For arthritis of the hand, how does a doctor determine if surgery is necessary?Hand Surgery Geriatrics
Arthritis in the hand can be categorised into 2 main types:
1. Degenerative or osteoarthritis
2. Inflammatory arthritis such as psoriatic arthritis, rheumatoid arthritis, septic arthritis and gouty arthritis
Of the two, degenerative or osteoarthritis is the more common type. Osteoarthritis is simply the premature wear of the cartilage surfaces in a joint and can be primary or secondary.
Primary causes of osteoarthritis can be either from age-related degeneration or excessive wear and tear from repeated overuse of the particular joint. Secondary causes include previous injury to the joint or developmental abnormalities causing deformities in the joint.
Any of the multiple joints in the hand can become osteoarthritic. The most common of the hand joints to develop osteoarthritis are:
- 1st carpometacarpal joint, also known as the thumb basal joint
- Distal interphalangeal joints of the fingers
- Proximal interphalangeal joints of the fingers
The metacarpophalangeal joints are rarely involved in osteoarthritis.
The main symptom of osteoarthritis is pain. The pain is usually worse with motion at the joint and is relieved with immobilisation and resting of the joint. Often times, the pain in the joint is not consistent and may flare and abate unpredictably.
A hand surgeon will assess the patient comprehensively to diagnose the type of arthritis afflicting the joint in the presenting patient. This will include:
- Full medical history
- A detailed clinical examination followed by radiological investigations such as X-rays, CT-scans or MRI scans
- Blood investigations may be necessary if the doctor suspects inflammatory arthritis.
The principles of treating osteoarthritis in the hand are similar to that of the other joints in the body:
1. Non-surgical treatments to reduce loading of the joint, diminish swelling, control pain and prevent further degeneration. These include:
- Activity modification
- Splinting with custom-moulded rigid splints or over-the-counter braces
- Oral medications such as non-steroidal anti-inflammatory drugs (NSAIDS), joint supplements such as glucosamine and complementary anti-inflammatory agents such as ginger or turmeric supplements
- Intra-articular injections of corticosteroids (strong anti-inflammatory agents) or viscoelastic preparations such as hyaluronic acids
2. Surgical treatments including the following options:
- Arthroscopic surgery (key-hole surgery) to debride (clean up) the joint of all inflammatory tissue
- Joint balancing procedures involving cutting bone, adjusting angles of the joint and fixation using metal implants
- Arthroplasty (joint-moulding) procedures including:
i. Excisional arthroplasty (removal of the painful joint) with or without additional procedures to stabilize the related bones
ii. Interpositional arthroplasty (joint-cushioning procedures) using the patient’s own tissue (usually tendon grafts) to cushion the worn-out cartilage and relieve pain
iii. Replacement arthroplasty involving the removal of the natural joint and replacing it with an artificial joint implant
The surgeon usually exhausts all non-surgical options before offering surgical treatments. Surgery is indicated when the individual continues to experience pain in the joint despite all the non-surgical options. The type of surgery will also depend on the grade and severity of the osteoarthritis and the expected function of the joint post-surgery.
Dr Aaron Gan
MBBS (Singapore), MRCS (Edinburgh), MMed (Surgery)
3 MOUNT ELIZABETH,
MOUNT ELIZABETH MEDICAL CENTRE #06 - 05,
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