The Journal of Hand Surgery
Volume 36, Issue 2,
, Pages 345-353
Arthritis of the metacarpophalangeal joint can result in considerable disability and pain. Inflammatory, posttraumatic, crystalline, and osteoarthritis are common etiologies of joint disease. A variety of nonsurgical treatment options have been shown to be effective, including activity modification, anti-inflammatory medications, splinting, and cortisone injections. In addition, newer generation disease-modifying antirheumatic drugs geared toward the treatment of rheumatoid arthritis have shown promise in retarding the inflammatory process. Another, relatively newer, conservative treatment option includes topical anti-inflammatories such as diclofenac sodium that are now approved by the Federal Drug Administration. Surgical treatment options most commonly include arthroplasty and arthrodesis. In the treatment of thumb metacarpophalangeal arthritis, arthrodesis is a popular and generally reliable surgical solution. In the fingers, arthroplasty remains the most common treatment option. Traditional constrained silicone joint replacements remain the most commonly used. Newer generation, unconstrained, surface replacement arthroplasties have shown promise in the treatment of osteoarthritis and select cases of inflammatory arthritis in which there is good bone stock, no or minimal deformity, adequate supporting soft tissues, and good disease control.
Clinical and Radiographic Evaluation
Patients with MCP arthritis typically present with pain, swelling, and limited motion of the MCP joint. Persons affected with rheumatoid arthritis (RA) will frequently have varying degrees of deformity. Typically, the fingers will deviate in an ulnar direction, and this deformity can also be driven by more proximal malalignment, such as radial deviation of the wrist. As the inflammatory disease progresses, the proximal phalanx will subluxate in a volar direction on the metacarpal head. The
Conservative treatment options for the management of osteoarthritis and inflammatory arthritis primarily include splinting, pharmacologic medications, and corticosteroid injections. There have been notable developments in the evolution of some of the pharmacologic treatments for RA over the past decade. Traditional disease-modifying antirheumatic drugs (DMARDs) such as oral corticosteroids, methotrexate, azathioprine, sulfasalazine, and leflunomide have been used for many years. A usual
Considerations Regarding Surgery
Surgery for MCP arthritis is an option for patients who have failed conservative measures. Persistent symptoms, synovitis, or swelling despite a 3- to 6-month course of nonsurgical interventions is viewed by most surgeons as an appropriate indication for surgery. Considerations for surgery, especially in patients with RA, require a thoughtful assessment of multiple factors such as nutritional status, comorbidities, pharmacologic disease control, infection risk, and the presence of cervical
Surgery for the Thumb Metacarpophalangeal Joint
Surgical treatment of thumb MCP arthritis is less common than that of the trapezial-metacarpal joint. The most common surgical treatment of the arthritis thumb MCP joint remains arthrodesis. Most of the mobility of the thumb arises from the carpometacarpal joint; therefore, MCP arthrodesis is generally well tolerated. The optimal position of arthrodesis is typically 5° to 15° of flexion. It is important to examine and assess the carpometacarpal and interphalangeal joints for arthritis and range
Surgery for the Finger Metacarpophalangeal Joints
Arthroplasty is favored over arthrodesis for arthritis of the index through small finger MCP joints. Preserving some degree of flexion-extension and abduction-adduction of the digits not only helps function but also allows for better hygiene. However, MCP joint arthrodesis can reliably relieve pain. The etiology and activity of disease are important considerations in deciding the optimal arthroplasty treatment. Hinged silicone implants and newer-generation unconstrained surface replacement
- S.D. Burgess et al.Results of revision metacarpophalangeal joint surgery in rheumatoid patients following previous silicone arthroplasty
J Hand Surg
- B.G. Escott et al.NeuFlex and Swanson metacarpophalangeal implants for rheumatoid arthritis: prospective randomized, controlled clinical trial
J Hand Surg
- K.C. Chung et al.Outcomes of silicone arthroplasty for rheumatoid metacarpophalangeal joints stratified by fingers
J Hand Surg
- K.C. Chung et al.A prospective outcomes study of Swanson metacarpophalangeal joint arthroplasty for the rheumatoid hand
J Hand Surg
- W.L. Parker et al.Preliminary results of nonconstrained pyrolytic carbon arthroplasty for metacarpophalangeal joint arthritis
J Hand Surg
- K.C. Chung et al.A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment
J Hand Surg
- A.K. Alderman et al.Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists
J Hand Surg
