Rheumatoid Arthitis: Proximal Interphalangeal Joint Arthrodesis

72 Rheumatoid Arthritis: Proximal Interphalangeal Joint Arthrodesis

R. John Naranja, Jr. and Kevin D. Plancher

History and Clinical Presentation

A 50-year-old right hand dominant man was originally diagnosed with rheumatoid arthritis 16 years ago. Medical management of his disease process has included chronic oral prednisone. His primary complaint includes pain and deformity of his hands and decreased function secondary to lack of mobility and strength.

Physical Examination

The patient has ∼ 25 degrees of ulnar drift at the index through small finger metacarpophalangeal (MP) joints. An extension deficit at the MP measures ∼ 45 degrees. The arc of motion of the digits at the MP is 20 degrees. The proximal interphalangeal (PIP) joint of the index and long fingers demonstrates a 30-degree flexion contracture with pain and crepitus with range of motion. Key pinch strength is 30 N and grip strength is 70 N at position II using the Jamar dynamometer.

PEARLS

The position of the joint fusion should allow for the best function, which includes grasp function and the ability to put on a glove.
The goal of the procedure is to provide complete pain relief and maximize function.
Fixation can be assessed with intraoperative radiographs.

PITFALLS

Bone quality and soft tissue coverage may be a technical limitation that may not be assessed until surgery and may alter the treatment plan.
The number of passes of the K wires through bone and soft tissue should be limited.
Stretching of the skin by K wires should be avoided.

Diagnostic Studies

Radiographs, including posteroanterior (PA) (Fig. 72–1), lateral, and oblique views, demonstrated degenerative changes with associated subluxation at the MP joints and the PIP joints.

Differential Diagnosis

Degenerative joint disease

Rheumatoid arthritis

Septic joint

Diagnosis

Rheumatoid destruction and deformity of the index through small finger MP joints with associated severe degenerative arthritis of the PIP joints of the index and long fingers

Surgical Management

As initial conservative management has failed and the patient is having progressive disability secondary to the pain, operative options were discussed. In this situation, fusion of the PIP joint can provide good pain relief with maintenance of sufficient function in the context of MP joint arthroplasty.

Figure 72–1 Posteroanterior (PA) radiographs of degenerative changes in the index proximal interphalangeal (PIP) and associated subluxation of the metacarpophalangeal joint.

Several techniques have been described for arthrodesis of the PIP joint (Table 72–1

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