Mayo Surgeon Reviews Treatment for Hand Arthritis
In many of the classic cartoons, the wicked witch is portrayed as an old crone with bony, crooked, and deformed fingers. We don't feel sorry for her appearance at all -- or for the pain she might be suffering with what looks like arthritis of the hands.

But if you are that arthritis sufferer (young or old), you might feel differently. Pain, disfigurement, and disability of the hands is more than unsightly -- it's a major stumbling block in accomplishing everyday tasks like picking up a piece of mail, opening a jar of pickles, or even taking care of business in the bathroom.

In this article, orthopedic 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. The MCP joints are what we more commonly refer to as the "knuckles" across the back of the hand (prominent when making a fist).

Without treatment, considerable destruction and cartilage loss occur in the joint. The MCP joints in all the fingers and the thumb can develop these types of changes with both osteoarthritis (OA) as well as rheumatoid arthritis (RA). And after an injury or trauma to the fingers or hand, another type of arthritis called posttraumatic arthritis can occur.

With all types of arthritis, the symptoms are similar. There are more inflammatory symptoms with rheumatoid arthritis and more deformity. The fingers start to drift to one side. Tendons tighten up pulling on the bones until the fingers curl and twist -- just like the witch in the cartoons. Poor dear! What's worse is that as the joint cartilage is destroyed and the soft tissues lose power, the bone starts to disintegrate as well.

What can be done for this condition? There are two basic choices: conservative (nonoperative) care and surgery. Let's see what Dr. Rizzo recommends for each. 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.

When selecting joint implants, the patient's goals and lifestyle are also taken into consideration. The silicone implants still remain the top choice but newer carbon and metal-plastic are gaining in popularity. Patients must have good bone stock to benefit from the newer-generation implants. The carbon and metal-plastic implants are less likely to fracture compared with the more fracture-prone silicone implants.

Dr. Rizzo concludes by saying metacarpophalangeal (MCP) joint arthritis is a common problem. One that can be very disabling and deserves our attention. When diagnosed early, conservative care can be very helpful in treating symptoms and even preventing progression of disease. Newer drugs on the market have made this possible. Splinting seems to be effective but studies are needed to really prove this point. And for those patients who need surgery, joint implant procedures have improved steadily over the years.
Marco Rizzo, MD. Metacarpophalangeal Joint Arthritis. In The Journal of Hand Surgery. February 2011. Vol. 36A. No. 2. Pp. 345-353.