- S.A. Formsma et al.Effectiveness of a MP-blocking splint and therapy in rheumatoid arthritis: a descriptive pilot study
J Hand Ther
- H. Bliddal et al.Safety of intra-articular injection of etanercept in small-joint arthritis: an uncontrolled, pilot-study with independent imaging assessment
Joint Bone Spine
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Semin Arthritis Rheum
J Hand Surg
J Hand Surg
- Management of the Metacarpophalangeal and Scaphotrapeziotrapezoidal Joints in Patients with Thumb Trapeziometacarpal Arthrosis
2022, Hand Clinics(Video) Metacarpophalangeal Joint Arthroscopic Synovectomy
- Arthrodesis and Arthroplasty of the Small Joints
2020, Operative Techniques in Orthopaedics
Arthritis of the small joints of the hand is a common problem encountered by orthopaedic hand surgeons. Nonoperative management is maximized to include splinting, injections, therapy in some situations, and oral analgesics. Pain is the main indication for joint arthroplasty and arthrodesis of the small joints of the hand. Additional indications include deformity, stiffness, and joint incongruity as seen in degenerative and inflammatory arthritis. We describe specific indications for treatment of the metacarpal phalangeal, finger proximal and distal interphalangeal, and thumb interphalangeal joints. Treatment options include open debridement of painful osteophytes, arthroplasty, and arthrodesis. Bone and soft-tissue stability is necessary to support an implant, thus treatment is dependent on the soft-tissue envelope and the amount of joint destruction. Based on the literature and the authors’ experience, arthrodesis is a better alternative than arthroplasty in most cases.
- Joint Fusion and Arthroplasty in the Hand
2019, Clinics in Plastic Surgery
Unconstrained surface replacement arthroplasty for the MCP joint is indicated for patients with good bone stock and fewer deformities. Osteoarthritis rather than RA of the MCP joint can be a candidate for surface replacement arthroplasty.31 The PyroCarbon implant has an iso-elasticity to cortical bone with higher durability and biocompatibility.
- Biomechanical analysis of metacarpophalangeal joint arthroplasty with metal-polyethylene implant: An in-vitro study
2019, Clinical Biomechanics
The most common implant options for the metacarpophalangeal joint arthroplasty include silicone, pyrocarbon and metal-polyethylene. A systematic review of outcomes of silicone and pyrocarbon implants was conducted; however, a similar exercise for metal-polyethylene implants revealed a scarcity of published results and lack of long-term follow-up studies. The aim of the present work is to test the hypothesis that the magnitude of metacarpophalangeal joint cyclic loads generates stress and strain behaviour, which leads to long-term reduced risk of metal-polyethylene component loosening.
This study was performed using synthetic metacarpals and proximal phalanges to experimentally predict the cortex strain behaviour for both intact and implanted states. Finite element models were developed to assess the structural behaviour of cancellous-bone and metal-polyethylene components; these models were validated by comparing cortex strains predictions against the measurements.
Cortex strains in the implanted metacarpophalangeal joint presented a significant reduction in relation to the intact joint; the exception was the dorsal side of the phalanx, which presents a significant strain increase. Cancellous-bone at proximal dorsal region of phalanx reveals a three to fourfold strain increase as compared to the intact condition.
The use of metal-polyethylene implant changes the strain behaviour of the metacarpophalangeal joint yielding the risk of cancellous-bone fatigue failure due to overload in proximal phalanx; this risk is more important than the risk of bone-resorption due to the strain-shielding effect. By limiting the loads magnitude over the joint after arthroplasty, it may contribute to the prevention of implant loosening.
- Outcomes Following Acute Metacarpophalangeal Joint Arthroplasty Dislocation: An Analysis of 37 Cases
2018, Journal of Hand Surgery
There remains a paucity of information regarding the treatment outcomes of dislocation after metacarpophalangeal (MCP) joint arthroplasty. The purpose of this study was to assess the outcomes of surgical and nonsurgical treatment modalities of MCP arthroplasty dislocations.
Of 816 MCP joint arthroplasties over a 14-year period, there were 37 (4%) acute MCP joint dislocations that required intervention by a health care professional. Implants involved included 28 nonconstrained implants including pyrocarbon (n= 17) and surface replacement arthroplasty (n= 11), and 9 silicone implants. The analysis included the treatment of dislocations after primary (n= 30) and revision (n= 7) MCP joint arthroplasty. Dislocation was defined as clinical and radiographic evidence of MCP joint prosthetic acute dislocation diagnosed and treated by a fellowship trained hand surgeon.
