Dr. Budoff's Blog

Metacarpophlangeal (MP) Joint Replacement

November 23rd, 2011

The metacarpophalangeal (MP) joint is the large joint where the finger attaches to the hand. Arthritis of the MP joint can lead to pain, swelling and stiffness. Nonoperative management includes a steroid injection or two, activity limitation and buddy taping the finger to its neighbor. In patients with rheumatoid arthritis, all of the MP joints can be involved, and the fingers can deviate away from the thumb, making it difficult to use the hand to pick up and pinch objects. Rheumatoid arthritis causes the fingers to angulate, sublux and/or dislocate because it is a systemic disease that destroys not only the joint, but also the ligaments that hold the joint in position.

Once rheumatoid arthritis causes the MP joint to dislocate, joint replacement should be strongly considered. The reason is because following the dislocation, the finger starts to drift up into the palm of the hand. This causes the soft tissues to shorten. Then, when MP joint replacement is finally performed, the finger cannot be brought out to length. At this point, in order place the new joint, a significant amount of bone needs to be removed from the metacarpal bone of the hand. So now the MP joint replacement can no longer be placed in the wide area at the end of the bone. It now must be placed in the narrow shaft of the bone (think of how a dog bone in wider on either end than in the middle). Placing an MP joint replacement in the narrow shaft doesn’t provide as much stability as the wider bone ends do, predisposing to complications.

If non-operative management fails, MP joint replacement is an effective surgical option. Patients without rheumatoid arthritis usually have good tendons and ligaments, and can therefore benefit from the newer total joint replacements now available. These newer MP joint replacements are made of metal and polyethylene (a very tough plastic-like material). Each side of the joint is resurfaced by a separate piece, for a total of two pieces. These replacements are made of the same materials that hip, knee and shoulder replacements are made out of, and are believed to last longer and provide better function than the older single-piece hinged silastic (a rubbery material) joint replacements.

If the ligaments have been compromised, which is almost always the case with rheumatoid arthritis, than the newer type of total joint replacement cannot be used, because there are no ligaments to stabilize the two separate pieces. The older hinged silastic replacement must be used, as these single-piece joint replacements provide their own stability to the joint. These silastic implansts work well, but will eventually break after a number of years. Having said that, good function often remains even after they break; broken silastic joints don’t necessarily have to be replaced.

Both types of replacement provide an average of about 50% of normal motion. However, that amount of MP joint motion is still very functional. Even though it’s not full motion, having 50% of pain-free motion is almost always better than having motion that causes pain, as when a joint hurts its function is usually significantly compromised.

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Proximal Interphalangeal (PIP) Joint Replacement

August 2nd, 2011

The proximal interphalangeal joint is the middle joint of the finger. Injuries to the proximal interphalangeal joint often lead to arthritis. The treatment of proximal interphalangeal joint arthritis starts with buddy taping of the finger to its neighboring digit and a steroid injection into the proximal interphalangeal joint. If significant proximal interphalangeal joint pain continues then the options for treatment are usually either fusion or replacement.

The proximal interphalangeal joint of the index finger is best fused. The index finger is used for pinch. When the index finger opposes the thumb to create power during pinch, this creates a significant sideways stress on the proximal interphalangeal joint. Current proximal interphalangeal joint replacements simply cannot handle this sideways stress, and will become unstable. On the other hand, fusion leads to a stiff but pain-free and stable platform for pinching. The loss of proximal interphalangeal joint motion is not a significant problem for the index finger.

Because the middle, ring and small fingers are used for grasp, motion of the proximal interphalangeal joint of these digits is important. For that reason, proximal interphalangeal joint replacement may be considered. As for most joint replacements, they have less problems as the patient’s age increases. The reason for this is because joint replacements have a limited ‘life expectancy’, and do not last as long in younger, higher demand individuals. Having said that, the newer joint replacements may be better suited for younger, higher demand individuals, within reason.

