in Rheumatoid Arthritis
Joseph A. Abboud, MD, Pedro K. Beredjiklian, MD, and David J. Bozentka, MD
Abstract
Rheumatoid arthritis (RA) is a chronic, progressive, systemic in-flammatory disease that affects mul-tiple organ systems, including the musculoskeletal system. Although its etiology is still incompletely un-derstood, evidence for an immune-mediated mechanism is mounting.1 The inflammatory process is trig-gered and perpetuated by a cascade of mediators that result in synovial proliferation, collagenous destruc-tion of the cartilage and soft tissues, and bone resorption. Even though RA can affect any synovial joint, the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the hand typically are in-volved early. In fact, the MCP joint is the most commonly affected joint in the rheumatic hand2(Fig. 1).
Anatomy
The normal MCP joint is a diarthro-dial, condylar-type joint that allows flexion, extension, radial/ulnar
de-viation, and circumduction. The metacarpal head is asymmetric in both the coronal and sagittal planes. The radial condyle of the metacar-pal head is larger than the ulnar condyle, which causes the metacar-pal head to slope ulnarly and prox-imally in the coronal plane, espe-cially in the index and long metacarpals. The volar surface of the metacarpal head is longer and broader than its dorsal surface, which accounts for the cam effect that tightens the collateral ligaments when the joint is flexed.3 The con-tour of its articular segment gives the MCP joint a mobile center of ro-tation, which allows it to move vo-larly with flexion. The normal syn-ovial membrane of the MCP joint is attached around the periphery of the articular cartilage with volar and dorsal synovial reflections. The synovial fold is largest dorsally on the neck of the metacarpal.4 The normal range of motion of the MCP joint is from neutral to 90° of flexion, although many individuals display
hyperextension up to approxi-mately 20°.5 There is also some ra-dial and ulnar deviation, which decreases with flexion and the asso-ciated tightening of the collateral ligaments.
The extensor mechanism has lim-ited attachments to the proximal phalanx via the dorsal capsule and extends the MCP joint through the sagittal bands.3The sagittal bands help extend the MCP joint through their insertion into the volar plate, and they center the extensor mech-anism over the joint (Fig. 2, A). The ulnar sagittal bands are stronger and denser than the radial sagittal bands.6The intrinsic musculature provides flexion, abduction, and ad-duction of the MCP joint.7 The in-terosseal and lumbrical muscles ex-ert their forces on the joint through their attachments into the extensor hood and proximal phalanx.
Dr. Abboud is Resident, Department of Ortho-paedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA. Dr. Bered-jiklian is Assistant Professor, Department of Or-thopaedic Surgery, Division of Hand Surgery, University of Pennsylvania School of Medicine. Dr. Bozentka is Assistant Professor, Department of Orthopaedic Surgery, and Chief, Division of Hand Surgery, University of Pennsylvania School of Medicine.
Reprint requests: Dr. Beredjiklian, Presbyterian Medical Center, 39th and Market Streets, 1 Cupp Pavilion, Philadelphia, PA 19104.
Copyright 2003 by the American Academy of Orthopaedic Surgeons.
Although metacarpophalangeal joint arthroplasty is occasionally performed for joints affected by osteoarthritis, it is most often done in patients with rheumatoid arthritis. The metacarpophalangeal joint is critical for proper finger function but is the most common site of involvement in the rheumatoid hand. A thorough under-standing of the anatomy, pathophysiology, and mechanics of the metacarpopha-langeal joint is a prerequisite for the evaluation and treatment of patients requiring metacarpophalangeal arthroplasty. Silicone rubber implants are the most frequently used device for treatment of revised metacarpophalangeal arthroplasty. Follow-up studies show that this surgery improves function and deformity and achieves nearly uniform patient satisfaction.
The volar plate supports the MCP joint volarly and limits its extension. The membranous portion of the vo-lar plate attaches to the metacarpal neck and has more laxity than its dis-tal insertion. The cartilaginous por-tion of the volar plate is distal and at-taches firmly to the base of the proximal phalanx. The volar plates of adjacent digits are interconnected by the fibers of the deep transverse intermetacarpal ligament.3 The ac-cessory collateral ligaments lie volar to the radial and ulnar collateral lig-aments. The accessory ligaments ex-tend from below the collateral liga-ment at the metacarpal head to the volar plate and are thought to stabi-lize it.8
The radial and ulnar collateral ligaments, which lie dorsal to the center of rotation of the MCP joint, reinforce the joint. These ligaments are lax when the joint is extended and, because of the cam effect, be-come taut when the joint is flexed. They are also asymmetrical, espe-cially at the index MCP joint. The ul-nar collateral ligament is more nearly parallel with the longitudinal axis of the finger than is the radial collateral ligament, which has a more oblique orientation.9When the joint is flexed, supination of the
fin-ger relaxes the radial collateral liga-ment, allowing it to run a less ob-lique course. Therefore, the index and long fingers allow increased ul-nar deviation of the MCP joint with the joint in both flexion and supina-tion.
