When is joint replacement surgery the best surgical option?
Joint replacement surgery in the hand is an excellent option for
treating arthritis of the hand in older, low-activity patients and
for those with rheumatoid arthritis. Joint replacement surgery can
provide pain relief, increase finger range of motion, and improve
How do the surgical options vary with the different joints of
the hands and wrists?
Hand joint replacement surgery options differ according to the
specific joint(s) involved.
1. DIP joint (joint closest to the fingertip): This joint is
not a good candidate for joint replacement. The bones are very small
and do not hold the implant very well. The best treatment option for
advanced arthritis at this joint is fusion. Hand function is only
minimally compromised by lack of motion at this joint after a fusion
procedure, while pain is relieved.
2. PIP joint (second joint from the fingertip): Joint
replacement is commonly performed in the PIP joint. Hand function,
especially power grasp, can be hindered by fusion of this joint. The
small and ring fingers are the best candidates for joint replacement
as they are the most important for power grasp. The index finger is
not a good candidate for a PIP joint replacement, as it must
withstand sideways forces which accompany movements such as key
turning and fine manipulation of objects. These forces cause excess
stress on the joint implant and can lead to early implant breakage.
There have been numerous false (prosthetic) joints designed for PIP
joint replacement, but only one has stood the test of time. The only
nonexperimental PIP joint replacement is the silicone
interpositional arthroplasty. These joints are made of silicone
rubber and have a flexible hinge in the middle and stems at the ends
which insert into the shaft of the bone, providing stability. The
most frequently used silicone joint implants are termed the Swanson
implant and the Sutter implant.
The best results with PIP joint replacement are in patients with
rheumatoid arthritis and in older, lower-activity patients.
3. MCP joint (third joint from the fingertip): Osteoarthritis
rarely affects the MCP joints. The most common need for joint
replacement in this joint is destruction from rheumatoid arthritis.
Silicone joint replacement of the MCP joint has been used since the
1960s and has produced excellent long-term results.
4. Thumb basal joint (where the thumb meets the wrist): This
joint is exposed to very high stresses with normal activities.
Forces felt at the tip of the thumb are multiplied 12 times in
their effect to the thumb base, thus predisposing this joint to
wear. Arthritis of this joint is very common, especially in women,
and frequently requires joint replacement. Attempts at silicone
replacement of this joint have not been as successful as hoped due to
implant failure and bone destruction. Thus, the most common joint
replacement procedure for the thumb base is done with natural
material. The procedure is termed the ligament reconstruction-tendon
interposition procedure (LRTI). This procedure uses the patient's
own tendon to stabilize the thumb and resurface the joint. LRTI
provides stability and pain relief. Long-term results have been
excellent. This has also been called the tendon roll or "anchovy"
procedure because the tendon used is curled to form the new joint
5. Wrist joint: Most patients with wrist arthritis are best
treated with surgical joint cleaning or fusion and not joint
replacement. Most wrist-joint prostheses on the market are currently
investigational and for use in extremely low activity patients with
osteoarthritis or rheumatoid arthritis.
Arthritis of the hand and wrist is a very common and complex
problem with many nonsurgical and surgical treatment options.
Deciding which alternative is best can require the skills of the primary
doctor, the arthritis specialist (rheumatologist), and/or an