Etiologies underlying the dislocations included implant fracture (n= 6), component loosening (n= 2), and soft tissue deficiency (n= 29). Of the 37 dislocations, treatments included 14 nonsurgical (closed reduction, orthosis fabrication) all of which ultimately failed. Surgically, including some of the failed prior procedures, 18 soft tissue stabilization procedures and 21 revision arthroplasties were performed, with 6 that had failed soft tissue stabilization. The soft tissue stabilization procedures had a 28% success rate in achieving a stable MCP joint. Revision arthroplasty had a 71% success rate. Subgroup analysis showed an 86% success rate for silicone revisions and a 43% success rate with nonconstrained revisions, with 80% and 36% 5-year survival free of instability, for the 2 types of implants, respectively.
The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation.
- Nonrheumatoid Arthritis of the Hand
2018, Journal of Hand Surgery(Video) Chiropractic Extremity Adjustment Thumb Metacarpophalangeal MCP Joint
Arthralgia is treated by placement of an orthosis, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroid injections. If nonoperative treatments are ineffective, arthroscopy, arthroplasty, and arthrodesis are options for treatment.12 In the case of unexplained isolated MCP arthritis involving the index or middle finger, hemochromatosis should be considered.
Arthropathy of the hand is commonly encountered. Contributing factors such as aging, trauma, and systemic illness all may have a role in the evolution of this pathology. Besides rheumatoid arthritis, other diseases affect the small joints of the hand. A review of nonrheumatoid handarthropathies is beneficial for clinicians to recognize these problems.
Research articleComplications Following One-Bone Forearm Surgery for Posttraumatic Forearm and Distal Radioulnar Joint InstabilitySee AlsoAbstracts zum 40. Kongress der Deutschen Gesellschaft für Rheumatologie (DGRh) - PDF Free DownloadL5-S1 Disc Bulge, Slip Disc, Stenosis & SpondylolisthesisWhat is the icd 10 code for equinus?
The Journal of Hand Surgery, Volume 38, Issue 5, 2013, pp. 976-982.e1
To present the outcomes after one-bone forearm (OBF) surgery for chronic posttraumatic forearm and distal radioulnar joint instability.
We conducted a retrospective chart review to study patients who underwent OBF surgery because of a traumatic etiology. We collected patient demographics, surgical technique, preoperative and postoperative range of motion, final grip strength, and complications from the medical records. Patients were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, a 0- to 10-point pain scale, and a 0- to 10-point treatment satisfaction scale.
There were 5 male and 5 female patients, with a mean age of 32 years at the time of OBF surgery (range, 17–44 y). The mean number of procedures before OBF surgery was 3.6 (range, 2–7); 4 patients had undergone a Darrach procedure and 3 patients had undergone a Sauvé-Kapandji procedure. The median clinical follow-up duration was 6 years (range, 1–17 y). Wrist and elbow range of motion did not change remarkably before and after surgery. Of 8 primary OBF surgeries, 3 resulted in nonunion. Of 10 patients, 4 experienced painful impingement of the remaining proximal radius on adjacent bone and soft tissue and required a total of 7 procedures after OBF surgery. The median follow-up duration for patient-rated outcomes was 10 years (range, 5–21 y; n = 7). The median Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 77, the median pain score was 7, and the median satisfaction score was 7.
In our experience, complications after OBF surgery are common. Although wrist and elbow range of motion were spared, pain persisted and functional outcomes were poor. One-bone forearm surgery is our last resort for a chronically painful and unstable forearm.
Research articleFunctional Impact of Congenital Hand Differences: Early Results From the Congenital Upper Limb Differences (CoULD) Registry
The Journal of Hand Surgery, Volume 43, Issue 4, 2018, pp. 321-330
To characterize the functional, emotional, and social impact of congenital upper limb differences on affected children and families before treatment, using validated functional outcome instruments.
From June 2014 to March 2016, 586 children with congenital upper limb differences from 2 pediatric hospitals were enrolled in the Congenital Upper Limb Differences registry. Demographic, clinical, and radiographic data were collected, and diagnoses categorized according to the Oberg-Manske-Tonkin classification. Functional outcomes were assessed in 301 patients using the Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) function, pain, anxiety, depression, and peer relationships modules.
The cohort had high median PODCI scores in all domains, ranging from 83 to 100 in children and adolescents. Patients had decreased PROMIS UE scores compared with population norms; however, they showed low scores for pain, anxiety, depression and higher scores in the peer relationship domain, respectively. Patients with entire limb involvement had higher PROMIS pain scores and lower PODCI UE and global functioning than those with differences limited only to the hand. Compared with those with bilateral involvement, patients with unilateral differences reported higher scores for PODCI sports global functioning, better PROMIS UE function, and lower pain scores. Additional orthopedic conditions and medical comorbidities negatively influenced all PODCI scores and PROMIS pain and UE function domains.