Proximal interphalangeal joint replacement is performed as an outpatient surgery. The newer metal and polyethylene (a fancy plastic) replacements usually work better than the pyrocarbon implants that were popular a few years back. An example of the newer (SR-PIP) joint implant can be seen at www.totalsmallbone.com/us/products/hand/sr_pip.php4

After proximal interphalangeal joint replacement, motion is started within a few days after surgery with hand therapy. Ultimate motion is about 50% of normal, about 60°. It is unclear how long the newer proximal interphalangeal joint replacements will last.

Unfortunately, these newer unlinked proximal interphalangeal joint replacements are not appropriate for patients with advanced rheumatoid arthritis. Rheumatoid arthritis is a much rarer inflammatory condition than the typical osteoarthritis (wear and tear) that is much more common. If you’re not sure what type of arthritis you have, unless a rheumatologist (arthritis expert) has formally diagnosed you with rheumatoid arthritis, you most probably have simple osteoarthritis or a similar condition. People with rheumatoid arthritis have poor ligaments. Because of this, unlinked replacements, such as the SR-PIP, will become unstable. In cases of rheumatoid arthritis, one-piece linked silastic (a type of rubbery plastic) replacements provide some intrinsic stability and are better options. The post-operative therapy is the same. In cases of rheumatoid arthritis, motion is limited more by the conditions of the finger’s tendons than the joint replacement itself.

So if you are suffering with proximal interphalangeal joint arthritis, there are now better treatment options than were previously available. Most patients are very happy with the pain relief and function afforded by these newer implants.

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The Stiff Finger

January 4th, 2011

There are many causes of finger stiffness. Usually finger stiffness is due to previous fracture, ligament injury or surgery. Finger stiffness can be debilitating and may severely impair hand function.

Initial treatment for finger stiffness is hand therapy. A certified hand therapist will be most effective in mobilizing the digit. Therapy is continued for as long as it results in an increase in motion. Occasionally, a steroid injection may be helpful to decrease inflammation and allow therapy to progress.

Once motion ‘plateaus’, ie. stops improving, a decision is made. If finger motion is good enough that the residual stiffness doesn’t cause significant dysfunction, then no further treatment is necessary. On the other hand, if residual stiffness impairs hand function, then a surgical release may be considered.

All other issues should usually be resolved before releasing the joints. Specifically, the bones of the finger should be healed in good position. If they’re not, then they will usually need to be cut and fixed in better position as a ‘first stage’ surgery. If the joints are injured, they will either need to be repaired or reconstructed, if possible, again as a ‘first stage’ surgery. Not every injured joint can be salvaged, in which case joint fusions may be necessary, where the joint is permanently stiffened to decrease pain and increase stability. Following any ‘first stage’ surgery, there is at least a 3-4 month waiting period for inflammation and swelling to end before the surgical release is performed. It’s better to have the release performed within a year of the injury or surgery that led to the stiffness, but that’s not always possible. It’s always easiest if only one finger is involved; the more fingers and the more joints involved, the more difficult it is to ‘focus’ on any particular finger or joint afterwards in therapy, and the more painful the therapy, which can decrease its effectiveness.

Surgical releases of the finger release both the joint and one of the tendons that become scarred down. If both the flexor and extensor tendons are scarred down, they will need to be released at separate operations, again at least 3-4 months apart. Attempts to release both tendons at the same time usually results in failure of the procedure. The extensor tendon and any stiff joints are usually released first and the flexor tendons at a later time, if necessary.

The surgery is an outpatient procedure that is usually very successful and not very painful. However, the main issue is the serious time commitment required after surgery. Therapy usually starts the same day as surgery. Therapy is usually 5 days/week for 4 weeks, then 4 days/week for 4 weeks then 3 days/week for 4 weeks. That’s a big commitment. Some people need less, but that’s not something to count on until after hand therapy is begun and it’s seen how finger motion progresses. The goal is to maintain the motion attained surgically. A home program is performed 7 days/week for many months, often for a year.

In summary, stiff fingers can usually be mobilized and good function regained. But it’s a lot of work, and a big commitment as far as time and effort from the patient. As for most things in life, dedication and persistence are the keys.

