Ring finger PIP joint arthritis, treated with a pyrocarbon joint replacement.

What is it?
Loss of the cartilage in the joints of the hand leads to pain, deformity and functional loss. The cause of this loss and subsequent arthritis can be due to:-

• Trauma – where the smooth joint surfaces have been damaged by injury or infection, and then have worn.
• Osteoarthritis – where the joint surfaces have decayed through natural wear and tear.
• Inflammatory arthritis – where the cartilage is attacked by cells that line the joint in “auto-immune” conditions such as rheumatoid arthritis.

What can be done?
The methods for relieving pain in any arthritic joint, whether it’s the hip, knee, spine or hand, is always the same. This is the therapeutic ladder.

1. Activity modification
2. Pain killers
3. Splints
4. Physiotherapy
5. Steroid injections
6. Surgery

Treatment will commence at some point on the therapeutic ladder depending on the severity of the symptoms.

Surgery is the only definitive treatment for persistent problems but no operation restores normal function. There are a number of operations available to your surgeon but the choice is complex.

Cheilectomy: The bony lumps around the joint are smoothed off, and the joint washed out.

Synovectomy: Applicable only to early cases of inflammatory arthritis where there is considerable swelling (synovitis). It is suitable only if the joint is reasonably mobile and if the joint surfaces have not been badly damaged.

Arthroplasty: Involves removal of the joint and its replacement by one of a number of implants. It is most suited to a reasonably stable and mobile but painful joint in patients who do not need high power levels for work or play. There are two types of implants available and these will be discussed with you by the surgeon.

Arthrodesis (fusion): Involves removal of the joint and joining of the two bones together by either metal wires or screws and plates. The joint is generally set in a slightly bent position for best function. Although the operation abolishes movement at this (and only this) joint, the resulting fusion is very tough. This option is chosen when (i) joints are badly damaged (ii) there is already little movement, (iii) there is damage to nearby ligaments and tendons (iv) a previous arthroplasty has failed and (v) when heavy manual use is anticipated.

Rehabilitation
Activity will be restricted for a minimum of twelve weeks after most of these operations at which time bones have usually united and soft tissues have recovered normal strength. Your surgeon or therapist will, however, modify splinting and exercises depending on your progress.

Splints are made to rest and protect the operation as well as to maintain alignment and position. These should be removed to allow wound care and for exercise of the joint after surgery. Arthrodesed joints are not intended to be moved and will be protected until united. The splint can generally be removed when sitting quietly but should always be worn at night or when the hand is liable to be knocked or strained.

Exercise is necessary to maintain mobility in neighbouring joints and to recover movement in joints after synovectomy or arthroplasty. You will be advised by a Hand Therapist.

There are a number of potential complications of surgery:

Scar
You will have a scar. This will be somewhat firm to touch and tender for 6-8 weeks. Massaging it firmly with moisturizing cream can help this.

Infection
This can occur after any operation and would be treated by antibiotics. Very rarely the metal or prosthesis will have to be removed if deep infection is noted.

Stiffness
Generalised joint stiffness is common after surgery, and will be reviewed and treated by the Hand Therapist. About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex Regional Pain Syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Neuroma
A small nerve running in the region can occasionally be damaged during the surgery and either cause numbness or form a painful spot in the scar (neuroma). The latter complication may require a further operation to correct it.

Function Recovery from this operation can take time. Return to work is variable according to your occupation and you should discuss this.