Surgery for Aching Hands
Treating arthritic finger joints can relieve pain – but at a price.
Arthritis can take a heavy toll on hands, causing pain, deformity and disability. Yet surgery to repair the damage from hand arthritis is relatively rare. According to the Agency for Healthcare Research and Quality, fewer than 1,000 finger surgeries were performed in 2009 compared with nearly one million hip and knee replacements. One reason is that finger surgery has a high complication and failure rate and often sacrifices mobility for pain relief.
Still, for people who have severe pain not relieved by conservative measures, the trade-off can be worth it, according to hand surgeon Amy Ladd, MD, a professor of orthopaedic surgery at Stanford University Medical Center in Stanford, Calif.
"Pain relief is far and away the reason we perform surgical procedures [for hand arthritis]," she says.
Fusion vs. Replacement
The two main surgical options for hand arthritis are fusion (arthrodesis) and total knuckle replacement (arthroplasty). In arthrodesis, the bones of the joint are fused together, creating a stronger, more stable and essentially pain-free knuckle, but one with little flexibility or movement.
Arthroplasty involves removing the damaged joint and inserting an artificial implant in its place. The goal is to relieve pain and restore shape and some function in the hand, but the results are usually less satisfactory than with hip and knee replacements.
One problem is that hinged finger implants don't fully replicate normal finger motion. And most are made from silicone rubber, which is flexible but breaks and slips easily. Some studies have found that up to 30 percent of silicone implants fail within 10 years, making them a poor choice for younger patients.
"Over the last few years, implants have gotten much better, but they are far from perfect," Dr. Ruch says. "The hope is that some of the newer metal-and-plastic implants [which are designed more like a ball-and-socket joint] will hold up better than silicone."
Jose Ortiz, Jr., MD, a hand surgeon at Mayo Clinic Health System in Eau Claire, Wis., has a somewhat different perspective, noting, "Sometimes even the best artificial joint is not as good as a banged-up real joint, so you have to be very, very careful."
Whether arthrodesis or arthroplasty is used depends mainly on the joint needing repair but also on a person's age, activity level and the amount of stiffness the finger – and patient – can tolerate. It's not uncommon to have both procedures performed on different joints in the same hand.
Here's a closer look at the two surgeries and the joints where they're commonly used.
Metacarpophalangeal (MCP) joint. Arthroplasty is almost always used to repair the knuckles at the base of the fingers, where flexibility and motion are crucial. The MCP joints – the largest in the hand – are critical to finger function but can be seriously damaged by rheumatoid arthritis (RA).
"Before disease-modifying antirheumatic drugs, we used to see a lot more severe deformity in the MCP joint, but arthritis in this joint still does occur primarily in patients with RA," Dr. Ruch says.
Ideally, joint replacement eliminates pain and restores some mobility, but Dr. Ruch says the outcome depends on the amount of healthy soft tissue a person has.
"In many patients with longstanding rheumatoid disease, it's difficult to get enough soft tissue to reconstruct around the implant, which can lead to failure over time," he explains. "The tendency is for implants to fail at seven to 10 years, but even if the prosthesis isn't holding, it keeps the bones from touching so the patient is still comfortable." In such cases, though, fingers aren't likely to maintain their normal function or shape.
Proximal interphalangeal (PIP) joint. The PIP joints are the second from the base of the hand. They're prone to stiffness and a significant loss of motion, usually as a result of osteoarthritis (OA). Replacement surgery is sometimes used to relieve these symptoms, especially in the middle and ring fingers, which need to remain flexible for griping. But because these joints get heavy use, implants wear out quickly.
"Given enough time, the implants will fail," Dr. Ruch says. He favors fusing most PIP joints because they tolerate stiffness better than joints closer to the hand and fusion is a reliable, life-long solution. But he adds, "Some people need motion for this or that activity, so they elect to have arthroplasty over fusion.”
Distal interphalangeal (DIP) joint. Arthrodesis is commonly used to treat arthritis pain in the joints at the end of the fingers and usually results in a stable, pain-free and reasonably functional joint. The most serious complication is failure of the fused bones to grow together or properly align, which may require further surgery. Most people, though, have good to excellent results.
Dr. Ruch says the key to successful finger surgery is a careful discussion about patient needs and expectations.
"You can spend a lifetime trying to figure out what people need in terms of hand function," he explains. "For instance, what do you want the index finger to do? You want it to be stable and a good pointer; [if so], it can be fused without much loss of function. But look at the ring finger – it's important that it come down into a tight grip because we do a lot of reaching and grabbing with that finger, and we want motion in it."
Motion is, in fact, one of the biggest failings of finger surgery. Not only does it not improve after treatment, it's often reduced further in the pursuit of pain relief.
"[After surgery], there is some improvement in function because pain has been eliminated, Dr. Ruch says. "But we don't see a dramatic improvement in motion or a return to activities that arthritis made impossible. If pain was the only thing preventing someone from playing a sport, then he or she can return to that sport. But if you were unable to hold a golf club before surgery, you won't be able to hold a golf club after it."