Arthritis is an inflammatory condition that affects the joints of the body, leading to significant joint pain and stiffness. Arthritis can severely impact a patient’s quality of life, not only due to the pain but also due to a restriction in range of motion. Thus, many patients are no longer able to participate in activities that they previously enjoyed.
In particular, arthritis can take a significant toll on hands, leading to significant pain, disability and even deformity. While several different surgeries are regularly conducted to treat arthritis, surgery to repair damage to the joints of the hand are rare. In fact, in 2009 less than 1000 surgeries of arthritic fingers were performed compared to almost one million hip and knee replacements.
There are two main types of surgeries that surgeons can perform for treatment of pain in patients with arthritis of the hand: fusion (arthrodesis) and total knuckle replacement (arthroplasty).
In a joint fusion surgery, the surgeon fuses the bones of the joint together, which helps create a strong and stable knuckle that is pain-free but is restricted in terms of flexibility of movement.
On the other hand, a knuckle replacement involves the removal of the damaged joint and replacement with an artificial implant. A knuckle replacement is conducted to provide pain relief and restore shape and function of the hand. However, the outcomes with a total knuckle replacement are less favorable compared to a total knee or hip replacement. One of the reasons for this is that the implants don’t fully duplicate normal finger motion. Furthermore, the implants are generally made from silicone rubber, which is flexible but can break and slip quite easily.
In fact, some studies have shown that 30 percent of silicone implants fail within 10 years post-surgery. Hence, this is often a poor choice for younger patients. Fortunately, over the past decade, implants have gotten significantly better as medical device companies continue to improve on the design. This includes using metal-and-plastic implants. However, even these are far from perfect. Doctors hope that metal-and-plastic implants are better, in the long-term, compared to silicone implants.
It is important to carefully weigh the pros and cons of getting an implant as many doctors find that even the best artificial joint is not as good as a damaged real joint with regards to movement and flexibility. However, this can be a feasible option if you experience significant pain in your hands. Thus, the question is, which one is better: fusion or replacement? Doctors explain that either surgery can be used depending on the joint that needs repair as well as patient characteristics such as age, level of activity and amount of finger stiffness. In fact, some patients will have different procedures performed on different joints in the same hand.
For patients who need repair of their knuckles, surgeons almost always perform a total knuckle replacement as it is important to maintain flexibility and motion in that region. These joints, known as metacarpophalangeal joints, are the largest in the hand and are therefore vital for functioning of the fingers. These are often damaged in patients with rheumatoid arthritis, one of the most common subtypes of arthritis.
Fortunately, with the introduction of disease-modifying anti-rheumatic drugs, surgeons no longer see as much severe deformity in these joints as before. In an ideal situation, conducting a total knuckle replacement will eliminate the pain and restore mobility to the joint. However, the outcome of the disease depends on the amount of the healthy tissue the person has. For example, in patients who have had rheumatoid arthritis for a long time, it is hard to get soft tissue to reconstruct around the implant, leading to significant failure over time. In these cases, the implants are likely to fail seven to 10 years post-surgery. However, even if the implant fails, it still keeps the bones from touching each other and therefore, the patient is still comfortable.
Surgery on the base of the hand
Patients with osteoarthritis often experience stiffness and significant loss of motion in the proximal interphalangeal joints, which are the second set of joints from the base of the hand. In this case, surgeons often perform joint replacement surgery as a way of relieving these symptoms, particularly in the middle and ring fingers that are needed to be flexible for motions such as griping. However, again, these implants can wear out quickly as these joints are used frequently. Therefore, in some cases, surgeons chose to perform a fusion instead as these joint can tolerate being stiffer compared to some of the other joints. Furthermore, a fusion is more reliable and a long-term solution to the problem.
Surgery on the ends of the fingers
Surgeons commonly perform a fusion to treat pain in the joints that are at the ends of the fingers in a joint known as the distal interphalangeal joint. This is because a fusion in this region leads to a stable, pain-free and functional joint. The disadvantage of performing a fusion is that in some cases, the fused bone can fail to grow together or properly align, causing the need for more surgery. Furthermore, while it has good results, motion is often further reduced. Therefore, this is considered as an option in patients have significant pain.