What is the finger PIP joint and what problems occur?

The PIP (Proximal Inter-Phalangeal) joints are the middle joints of the fingers. They are hinge type joints and allow mobility in bending and straightening and stability in sideways and twisting movements. The PIP joints are therefore very stable but this can make them more prone to stiffness and other problems.

Common problems are related to osteoarthritis.

Osteoarthritis itself is either primary i.e. occurring Due to age related degeneration of the joint, or secondary i.e. occurring due to an underlying cause. The most common causes of secondary arthritis is previous injury, particularly a fracture (break) into the joint or infection.

Patients typically present in middle age (40 years and onwards) with gradually increasing symptoms, such as stiffness/pain/deformity.

The symptoms may increase giving marked disability due to restricted movement and pain, both at night and in the day. The commonest problem is stiffness with or without pain.

Making the diagnosis

Mr Murray will take a full history regarding symptoms, and will fully examine the wrists and hands. Usually a clinical diagnosis can be made at initial consultation.

What test(s) might be performed?

Typically an X-ray is requested to determine the extent of joint damage. Xrays can usually be performed and reviewed at your first consultation.

Treatment

What are the non-operative treatments?

PIP joint arthritis:

The first steps are activity modification and Pain killers, particularly anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol), which can be very helpful for the pain. These can be applied as a gel, massaging the area, or taken orally (if no contra-indications). A splint for certain activities can also be of value.

If these measures are insufficient then a steroid injection is usually recommended. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint. The steroid does not cure the arthritis, but can reduce the inflammation and pain associated with it.

Success cannot be guaranteed but in 70-80% of patients there is significant benefit. How long this lasts is unpredictable. Some people only have a few months of benefit, others may have longer. Patients often ask how many injections can be given. There is no set rule about this. Typically, however, a second injection will work a little less well than the first, and so on.

There are risks with steroid injections, but these are small. The steroid can cause thinning of the surrounding skin and discolouration. Infection into the joint is also a very small risk.

If conservative measures, or steroid treatment fails, then surgery is advised.

What does the operation involve?

The 2 main operations for PIP arthritis are either joint replacement (arthroplasty), or joint fusion (Arthrodesis).

An incision is made over the back of the joint. The joint is opened up and cleaned out. If the joint is to be replaced then a silicone type joint can be used or a pyrocarbon joint. Both types of joint are used for certain indications, and Mr Murray will discuss this with you on a case by case basis. If a fusion procedure is to be performed, then this can be done with small, low profile staples, wires or compression screws. At the end of the operation the deep tissues are closed and the skin is then stitched up usually with absorbable stitches. A supportive dressing is applied and the patient’s arm elevated.

The total time in hospital is usually 4-6 hours.

What happens in the next few weeks?

The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.

The patient is reviewed in clinic after approximately 1 week following the operation. Sutures are removed after 10-14 days. A splint is provided by Mr Murray’s hand therapist. Careful follow up is required to ensure a successful result with good relief of pain and a good range of movement.
The hand can be used for normal activity after the first few days out of the splint. Most of the movement gained following surgery occurs in the first 6 weeks and this time must be used productively to ensure a good result. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day.

Most patients can drive after a 2-3 weeks. Most patients return to work after 4 weeks, but this varies with occupation; heavy manual work usually takes about 3 months. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces scar sensitivity.

What are the results of the operation?

At least 85% of patients in studies say they have a good or excellent result following this operation, with relief of the pain and a reasonable range of movement.

Are there any risks?

All interventions in medicine have risks. In general the larger the operation the greater the risks. For PIP joint replacement or fusion the risks include:

• The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
• Grip strength can be reduced initially.
• Stiffness may occur in particular in the fingers. This is usually short-term, but it is very important that it is resolved quickly to avoid permanent stiffness.
• Numbness can occur around the scar but this rarely causes any functional problems.
• Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
• For joint replacement, there is a risk of long-term joint replacement failure requiring reoperation.
• Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which improve very slowly.
• Any operation can have unforeseen consequences and leave a patient worse than before surgery.