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Wrist Arthritis

November 13th, 2010

Wrist arthritis is very common. Wrist arthritis may occur from ligament injuries, fractures, or from chronic overuse. Wrist arthritis leads to pain, stiffness and often swelling of the wrist.

Regardless of why the wrist arthritis occurred, nonoperative treatment should usually be tried first. Nonoperative treatment consists of splinting, a steroid injection, and limiting activities to within the limits of pain. Non-steroidal anti-inflammatory medications, such as ibuprofen or Naprosyn can also be tried.

If these fail, surgical treatment can be extremely effective. Most cases of wrist arthritis can be treated by fusing only one of the two wrist joints, called the “midcarpal joint”. Bone graft (healthy bone that helps the joint fuse) is taken from the distal radius, the large bone of the wrist, through the same incision. I performed a study that demonstrated that removing the scaphoid bone, which is usually involved in the arthritic process, increases motion following partial wrist fusion.1 This should essentially always be done.

The traditional way to perform a partial wrist fusion is by a “four-corner” fusion, where 4 of the wrist’s bones are fused together using two screws. Please see the “Wrist Arthritis” section of this website for an x-ray and description of the four-corner fusion. However, recently I’ve changed to a lesser surgery, which fuses only two bones, the lunate and the capitate, using a single screw. This seems to generate less pain and heal quicker than the traditional four-corner fusion. Essentially, it’s less surgery for the same result.

Partial wrist fusions are performed as an outpatient surgery. Following surgery, a cast is worn for 4-6 weeks. If a normal wrist had this fusion performed on it (which would obviously never happen), it would lose approximately 35-40% of its motion. However, arthritic wrists are already stiff to some degree, and so less motion is lost in these cases. In some cases, where the arthritis has led to very severe stiffness, a gain in functional motion may actually occur. Hand therapy is often used once the cast is removed to maximize motion.

This is an easy surgery to recommend, as most patients do extremely well and return to work, sports and the other activities that they enjoy, without the pain that used to keep them from being so active.

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Elbow Arthritis

October 2nd, 2010

Elbow arthritis can limit function, cause pain, and lead to serious impairment of the arm. Initial treatment includes a steroid injection and decreasing any painful activities. Sometimes a rubber-like sleeve worn over the elbow can help decrease pain by providing some stability, warmth and compression. You can try some non-steroidal anti-inflammatory medications, like Ibuprofen or Naprosyn. If those don’t work, then surgery can be very effective. There are different surgical options, depending on how advanced the arthritis is and where it is.

Pain that occurs mainly at full flexion or full extension is usually due to arthritic bone spurs. These can often be removed by either arthroscopic or open surgery (if the bone spurs are really big), improving symptoms. The arthritis may continue to progress, but many years of increased comfort may be provided. Pain at rest is usually due to the inflammation of arthritis. This can be removed during the surgery. Any catching or locking due to pieces of bone spurs that have broken off and are floating around the joint can also be addressed.

If stiffness is a problem, this surgery may often improve motion by removing the joint capsule, which is the balloon around the joint. If increased motion is desired, then after surgery a fairly extensive physical therapy program will be required in order to maintain the motion that is gained at the time of surgery. If significant stiffness is present, an endoscopic cubital tunnel release will be required to release the ulnar nerve, which is often caught up in the scar, in order to avoid problems with this nerve following surgery.

Pain throughout the entire range of elbow motion is usually due to cartilage loss, causing the joint to be ‘bone on bone’. In cases of arthritis this advanced, simply removing loose bodies, bone spurs, inflammation and the joint capsule will not be enough. The placement of a new joint surface will be required.

In older patients, a total elbow replacement is an effective option. Total elbow replacement often requires a hospital stay of 1-2 nights. The elbow is splinted for 2 weeks and then motion is begun. Pain relief and function are very good, but elbow replacements can loosen over time. To protect against this, there is a lifetime lifting limit of 1-2 pounds repetitively and 5-10 pounds for a single time once in a while.