Pathoanatomy
Rheumatic involvement of the MCP joint begins as a proliferative syno-vitis that progresses to volar sublux-ation and ulnar devisublux-ation of the dig-its, resulting in eventual destruction of the joint’s articular surfaces. It is unclear whether disrupting the stat-ic supports of the artstat-iculation leads to the dynamic imbalance or vice ver-sa, but both play a role in the result-ing deformity4(Fig. 2, B). Articular car-tilage softening and erosion diminish the structural integrity of the meta-carpal head, removing effective sup-port for and resulting in a static im-balance of the PIP joint.3As the disease progresses, disruption of the subchon-dral surface and structural bony el-ements of the joint lead to misalign-ment of the articular segmisalign-ment.
Several factors have been impli-cated in the development of the de-formity. (1) Asymmetry of the meta-carpal head (larger radial condyle) leads to ulnar deviation of the MCP Figure 1 Aand B, Rheumatoid hand demonstrating characteristic deformities of volar
sub-luxation and ulnar drift of the digits at the MCP joints.
Figure 2 A,Normal anatomy of the MCP joint. B, MCP joint deformities with rheumatoid arthritis. CL = collateral ligaments, ET = extensor tendon, FT = flexor tendon, FTS = flexor tendon sheath, IM = interosseous muscle or tendon, IML = intermetacarpal ligament, L = lumbrical, MH = metacarpal head, PP = proximal phalanx, SB = sagittal bands, VP = volar plate. (Adapted with permission from Wilson RL, Carlblom ER: The rheumatoid metacar-pophalangeal joint. Hand Clin 1989;5:223-237.)
joints with progressive flexion. (2) Carpal collapse leads to radial deviation of the carpus and metacar-pals and to compensatory ulnar de-viation of the digits. (3) Attenuation of the radial sagittal band secondary to synovial proliferation within the joint causes ulnar subluxation of the extensor mechanism.4,5,9 (4) Volar subluxation or rupture of the exten-sor mechanism potentiates the flex-ion forces of the intrinsic and flexor tendons, resulting in volar sublux-ation of the proximal phalanx.3,10 (5) Synovial proliferation results in attenuation of the accessory collat-eral ligaments and the membranous portion of the volar plate, leading to ulnar and volar displacement of the proximal portion of the flexor sheath from the midline. The displaced flex-or tendon results in an abnflex-ormal force on the proximal phalanx, fur-thering the ulnar and volar displace-ment of the articular segdisplace-ment.3,6 (6) Rheumatic synovitis produces changes within the interosseal mus-cles. Interosseal muscle contractures lead to a volar-directed force on the MCP joint, again contributing to vo-lar subluxation.11
The rheumatic wrist joint also con-tributes to MCP deformity. Wrist syno-vitis weakens the volar wrist liga-ments, leading to volar flexion of the scaphoid and associated radial de-viation deformity. At the distal radio-ulnar joint, synovitic stretching of the ulnar carpal and distal radioul-nar ligaments leads to dorsal dislo-cation of the distal ulna, supination of the carpus on the hand, and volar subluxation of the extensor carpi ul-naris muscle12,13(Fig. 3). Ulnar drift of the MCP joints in RA occurs more commonly in patients with radial deviation of the wrist than in pa-tients without it.14
Clinical Assessment
Assessing global function and the deformities of the adjacent joints is
critically important in evaluating candidates for MCP joint arthroplas-ty. Hand surgery, if indicated, should be timed appropriately.6In general, lower extremity and more proximal upper extremity proce-dures should be done before hand surgery.
Cervical spine involvement is common in patients with RA, partic-ularly in those with long-standing disease and multiple joint involve-ment.15Nearly one third of patients have unstable cervical joints, with atlantoaxial subluxation being the most common instability. Radicu-lopathy and myeRadicu-lopathy secondary to cervical spine instability must be differentiated from a peripheral compression neuropathy. Cervical stability must be assessed before sur-gical intervention in the upper ex-tremity, especially if general anes-thesia with endotracheal intubation is being considered.
