger to do the operation. The opening can be through the back, side or front of the finger. Coming through the back of the finger the extensor tendon always has to be repaired. This is the tendon that straightens out your finger. Coming through the side the extensor tendon sometimes has to be repaired. If the tendon has been repaired this can sometimes fail to heal and occasionally this might mean more surgery is needed.
Recovery Therapy supervised by a trained hand therapist is almost always required after any joint replacement surgery, usually for several months. Special splints are generally used depending on which joint was replaced and how the surgery was done. To ensure the best results after joint replacement surgery, follow your in pain or swelling, and call your surgeon if your hand or wrist becomes red, hot or crooked. Call your surgeon or therapistsurgeon ifand you therapists’ have specific directions, questions call about your yoursurgeon new if joint(s). you experience a sudden increase
BMI Three Shires Hospital, Northampton Ramsay Woodland Hospital, Kettering BMI Saxon Clinic, Milton Keynes 01604 633730 [email protected] www.upperlimb.co.uk