Case Report: Restoring Motion in Fused Finger Joints

In a case report published in the American Journal of Orthopedics, physicians report a rheumatoid arthritis patient who sought treatment for ankyloses, or fusion of the finger joints. She was treated with silicone arthroplasty and at two years, reported being pain free.

“Most patients with bony ankylosis of proximal interphalangeal (PIP) joints present with minimal pain and do not seek surgical treatment. However, patients with ankylosis that limits functioning or activities of daily living, may wish to pursue intervention that could be restorative. PIP joint arthroplasty may be effective in improving motion in patients with bony ankylosis of the finger joints,” write Hisham M. Awan, M.D., and Joseph E. Imbriglia, M.D. in the case report.

There are few treatment options for bony ankylosis of the finger joints in rheumatoid arthritis. In this case, the patient experienced loss of hand motion in her ring and small fingers causing difficulty at work.

Summary

Common manifestations of rheumatoid arthritis of the hand include synovitis, tendon ruptures, Boutonniere and swan-neck deformities as well as joint destruction involving the metacarpophalangeal and proximal interphalangeal joints.

The authors point out that even though ankylosis of the finger joints is a known complication of rheumatoid arthritis, it has seldom been reported. Prior studies report an incidence of ankylosis of the finger joints in patients with rheumatoid arthritis at 23.6%. Those patients reported more difficulties in daily life.

Implant arthroplasty is an established treatment for arthritis of the hand and fingers due to rheumatoid arthritis, osteoarthritis or post-traumatic arthritis. In addition to pain relief, the procedure can restore some joint movement. Silicone arthroplasty is generally used for pain relief, but not necessarily to restore motion of an ankylosed joint.

Case

In this report, a 56-year-old patient with rheumatoid arthritis of more than 20 years underwent left carpometacarpal arthroplasty and thumb reconstruction. She presented with fusion of her proximal interphalangeal joints at 15 degrees of flexion in her left ring and small fingers.

She reported worsening function of the left ring and small fingers. Radiographs showed severe diffuse arthritis of the hands and complete bony ankylosis of the ring and small finger PIP joints with radial deviation of the ring-finger middle phalanx. The patient had minimal pain and sought improved hand motion.

The authors point out that intra-operatively; identification of the native joint was complicated by ankylosis. Once identified, bony resection was performed within the affected joints followed by placement of silicone prostheses.

Post-op

The patient was immobilized in 10 degrees of PIP joint flexion for 10 days. Therapy was initiated after the splint was removed. The patient reported being pain-free after 24 months and had a 60 degree active PIP joint flexion, with extensor lag of only 10 degree. Alignment of the fingers was satisfactory with a mild persistent radial deviation of 10 to 15 degrees. Radiographs showed good positioning of the implants. The patient was satisfied with her improved functioning and returned to employment as a hospital clerk, working full-time.

Discussion

Proximal interphalangeal joint arthroplasty has become a common option for finger joint arthritis leading to pain relief in 98 percent of patients and increased range of motion with complications being rare.

Use of silicone arthroplasty in non-rheumatoid arthritis patients and patients with post-traumatic arthritis has not been as successful. Considerable implant deformation or fracture, as well as rotational deformity, alignment deviation and loss of pinch strength in the fingers occurs.

Key Points

• Ankylosis of the finger joints in patients with rheumatoid arthritis is common and usually affects multiple joints.
• While not usually painful, ankylosis of the finger joints limits range of motion and affects activities of daily living.
• Silicone arthroplasty for ankylosis of the finger joints is an effective treatment increasing range of motion and alleviating pain if present.
• Finger joint arthroplasty for post-traumatic arthritis and other non-rheumatoid arthritic states may improve pain but typically results in implant failure and deformity.

References:

Awan HM, Imbriglia JE. “Silicone arthroplasty after ankylosis of proximal interphalangeal joints in rheumatoid arthritis:  A case report,” American Journal of Orthopedics. May 2016;45(4):E221-E223