Because deformities in the proxi-mal joints should be corrected before distal articulations are addressed, evaluation of the shoulder, elbow, and wrist is necessary in candidates
for MCP joint arthroplasty. An ax-iom for surgery in patients with RA is to start proximally and work dis-tally, alternating fusion with motion-sparing procedures.6Addressing the radial deviation wrist deformity is very important before MCP joint ar-throplasty because progression of ulnar drift at the MCP joints after ar-throplasty is inevitable in patients with significant wrist involvement. In addition, distal radioulnar joint instability can result in attritional ex-tensor tendon ruptures. Focusing solely on the MCP joint can lead to unsuccessful surgical outcomes.
Rheumatic involvement of the PIP and distal interphalangeal joints also must be assessed because their function is coupled to the mechani-cal properties of the MCP joint. Swan-neck and boutonnière defor-mities are common, occurring re-spectively in 14% and 36% of pa-tients with RA.16Unlike other distal joints, PIP joints may be treated ei-ther after or at the same time as the more proximal MCP joints.11,17Most surgeons prefer to retain motion at the MCP joints while gaining stabil-ity and optimal position at the PIP level. Implant arthroplasties of both the MCP and PIP joints are rarely in-dicated.18Rather, the preferred ap-proach is to perform MCP implant arthroplasties and correct the PIP joint problems with either tendon re-construction (for flexible deformi-ties) or arthrodesis (for fixed defor-mities).
In addition to assessing associat-ed joints, the status of the flexor and extensor tendons also should be eval-uated for the presence of synovitis and potential rupture. The severity of teno-synovium proliferation around the ex-trinsic flexor tendons should be not-ed because this may limit the amount of tendon excursion, leading to lim-ited MCP joint motion. With concom-itant extensor tendon rupture, syn-ovectomy and extensor tendon repair should precede MCP joint arthroplasty by 6 to 8 weeks.19 Some surgeons, Figure 3 Posteroanterior radiograph of a
rheumatoid hand demonstrating subchon-dral cysts, osteopenia, and volar subluxation of MCP joints with ulnar deviation.
however, perform both the MCP joint arthroplasty and the extensor tendon reconstruction at the same time be-cause it is difficult to tension the ten-don reconstruction properly when the MCP joints are dislocated.19
Classification of Joint Deformity The deformities of the MCP joint can be classified in stages, as de-scribed by Millender and Nalebuff.20 This grading system correlates well with the radiographic grading sys-tem of Larsen et al21for RA joint in-volvement6(Fig. 4).
Stage I (Larsen grade I) represents early RA with MCP joint synovitis. The patient retains the ability to fully extend the joint, with few bony or ar-ticular changes and little ulnar devi-ation present. Patients can be treated with occasional splinting and/or corticosteroid injection to relieve symptoms. Night splints to hold the MCP joints in extension and correct ulnar deviation also can be used.
Stage II (Larsen grade II) is marked by the development of early bony erosions. In this stage, chronic synovitis can lead to stretching of the radial sagittal bands, resulting in the ulnar subluxation of the extensor tendons over the metacarpal head. An extensor lag is common, but flex-ion is preserved. Pain is usually the primary complaint. Clinical inter-vention focuses on maximizing treatment. Surgery at this stage may consist of soft-tissue realignment procedures in select cases and syn-ovectomy. Synovectomy is not thought to alter long-term prognosis of the disease but is considered to re-sult in temporary symptom im-provement.15
Stage III (Larsen grades III to IV) is characterized by progression of ar-ticular surface destruction and an in-crease in the ulnar deviation and volar subluxation deformities. At this stage, nonoperative manage-ment typically is ineffective, and patients with pain and functional disability often require surgery.
Sur-gical options include tendon central-ization and synovectomy or silicone interposition arthroplasty.
