Small Joint Replacement

Hand and Foot joint disorders

The joints of the hands and feet are miniature joints of the body. Arthritis could be considered as the most prevalent cause of the serious damages to these small joints. On the other hand, being careless about the health of your feet like wearing unstandard shoes is another cause of severe damage.

Arthritis

Three subgroups of arthritis could cause disorders of the joints of the hand and feet.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. While inflammation of the tissue around the joints and inflammatory arthritis are characteristic features of rheumatoid arthritis, the disease can also cause inflammation and injury in other organs in the body.

Psoriatic Arthritis

Psoriatic arthritis is a chronic disease characterized by a form of inflammation of the skin (psoriasis) and joints (inflammatory arthritis). Psoriasis is a common skin condition that features patchy, raised, red areas of skin inflammation with scaling. Patients who have inflammatory arthritis and psoriasis are diagnosed as having psoriatic arthritis.

Osteoarthritis

Osteoarthritis is a form of arthritis that features the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a “cushion” between the bones of the joints. When the cartilage undergoes damage, the bones would be left without protection and they rub together. Osteoarthritis is the most common cause of injury to the small joints.
If osteoarthritis in the joints of the hands or feet is so severe that function is impossible (rare with osteoarthritis), surgery or joint replacement will allow some pain-free motion.
In the hands, the goal is enough pain-free motion to allow the person to do basic daily activities such as eating, bathing, and dressing. Surgery for severe arthritis in the small joints of the hands is more commonly seen with rheumatoid arthritis.
In the feet, the goals of surgery are usually to allow the person to be able to wear shoes comfortably and to walk as normally as possible. Surgery to repair bunions or hammer toes is fairly common in osteoarthritis.

Ill-fitting shoes

Hammer, claw, and mallet toes are toes that do not have the right shape. They may look odd or may hurt, or both. The muscles that control your toes get out of balance and cause the toe to bend into an odd position at one or more joints. These toe problems almost always happen in the four smaller toes, not the big toe.
If you notice that your toe looks odd or hurts, talk to your doctor. You may be able to fix your toe with home treatment. If you do not treat your toe right away, you are more likely to need surgery.
These toe problems develop over years and are common in adults. Women have more of these problems than men because of the types of shoes they may wear, such as high heels.
Claw toe and hammertoe conditions are fairly common in cultures that wear shoes. In most cases, these problems can be traced directly to ill-fitting shoes.

Symptoms

A hammer toe is a toe that bends down toward the floor at the middle toe joint. It usually happens in the second toe. This causes the middle toe joint to rise up. Hammer toes often occur with bunions.
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Claw toe often happens in the four smaller toes at the same time. The toes bend up at the joints where the toes and the foot meet. They bend down at both the middle joints and at the joints nearest the tip of the toes. This causes the toes to curl down toward the floor.
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A mallet toe often happens in the second toe, but it may happen in the other toes as well. The toe bends down at the joint closest to the tip of the toe.
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Surgery

Treatment depends on how far along the process is. If the primary solutions like changing life style and habits, using medications, rehabilitation exercises or ortesis could not ameliorate the situation, then a surgery might be suggested.
Since these four surgeries has some similar stages as well as some differences, we first explain the common steps then go through specifications.

General stages of the procedures
Anesthesia

Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the joint area. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Preventing infection

Once you have anesthesia, your surgeon will make sure the skin of the joint region is free of infection by cleaning the skin with a germ-killing solution.

Opening up the surgery path

An incision is made across the joints that are to be replaced. The soft tissues are spread apart with a retractor. Special care is taken not to damage the nearby nerve that passes by the joint. An incision would be made in the joint capsule so that the joint is exposed.

Elaborating surgical procedure and prosthesis features

Finger joint replacement surgery

The Artificial Finger Joint
Surgeons use silicon plastic implants to replace the original joint surfaces. The artificial joint, as could be seen in the figure, consists of a body and two stems and functions the same way a hinge on a door does.
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The Operation
      • The procedure takes about two hours to complete.
      • An incision is made across the back of the finger joints that are to be replaced and the joint is exposed as described before.
      • The ends of the bones that form the finger joint surfaces are taken off, forming flat surfaces.
      • A burr (a small cutting tool) is used to make a canal into the bones that form the finger joint.
      • The surgeon then sizes the stem of the prosthesis to ensure a snug fit into the hollow bone marrow space of the bone. The prosthesis is inserted into the ends of both finger bones.
      • When the new joint is in place, the surgeon wraps the joint with a strip of nearby ligament to form a tight sac. This gives the new implant some added protection and stability.
      • The soft tissues are sewn together, and the finger is splinted and bandaged.
Wrist joint replacement
The Artificial Wrist

Some early artificial wrist joints were made entirely of flexible silicon plastic. These plastic joints were used primarily as spacers to keep the joint surfaces from rubbing together. Modern artificial wrist joints are made of metal and plastic and mainly consist of three parts.
The part that fits against the end of the radius bone of the forearm is called the radial component. It is made up of two pieces. A flat metal piece is placed on the front part of the radius. It has a stem that attaches down into the canal of the bone. A plastic cup fits onto the metal piece, forming a socket for the artificial wrist joint.
The part that replaces the small wrist bones is called the distal component. This piece is made completely of metal. It is globe shaped to fit into the plastic socket on the end of the radius. The metal distal component is attached by two metal stems that fit into the hollow bone marrow cavities of the carpal and metacarpal bones of the hand.
The plastic used in artificial joints is tough and slick. It allows the two pieces of the new joint to glide easily against each other as you move your wrist. The ball and socket allow movement of the wrist in all directions.