In young patients who cannot live with these restrictions, the best operation is often a fascial-interposition arthroplasty, where the Achilles tendon from a cadaver is used to resurface the elbow joint. The Achilles tendon is broad and slippery, and can provide a pain-free surface for an elbow. This surgery also usually requires a night in the hospital. In order to keep the joint surfaces apart to allow healing and motion, an “external fixator” is placed around the elbow. This external fixator consists of 2 metal screws placed into the humerus (the large bone above the elbow) and 2 metal screws placed into the ulna (one of the forearm bones), connected by a hinge to allow motion. This device remains in place for 4-5 weeks and is then removed under general anesthesia as a second procedure. While fascial-interposition arthroplasty is not as predictable as a total joint replacement, it does very well in patients without ligament or bone loss. And unlike a total elbow replacement, once the fascial-interposition arthroplasty is healed, the elbow can be used within the limits of pain, without lifting restrictions.

For the best advice, and often the best results, consult an elbow specialist to find out what the best treatment is for your arthritic elbow.

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Elbow Arthritis

July 18th, 2010

Elbow arthritis can be due to osteoarthritis (wear and tear arthritis), post-traumatic arthritis (after a fracture or dislocation) or due to rheumatoid arthritis (a systemic, inflammatory disease). Elbow arthritis can limit function, cause pain, and lead to serious impairment of the arm.

Initial treatment should be nonoperative, with an injection, activity modification, and occasionally physical therapy. If that is ineffective, then options depend on how advanced the arthritis is and the symptoms it is causing. Pain at terminal motion (at full flexion or full extension) is usually due to bone spurs, which are the body’s reaction to arthritis. Pain during mid-motion is usually due to loss of the joint’s normal slippery cartilage surface. Pain during rest is usually due to reactive synovitis (inflammation of the joint lining in response to the mechanical irritation of the arthritis). Catching, locking, and feelings like something is ‘loose’ in the joint are often due to loose bodies, which are pieces of bone spurs and damaged cartilage that have broken off and are floating around the joint.

If the arthritis is mild, an arthroscopic debridement can help. Arthroscopy can remove bone spurs, inflammation, and any loose bodies in the joint. This often relieves pain during terminal motion and often at rest. Mid-motion pain will usually not be improved, and if the arthritis is significant, the inflammation and rest pain will recur. In some patients, such as those who have already had their ulnar nerve moved (putting it at risk unless it’s visualized), or those who are undergoing additional surgeries, elbow debridement may be better performed through an open incision.

If stiffness is a problem, release of the restraining joint capsule (the balloon around the joint) may be performed, either openly or arthroscopically. In order to maintain the motion that is gained during surgery, extensive physical therapy will be required after surgery. When significant stiffness is present, the ulnar nerve will usually be scarred in, and should be released or transposed (moved) to avoid problems with traction on the nerve once motion is restored.

If mid-motion pain is prominent, then cartilage loss has probably occurred. Simple debridement of bone spurs will not provide pain relief. In older patients, a total elbow replacement is an effective option. Total elbow replacement usually involves a hospital stay of 1-2 nights. The elbow is splinted for approximately 2 weeks, and then motion is begun. Pain relief and function are very good, but elbow replacements can loosen over time. To protect against this, there is a lifetime lifting limit of 1-2 pounds repetitively and 5-10 pounds for a single time once in a while.

In young patients who cannot live with this restriction, the best operation may be a fascial-interposition arthroplasty, where the achilles tendon from a cadaver is used to resurface the elbow joint. This tendon is broad and slippery, and may provide a pain-free surface for the reconstructed elbow. This surgery also usually requires a night in the hospital. In order to keep the joint surfaces apart to maximize healing and motion, an external fixator is placed about the elbow. This involves placing 2 metal screws into the humerus (the large bone above the elbow) and 2 metal screws into the ulna (one of the forearm bones), connected by a hinge to allow motion. The fixator remains in place for 3-6 weeks, and is then removed under general anesthesia as a second procedure. While fascial-interposition arthroplasty is not as predictable as a total joint replacement, it does very well in select patients without ligament or bone loss. And unlike a total elbow replacement, once the fascial-interposition arthroplasty is healed, the elbow can be used within the limits of pain, without lifting restrictions.

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