Stage IV (Larsen grades IV to V) is marked by fixed malalignment of the articular segment and destruc-tion of the articular surface of the MCP joint. Resection arthroplasty with flexible implants is widely con-sidered to be the treatment of choice. Indications for Arthroplasty
Advanced arthritis of the MCP joint requiring surgery is uncom-mon, except in the rheumatic hand. Because the number of published studies of MCP arthroplasty in os-teoarthritis or posttraumatic arthri-tis is limited, specific indications have not been well established. The
general indications for MCP arthro-plasty in patients with RA are pain-ful deformity with destruction or subluxation of the joint and fixed de-formity that cannot be corrected with soft-tissue reconstruction alone. Implant arthroplasty is indi-cated in patients with (1) decreased arc of motion (≤40°), (2) marked flex-ion contractures with the joint fixed in poor functional position, (3) MCP joint pain with associated radio-graphic abnormalities, and (4) se-vere ulnar drift (>30°).6In a relative-ly young (<50 years) patient with a functional range of motion of the MCP joint (active arc, 60° to 70°), sur-gical intervention should be consid-ered carefully because it may pro-duce little functional improvement. Contraindications to surgery in-clude the presence of vasculitis, poor skin condition, or inadequate bone stock. Excessive erosion of the metacarpal head and proximal pha-lanx or excessive fatty replacement of the cancellous bone may make prosthetic fit unsuitable, and the im-plant may rotate.22
Surgical Technique
The techniques for resection arthro-plasty of the MCP and other digital joints, with and without prosthetic components, have been well re-searched.11,12,14The earliest techniques for soft-tissue arthroplasty23-27were followed by the introduction of cup arthroplasty and the metallic hinged prosthesis.28,29The Swanson silicone rubber implant was developed in the 1960s. Despite some drawbacks, the modified Swanson implant remains the most reliable and accepted for re-placement arthroplasty in the hand.30 The flexible silicone rubber im-plant used for MCP arthroplasty dif-fers in fixation, articulation, and mo-tion from other joint replacement prostheses31(Fig. 5 ). The various im-plants do not function as true pros-theses but serve as dynamic spacers Figure 4 Larsen radiographic scale for
grading joint involvement in RA using stan-dard reference films. Grade 0: no change. This signifies a normal joint without changes related to arthritis. Grade I: slight changes, including periarticular swelling. Grade II: erosions, with definitive joint-space narrow-ing. Grade III: medium destructive changes with erosions and joint spaces poorly de-fined. Grade IV: severe destructive changes and collapse with significant erosions. Grade V: mutilating changes. The original articulat-ing surfaces have disappeared, and there is gross bony deformation. (Adapted with per-mission from Wilson RL, Carlblom ER: The rheumatoid metacarpophalangeal joint.
to maintain the joint alignment after resection.22The pistoning or gliding of the implant within the medullary canal is thought to add to the range of motion achieved by the arthro-plasty and to disperse the forces along the implant-bone interface.5,31 The technique for MCP arthro-plasty has been described exten-sively.31-35A pneumatic tourniquet is placed in the proximal arm and set to 250 mm Hg. The extremity is ex-sanguinated with a compression bandage. A dorsal transverse inci-sion is made at the junction of the
metacarpal head and neck (Fig. 6, A). The dorsal veins should be pre-served to minimize postoperative digital swelling. The extensor mech-anism is exposed, and a longitudinal incision is made in the extensor hood. Swanson31 and others make this incision on the ulnar aspect of the hood, although Beckenbaugh and Linscheid30 recommend pre-serving the ulnar hood, if possible, and incising the radial aspect of the extensor mechanism. The capsule is then incised longitudinally, and the neck of the metacarpal is exposed. Soft-tissue release is necessary to re-locate the phalanx and to allow preparation of the bony structures for insertion of the components. The collateral ligaments are released subperiosteally at their origins, and the contracted ulnar intrinsic mus-cles, including the abductor digiti minimi manus, are released with a blade. The flexor digiti quinti brevis manus is preserved because achiev-ing active flexion postoperatively in the small finger is most difficult. In an attempt to preserve the function of the first palmar interosseous mus-cle in pinch, some surgeons prefer not to release the ulnar intrinsic muscle to the index finger. After the metacarpal neck is transected with a saw or rongeur, the metacarpal head
is removed along with capsular at-tachments. The level of resection is just distal to the origin of the collat-eral ligaments and perpendicular to the axis of the metacarpal shaft. Any synovial proliferation can be re-moved at this time by flexing or dis-tracting the joint.
The medullary canal of the meta-carpal is then reamed with a hand reamer. A trial prosthesis is selected, and the largest prosthesis possible is fitted without applying excessive force.36An appropriately sized pros-thesis should fit snugly while the transverse midportion of the im-plant rests against the cut surface of the bone (Fig. 6, B). After the articu-lar cartilage is removed at the base of the proximal phalanx, a perforation is made in the subchondral bone in line with the center of the medullary canal. With a rasp or burr, the hole is enlarged to accept a rectangular prosthesis. The proximal phalanx of the index finger is reamed in a supi-nated position to allow for better tip pinch postoperatively. In contrast, the proximal phalanx of the small finger is reamed in slight pronation to improve grip. After preparation and reaming, the trial prosthesis is again inserted to assure proper fit and reassess soft-tissue balance. With placement of a properly sized Figure 5 Silicone rubber MCP joint
im-plants. A, Swanson implant (Wright Medi-cal, Arlington, TN). B, Neuflex implant (DePuy, Warsaw, IN). C, Sutter implant (Avanta Orthopaedics, San Diego, CA).