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The Operation
  • The surgeon will first make an incision through the skin on the back of the wrist and open up the path.
  • The surgeon needs to make room for the artificial joint. To do this, most of the first row of carpal bones is removed from the wrist. The end of the radius is also shaped to fit the prosthesis.
  • The hand bones and the radius bone of the forearm are then prepared with special rasps. The rasps are used to bore holes in the bone for the metal stems of the replacement joint.
  • The surgeon will take some time to get the stems to fit tightly. The joint is put in place and tested through its range of motion to make sure it moves correctly. Once the surgeon is satisfied with the fit, the stems of each metal implant are cemented into place.
  • The tendons are then placed back into their proper place, and the skin is stitched together.
Ankle Joint Replacement
The Artificial Ankle

Each artificial ankle prosthesis is made of two parts:

    • The tibial component is the part of the artificial joint that replaces the socket portion of the ankle (the top section).
    • The talus component replaces the top of the talus.

The tibial component is usually made up of two parts: a flat metal piece called a metal tray that is attached directly to the tibia bone, and a plastic cup that fits onto the metal piece, forming a socket for the artificial ankle joint. The talus component is made of metal and fits into the socket of the tibial component.
Your surgeon may use a special type of epoxy cement to attach the metal components to the bone. This is called a cemented prosthesis.
Some surgeons prefer to put the new joint in without using cement. This is called an uncemented prosthesis. The surface of this type of prosthesis bears a fine mesh of holes that allow bone to grow into the mesh and attach the prosthesis to the bone.

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The Operation
      • The surgeon begins the operation by making an incision through the skin on the front of the ankle. The surgeon opens the joint as described before to prepare the surfaces to be replaced.
      • To fit the metal socket in place, the ends of the ankle bones are shaped. The tibia and fibula are shaped first. Next, the top of the talus is shaped so the metal talus component can be inserted. Finally, all the different pieces of the artificial ankle joint are put in place, and the ankle is tested to make sure the pieces fit properly.
      • To make sure that the ankle socket or the tibial component fits tightly, two screws are placed through the fibula and the tibia just above the artificial ankle joint.
      • Bone is grafted between the fibula and tibia to create a fusion between them. This stops any motion between the two bones that could loosen the artificial joint. The bone graft is taken from the bone that was removed from the ankle earlier during the shaping procedure.
      • When the surgeon feels that everything is satisfactory, the joint capsule is sewn back together, and the skin is stitched together.
Toes joint replacement

Depending on the disorder, arthroplasty of toes is done in one of the following three ways:

DIP Joint Arthroplasty

For the hammertoe deformity, an arthroplasty of the DIP joint may be suggested. This procedure is performed through a small incision in the top of the toe over the DIP joint. Once the joint is entered, an arthroplasty is performed by removing one side of the joint. This releases the tension on the ligaments and tendons around the joint and allows the toe to be realigned in the proper position. Once the toe is in the proper position, it is held with sutures (stitches) or a metal pin while it heals.
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PIP Joint Arthroplasty

One of the most common procedures to correct the claw toe deformity is an arthroplasty of the PIP joint. In this procedure an incision is made over the joint. Once the surgeon can see the joint, the end of the proximal phalanx is removed to shorten the toe and relax the contracture around the joint. The toe is then either held with metal pins or sutures in the straight position until it heals.
As the joint heals, scar tissue forms, connecting the two bones together and replacing the area where the joint once was. Surgeons refer to this as a false joint (or pseudo joint) because the scar tissue allows a bit of motion to occur between the two bones while keeping them from rubbing together and causing pain.

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MTP Joint Release

If clawing is a problem, then the MTP joint may also have to be released to relieve the contracture of this joint and allow the proximal phalanx to come into the correct position. This procedure is performed by making an incision on the top of the toe over the MTP joint. The surgeon then releases the tight ligaments and tendons until the toe easily moves back into the proper alignment. The toe may be held in the proper alignment with a metal pin until the soft tissues heal. The pin may remain in place for three or four weeks.

Preparation

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.
Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.
On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The length of time you spend in the hospital depends a lot on your recovery from anesthesia after surgery. In general, finger joint surgery can be done on an outpatient basis, meaning you can leave the hospital the same day.

Complications

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial finger joint replacement are

      • Complications due to the anesthesia
      • Complications due to the infection
      • Nerve Damage

All of the nerves and blood vessels that go to the finger travel across, or near, the finger joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.

      • Prosthesis Failure

One of the problems that occur with artificial replacements is that they can fail. The older silicon-type prosthesis has been shown to break apart and fragment. Most types of prostheses can displace, or move out of the correct position, causing problems. Most of these problems will require a second operation to remove and replace the prosthesis.

After Surgery

After surgery, your joint will be bandaged with a well-padded dressing and a splint for support. The splint will keep the region in a straightened position during healing. Your surgeon will want to check your hand in five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medicine to control the discomfort you have.
You should keep your joint elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.
In wrist and ankle surgery you may also have a small plastic tube that drains blood from the joint. Draining prevents excessive swelling from the blood. (This swelling is sometimes called a hematoma.) The draining tube will probably be removed within the first day.

Rehabilitation

A physical or occupational therapist will direct your recovery program. Recovery takes up to three months after prosthesis is implanted.
The first few therapy treatments will focus on controlling the pain and swelling from surgery. Heat treatments may be used. Your therapist may also use gentle massage and other hands-on treatments to ease muscle spasm and pain.
Then you’ll begin gentle range-of-motion exercise. Strengthening exercises are used to give added stability around the joint. You’ll learn ways to use your new joint to do your tasks safely and with the least amount of stress on your new joint. As with any surgery, you need to avoid doing too much, too quickly.
Some of the exercises you’ll do are designed to get your joint area working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your artificial joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.
The therapist’s goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your new joint. When you are well underway, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

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