What happens in joint replacement surgery?
Joint replacement surgery involves replacing a destroyed joint
with an artificial joint. In knee or hip replacement surgery, the
artificial joint is made out of metal and plastic. In the case of
joint replacement in the hand, the new joint is most commonly
composed of silicone rubber or the patient’s own tissues such as a portion of
tendon.
Joint replacement surgery, also known as arthroplasty, is very
common. Each year, orthopedic surgeons perform thousands of joint
replacement surgeries in the U.S. (Most of these procedures are performed on the large weight-bearing joints such as the hips and knees.)
Joint replacement surgery in the hand is typically used in treating
severe arthritis that involves the small joints of the hand.
The hips and knees receive continuous stress from walking,
running, sporting activity, or injury and are more commonly affected
by the wearing of cartilage (degenerative arthritis) than the hand
joints. However, the joints of the hand do experience stress in
everyday use, and because the hand joints are smaller, these stresses
are concentrated over a smaller surface area. The high ratio of
stress to surface area can cause the smooth joint cartilage to wear
over the years. As the cartilage degenerates, the underlying bone
becomes exposed. When the deteriorated joint moves, bone rubs upon
bone causing pain, swelling, limiting motion, and frequently causing
a grinding or popping sensation. Furthermore, forms of arthritis
that are caused by inflammation of the tissues lining the joint
frequently affect the small joints of the hands and wrists to cause
joint destruction. Examples include rheumatoid arthritis and
psoriatic arthritis.
Ultrasound Imaging of Joints in Rheumatoid Arthritis (RA)
A traditional method of monitoring the joint disease of patients with rheumatoid arthritis is X-rays, whereby images are produced by exposing photographic film (radiographs). This technique has proven useful for doctors to follow the course of joint destruction. The early development of discrete bony destruction (erosions) is associated with more severe rheumatoid disease. While standard
X-ray radiographs contribute substantially to the clinical evaluation of rheumatoid arthritis, they do lack some sensitivity early in the course of disease. This means that substantial joint destruction must happen before changes on the standard
X-ray test become apparent.
Read more about ultrasound imaging of joints in rheumatoid arthritis »
What are symptoms and signs of arthritis of the hand and
wrist?
The most common symptoms of arthritis of the hands include pain,
stiffness, and swelling over the joints. The pain is usually worsened
when the joint is moved. Moreover, motion of the joint is frequently
limited due to pain and joint contractures. Symptoms can lead to
difficulty with daily living activities including tying shoes,
buttoning buttons, opening jars, or turning a key in a lock.
Physical signs of arthritis of the hand include changes in the
appearance of the joints. The joints most commonly affected by
degenerative arthritis are those at the ends of the fingers. Swelling
and bumps, or nodes, can occur at the small joints at the area of the
base of the nail. These bumps are called Heberden nodes and can
become extremely painful. The joint at the base of the thumb can
also become swollen with bone spurs and cause pain and deformity.
The joint destruction also leads to severe pain when pinching the
fingers together and gripping forcefully. Joint motion limitation
can also decrease the ability to grip.
Wrist arthritis can cause pain with motion of the wrist or
grasping and lifting. Wrist range of motion is frequently limited by
the arthritis. Patients typically experience relief when the wrist
is stabilized by a splint.
Rheumatoid arthritis frequently causes swelling, pain, and
stiffness in the wrists, as well as the small joints in the middle
and at the base of the fingers. This disease frequently causes hand
deformities. Tissue lumps called rheumatoid nodules can form over
the joints of the hand and wrist. The joints of the fingers and
thumb can become deformed and contracted by the destruction of the
supporting ligaments, so that grasping and pinching movements are not
possible.
How are patients with hand joint abnormalities evaluated?
The diagnosis of hand joint problems typically involves
evaluating symptoms, physical examination, and the x-ray appearance of
the joints. Blood testing is sometimes also helpful in the
assessment process. Joint replacement surgery becomes a treatment
option when significant joint destruction and/or deformity are
present.
What are the different surgical options?
Surgical options include
- cleaning of the abnormal cartilage and bone, including removal of bone
spurs, - fusion of the joint, and
- joint replacement surgery.
The optimal surgical treatment of arthritis of the hand and wrist
varies from patient to patient and is based on many factors. These
factors include the patient’s age, hand dominance, employment, level
of pain, functional goals, and underlying disease.
When is surgical cleaning of the joint the best alternative?
Surgical cleaning of the joint, or salvage procedure, is usually
performed in cases of early “wear and tear” arthritis where there are
painful bone spurs or, in cases of rheumatoid arthritis, where there
is a large amount of inflamed tissue. Removal of bone spurs is
especially helpful when the arthritis involves the joints at the ends
of the fingers (distal interphalangeal or DIP joints).
What is a joint fusion? When is it the best surgical
option?
Fusion of a joint involves removing the joint and
surgically “fusing” the bone ends so that the two bones effectively
become one solid bone. This procedure terminates all motion at that
joint and thus eliminates the pain. The benefit of fusion is pain
relief and the downside is elimination of motion at the fused joint,
which can hinder function. This surgical option is reserved for
patients with advanced arthritis.
Joint fusion is usually the best surgical option in patients who
are younger and very active. Younger patients may not be candidates
for joint replacement because of the increased stress demand on the
joints which accompany higher activity levels. This increased stress
demand can quickly wear out an artificial joint.
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When is joint replacement surgery the best surgical option?
Joint replacement surgery in the hand is an excellent option for
treating arthritis of the hand in older, low-activity patients and
for those with rheumatoid arthritis. Joint replacement surgery can
provide pain relief, increase finger range of motion, and improve
hand function.
How do the surgical options vary with the different joints of
the hands and wrists?
Hand joint replacement surgery options differ according to the
specific joint(s) involved.
1. 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.
2. 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.
There have been numerous false (prosthetic) joints designed for PIP
joint replacement, but only one has stood the test of time. The only
nonexperimental PIP joint replacement is the silicone
interpositional arthroplasty. These joints are made of silicone
rubber and have a flexible hinge in the middle and stems at the ends
which insert into the shaft of the bone, providing stability. The
most frequently used silicone joint implants are termed the Swanson
implant and the Sutter implant.
The best results with PIP joint replacement are in patients with
rheumatoid arthritis and in older, lower-activity patients.
3. 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.
Silicone joint replacement of the MCP joint has been used since the
1960s and has produced excellent long-term results.
4. 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.
5. 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.
Summary
Arthritis of the hand and wrist is a very common and complex
problem with many nonsurgical and surgical treatment options.
Deciding which alternative is best can require the skills of the primary
doctor, the arthritis specialist (rheumatologist), and/or an
orthopedic surgeon.
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.