Figure 6 MCP joint arthroplasty. A, Dorsal transverse incision over the MCP joint with careful retraction of soft tissue and preservation of dorsal veins. B, An appropriately sized prosthesis, shown here fitting comfortably into the metacarpal. C, Posteroanterior postoperative radiograph.
prosthesis, there should be no sub-luxation of the joint, and the implant should fit snugly into both canals (Fig. 6, C).
Some authors advise using plants with titanium grommets to im-prove durability. Theoretically, the ti-tanium protects the silicone rubber from wear. However, no studies have documented clinical benefit of their use, and data from animal experiments are inconclusive.37
Before the chosen prosthesis is in-serted, preparations are made for soft-tissue reconstruction of the radial lig-ament complex. Two small (0.035 in) drill holes are made on the dorsora-dial aspect of the metacarpal neck for subsequent reattachment of the radi-al collaterradi-al ligament. A4-0 nonabsorb-able braided suture is placed through the holes. If the collateral ligament is severely attenuated, an alternative ra-dial ligamentous reconstruction may be done, with the volar capsule and half of the volar plate attached to the origin of the collateral ligament.23,30
Kirschenbaum et al35have described good long-term results without radi-al reconstruction.
The bony surfaces are then irri-gated and prepared for implanta-tion. A so-called no-touch technique is used with smooth forceps so as not to injure the surface of the silicone rubber because implant fracture has been related to propagation of sur-face defects. The implant is inserted into the metacarpal first; then, with flexion and distraction, the distal end is placed into the phalanx. The collateral ligament suture is repaired to the metacarpal, and the dorsal hood is repaired by imbricating or reefing the radial sagittal band to re-align the extensor tendon. The skin is closed with interrupted 5-0 nylon sutures over a subcutaneous drain. Unnecessary trauma to the skin dur-ing closure is to be avoided. A bulky dressing is applied, and the hand is splinted with the MCP joints in ex-tension and the digits in mild radial deviation to protect the soft-tissue
reconstruction.5The drain can be re-moved on postoperative day 1.
The dressings are removed on postoperative day 2 or 3, and range-of-motion exercises are started 1 week postoperatively. A dynamic extension splint and a night resting splint are used for the first 6 weeks to help maintain neutral or slight ra-dial deviation of the digits. The goals of the dynamic splinting program are to control alignment, maintain range of motion, and limit undesir-able forces on the soft-tissue recon-struction. Concomitantly, the patient is enrolled in therapy to encourage active range of motion of all digital joints. The dynamic splint is discon-tinued after 6 weeks, but the resting splint can be used for 3 to 4 months. In therapy, special attention is devot-ed to the small finger, which may achieve active flexion more slowly than the others because of the release of the hypothenar intrinsic muscles, and to the index finger, which has a greater tendency to ulnar drift than do the others.38
Postoperative Results
The results of MCP arthroplasty are well documented (Table 1), and post-operative function appears to improve in appropriately selected patients.5 Re-alistic expectations are important be-cause patients are not likely to achieve full range of motion of the MCP joint. In patients with a substantial exten-sor lag or ulnar deviation, the arc of motion may be only minimally in-creased, but this will be in a more func-tional extended position. Key and tip pinch also should improve because the index finger is brought over into radial position. Reported mean postoperative arcs vary from 27° to 60°.31-35,39-44Extension lags also vary, from 9° to 22°.31-35,40-44A loss of ap-proximately 12° of active motion from an early postoperative arc of motion of 51° has been documented at a mean follow-up of 63 months.33
Table 1
Long-term Follow-up of Swanson MCP Implant Arthroplasty
Study No. of Implants Follow-up (mo) Mean (Range) Mean Postoperative Arc of Motion Recurrent Deformity Swanson31 358 — (6 to 60) 60° <10° ulnar drift Beckenbaugh et al32 186 32 (12 to 65) 38° 11% mixed deformities Madden et al39 92 >24 — 57° <10° ulnar drift Blair et al34 115 54 (24 to 125) 43° 43% ulnar drift Bieber et al33 210 63 (24 to 96) 39° 12° mean ulnar drift Kirschenbaum
et al35 144 (60 to 195)102 43° ulnar drift7° mean
Hansraj et al44 348 64 (24 to 120) 27° N/A Gellman et al43 901 96 — 50° 15° mean ulnar drift N/A = not available. (Adapted with permission from Stirrat CR: Metacarpophalangeal joints in rheumatoid arthritis of the hand. Hand Clin 1996;12:515-529.)
