By: 25 October 2011

Guus M. Vermeulen, MD, et al.
Surgical Management of Primary Thumb Carpometacarpal Osteoarthritis: A Systematic Review. In Journal of Hand Surgery. January 2011. Vol. 36. No. 1. Pp. 157-169.

In this article, orthopaedic surgeon Marco Rizzo, MD from the Mayo Clinic (Rochester, Minnesota) offers us an update on what can be done for anyone with joint arthritis of the hands. In particular, he focuses on the metacarpophalangeal (MCP) joints.

There are two basic choices: conservative (nonoperative) care and surgery. Conservative care consists of three options: splinting to protect the joint and give it a rest, medications, and steroid injections.

Some patients have worried that wearing splints might cause them to lose motion in the end. But there’s no evidence that splints contribute to joint stiffness or muscle contractures. Usually splints are worn during activities and removed during rest periods. Daily exercises are performed with the splints off. Some physicians advise their patients to just wear the splints at night as they do seem to help prevent deformities from developing.

The biggest change in nonoperative care in the last 10 years has come from new medications that target the immune system and stop the inflammatory processes linked with arthritis. Patients with inflammatory arthritis and especially rheumatoid arthritis get the most benefit from these drugs.

The physician will often prescribe one drug to start. If it is not effective or doesn’t work as well as expected, a combination of drugs may be used. It can take a while before finding just the right mix of medications that work best for each patient. Patience and persistence are the keys to success here.

Nonsteroidal antiinflammatories (NSAIDs) are still used for all types of arthritis (even osteoarthritis, which doesn’t have a strong inflammatory component). NSAIDs help improve pain and function but they do have some potentially serious adverse side effects (GI, kidney, liver damage). There is also a new topical agent (diclofenac) that works well for the hands and is less likely to cause systemic problems.

Steroid injections are easy to give and provide immediate relief from pain. Having the freedom from pain gives the patient a new lease on life. Improved function follows but the effects wear off and aren’t long-lasting. If there’s more than one finger involved, then splinting and systemic medications are a better choice.

What about surgery? Surgeons and rheumatologists don’t always agree on surgery as an important option for the treatment of hand arthritis. Researchers put it to a test and did a study asking patients after surgery for their opinions. Based on surveys and patient-report, they found there were fewer deformities than in patients who did not have surgery. Grip and pinch strength weren’t better in the surgical group but all other outcomes were superior.

There are two main surgical choices: joint replacement and fusion. It’s more difficult to replace the thumb joint, so fusion is more common there. But silicone implants have worked well for the fingers and are an acceptable choice for all the other metacarpophalangeal (MCP) joints. If there is too much bone loss and deformity, surgery may not be as effective as patients hope for. On the other hand, even some pain relief and improved motion can help aid function and hygiene.

Dr. Rizzo provides an in-depth description, discussion, and analysis of the various types of joint implants available. The surgeon makes his or her decision on which implant to use based on the type of arthritis, amount of bone, and condition of the surrounding soft tissues. Patients with rheumatoid arthritis typically don’t get the same excellent outcomes as patients with osteoarthritis but they are still happy with improved results.