Children with congenital hand differences report decreased upper limb function but better peer relationships and positive emotional states compared with population norms.
The Congenital Upper Limb Differences registry is a valid source of information related to congenital upper limb differences in clinical practice. With continuous enrollment and longitudinal follow-up, the registry will increase the understanding of UE function and psychosocial aspects of health in pediatric population.
Research articleThe clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial(Video) Treating Basal Thumb Joint Arthritis - Mayo Clinic
The Lancet, Volume 392, Issue 10156, 2018, pp. 1423-1433
To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome.
We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452.
Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference −0·32; 95% CI −0·48 to −0·16; p=0·0001). No adverse events were reported.
A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.
Arthritis Research UK.
Research articleComparison of the Michigan Hand Outcomes Questionnaire, Boston Carpal Tunnel Questionnaire, and PROMIS Instruments in Carpal Tunnel Syndrome
The Journal of Hand Surgery, Volume 44, Issue 5, 2019, pp. 366-373
Patient-reported outcomes are important to assess improvement after surgery. Commoninstruments for carpal tunnel syndrome include the Michigan Hand Outcomes Questionnaire (MHQ) and Boston Carpal Tunnel Questionnaire (CTQ). The Patient-Reported Outcomes Measurement Information System (PROMIS) are newer measures. We evaluated how the PROMIS Pain Interference (PI) and Upper Extremity (UE) scores change after carpal tunnel release.
All adult patients with carpal tunnel syndrome treated surgically were asked to participate in this prospective study. PROMIS instruments, MHQ, and CTQ were completed by 101 patients. Estimated means and standard errors were calculated, and piecewise linear fixed effects regression models were applied to the data. Standardized response means were calculated for each outcome measure.
The MHQ Total Score did not show a considerable change from the preoperative to 1-week postoperative visit but improved from the 1-week to 3-month postoperative visit (55 to 80). The CTQ Functional Status Score (FSS) worsened from 2.3 preoperatively to 2.6 at the 1-week postoperative visit before improving through the 3-month postoperative visit (1.6). PROMIS UE showed responsiveness similar to the CTQ FSS with a decline at the 1-week visit, 38 to 33, followed by improvement (45 at 3 mo). However, the standardized response mean values were greater for the CTQ FSS compared with PROMIS UE. The average administration time was shortest for PROMIS UE. The CTQ Symptom Severity Scale and MHQ Pain Scores showed improvements as early as the 1-week visit. The CTQ Symptom Severity Scale improved from 3.1 to 2.3, and MHQ Pain Scores improved from 55 to 46. PROMIS PI did not change at the 1-week visit but improved at 6 weeks and 3 months, from 56 to 52 and 49. The standardized response means for PROMIS PI achieved a large effect size only at 3 months.
The CTQ FSS is more responsive than PROMIS UE and the MHQ, with the CTQ FSS showing the largest effect sizes. PROMIS PI does not show the responsiveness seen in the CTQ Symptom Severity Scale and MHQ Pain Score. PROMIS instruments require less time to complete.
This study demonstrates the change in PROMIS scores after carpal tunnel release and how they compare with legacy outcome instruments.
Research articleDistal Ulna Arthroplasties
Hand Clinics, Volume 28, Issue 4, 2012, pp. 611-615
Research articleImplant Arthroplasty for Proximal Interphalangeal, Metacarpophalangeal, and Trapeziometacarpal Joint Degeneration
The Journal of Hand Surgery, Volume 42, Issue 10, 2017, pp. 817-825
Arthritis of the hand can result from inflammatory arthritis, osteoarthritis (OA), or be posttraumatic and can cause pain and debilitation. Arthroplasty serves as 1 surgical option in the surgical management of arthritis and aims to create a pain-free joint with preservation of motion. Although implant arthroplasty of the proximal interphalangeal (PIP), metacarpophalangeal (MCP), and trapeziometacarpal (TMC) joints predictably produce pain relief and high satisfaction, it has historically suffered from high rates of complications. The hinged silicone prosthesis was 1 of the early implants and, in many cases, remains the gold standard. However, problems with deformity correction, implant fracture, and synovitis remain. Implants made of alternative materials such asmetal-plastic and pyrocarbon have evolved; however, survivorship and reoperation rates remain a concern. This review details the evolution and current options available for small jointimplant arthroplasty involving the MCP, PIP, and TMC joints.
Copyright © 2011 Published by Elsevier Inc.