Ulnar deviation can be reliably corrected, although there is a ten-dency for some ulnar drift to recur over the long term.31-33Nevertheless, correcting the deformity has been shown to be a major contributor to a patient’s subjective sense of im-provement.30,31,34Most series show correction to within a few degrees of neutral.31,33,34 Recurrent ulnar drift has been reported in up to 43% of pa-tients.30 The recurrent deviation, however, is usually <10°; fewer than 10% of patients will have a recur-rence >30°.22,31,32,34,35,43-45Recurrence of deformity correlates with a more severe disease course.
Pain relief is consistently document-ed in follow-up studies of MCP joint arthroplasty. Kirschenbaum et al35 re-ported that of 144 arthroplasties in 36 hands, none of the patients com-plained of pain, although Bieber et al33 reported that 20% of patients in their series complained of pain preopera-tively. Beckenbaugh et al32reported recurrence of pain in 2% of patients at a mean follow-up of 32 months. Be-cause the rates of pain recurrence are low, overall patient satisfaction rates are consistently high.
Silicone rubber MCP joint im-plants are associated with low rates of complications.41 Several other types of MCP prostheses have been associated with generally higher rates of long-term complica-tions.40,46-48In a review of complica-tions of Swanson finger joint im-plants, Foliart41 reported that the most frequently reported complica-tion was change in the bone sur-rounding the implant, found in 4% of silicone rubber implants. Swan-son et al49 found that metacarpal
midshaft cortical bone consistently decreased postoperatively and that the length of the metacarpals with implants in place decreased an aver-age of 9%. Bone remodeling also re-sulted in thickening of the bony surfaces at the metacarpal and pha-langeal metaphysis while maintain-ing the shape of the cut end of the metacarpal.49The bone resorption is likely related to the immunogenic response of macrophages to silicone rubber particulate debris. However, silicone particle disease does not ap-pear to be a critical issue for silicone MCP joint arthroplasty.
Implant fracture rates average 2% of cases (range, 0% to 38%).41In most cases, however, implant fracture does not require revision of the pros-thetic component. Many authors re-port that most patients with frac-tured implants have acceptable function and do not require revision surgery. This was shown in a study evaluating the Sutter implant, which had a higher fracture rate than the Swanson implant, although there was no correlation between implant fracture and patient satisfaction.46 Morbidity associated with the frac-tured prosthesis is low because it functions as a spacer rather than as an articulated prosthesis.50Several changes have been made in the im-plants to address this problem. Im-provements in silicone rubber have led to enhanced resistance to frac-ture and tear propagation in vitro.
Infection is rare, seen in 0.1% to 1% of reported implants.32,35,40,41 Fo-liart41noted infection in 0.6% of im-plants. Millender et al51 noted that all infections presented within 8 weeks of implantation.
Staphylococ-cus aureus was the most common
or-ganism isolated. In most cases, the prosthesis had to be removed, and an average of 2 weeks of antibiotic treatment was required.51
Particulate synovitis and silicone-induced lymphadenopathy have received substantial attention. Foli-art41reported both of these compli-cations in 0.1% of cases. Synovitis in MCP implants occurred almost ex-clusively in fractured implants or in implants with substantial signs of wear at removal.
Summary
The MCP joint is critically important for hand function, and when it is af-fected by RA, severe deformity and loss of function commonly occur. Treatment options include manage-ment with medications and splinting, synovectomy, soft-tissue procedures, or implant arthroplasty. The choice is based on the patient’s symptoms and severity of involvement. After MCP arthroplasty, patients typically can ex-pect correction of deformity and ef-fective pain relief. Recurrence of mild deformity because of ulnar drift oc-curs in a substantial percentage of pa-tients. Implant fracture remains a con-cern, although the incidence likely has been reduced with the improved quality of silicone rubber. Longevity and reliable function beyond 10 years, however, have yet to be documented. Despite only slight improvement in the arc of motion, most patients are satisfied with silicone implant arthro-plasty because of improved cosmesis and function and the reduction in pain.
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