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Metacarpophalangeal Joint Arthroplasty Rehabilitation

Information

Description of Intervention1-5

Arthritis involving one or more joints of the hand is relatively common, and affected patients typically experience pain, disability, and disfigurement. Over time, arthritis can severely damage the metacarpophalangeal (MP) joints and cause flexion or ulnar deviation deformity, with joint degeneration being more common in rheumatoid arthritis than osteoarthritis. Most patients with arthritis should initially be treated conservatively with physical and/or occupational therapy, but when conservative methods fail to elicit significant improvements, surgery may be required.

For arthritis involving the MP joints, the two primary surgical options are implant arthroplasty and arthrodesis. Although arthrodesis often leads to stable and pain-free outcomes, limitations in movement and hand function are common. Therefore, implant arthroplasty is typically regarded as the preferred surgical approach for MP joint degeneration, and the two most common implant options are silicone and pyro-carbon implants, followed by the metal-plastic surface-replacement arthroplasty (SRA) at a distant third.

The goals of surgery are to restore function, improve range of motion (ROM), alleviate pain, correct the deformity, and improve the aesthetic appearance of the hand. Afterwards, patients must participate in a comprehensive hand therapy program to help them continue to work towards these goals and eventually achieve joint stability and normal hand function. Therapy programs typically last for 8–12 weeks after surgery and involve resting the hand, the use of an orthotic device, various exercises to maintain and increase ROM, and a progressive return to activity while protecting the involved joint(s). The specific elements of each program regarding the type of splinting, exercises, and time frames vary widely, but all postoperative regimens share the common aims of encouraging MP flexion and extension without the recurrence of flexion or ulnar deviation deformity.

Indications for Intervention

After MP joint arthroplasty, all patients are indicated to participate in a comprehensive rehabilitation program to reduce pain levels and improve hand function.

Evaluation

  1. Ask the patient to describe their medical history, with a focus on their history with arthritis and details of the surgical procedure performed.
  2. Ask if the patient has any comorbidities, including diabetes, osteopenia/osteoporosis, cardiovascular issues, or a history of smoking.
  3. Perform a physical examination of the hand and wrist.
  4. Measure the active and passive ROM of the joints involved and compare these values with those of the contralateral side.
  5. Ask the patient to rate their pain on the visual analogue scale (VAS) or a similar pain scale.
  6. Consider using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, which is used to assess impairment of the upper extremity.
  7. Other parameters that may be evaluated include task performance with a hand function test, power grip with a hand dynamometer, pinch grip with a hydraulic pinch gauge, and dexterity with a pegboard.6,7

Intervention Options: Rehabilitation Protocol1-5

Postoperative therapy regimens for MP arthroplasty are based on the principles of healing and scar formation and should be personally designed for each patient depending on the preoperative degree of impairment, type of surgical procedure performed, and functional status of the patient. Rehab typically begins 2–7 days after surgery and should involve an appropriate splinting protocol, active and passive exercises, and a gradual return to normal activity.

Below is a guide to a typical MP joint arthroplasty rehab program with postoperative time points:

  • Day 1
    • Immobilize the hand in a volar slab that holds the wrist in extension, MP joints flexed 30–40°, and PIP and DIP joints flexed 10°
    • Elevate the upper limb to minimize edema and provide the patient with advice on active shoulder and elbow motion of the involved limb
  • Day 3
    • Remove the postoperative dressing and fabricate a customized static resting orthosis (splint or short-arm cast) that maintains the following:
      • The wrist at 0-10° extension and slight ulnar deviation
      • The MP joints in full extension with slight radial deviation
      • Full extension and flexion of the PIP and DIP joints
    • Initiate isolated active-assisted MP joint flexion and passive extension exercises out of the splint; the 2nd-5th MP joints should be flexed as a unit, while the wrist and IP joints should be extended during this exercise
    • Also initiate active-assisted IP joint flexion and extension exercises, and progress to active motion as swelling resolves
    • Encourage the patient to maintain active movement of the shoulder and elbow
  • Day 5
    • Fabricate a dynamic splint; one protocol involves positioning the wrist at 0-15° extension with slight ulnar deviation, the MP joints between 0–10° flexion with slight radial deviation, and the IP joints and thumb free; an alternative is a volarly- or radially-based gutter splint.  A static splint is utilized for night-time / sleep/
    • When the patient is not wearing the splint, they should continue with the MP and IP joint exercises described previously
    • While the patient is wearing the splint, teach them to actively flex the MP joints; they can also add a passive end range flexion stretch if necessary to help them achieve maximum MP joint flexion
    • Ensure that the patient can independently don and doff both the static and dynamic splints
  • 2–6 weeks
    • Instruct the patient to continue performing the prescribed exercises independently in the dynamic splint for the first 6 weeks after surgery
    • Regularly monitor the ROM of the MP joints; ensure the 2nd-5th MP joints are flexed as a unit and do not flex beyond 45°
    • Instruct the patients to avoid ulnar deviation at the wrist and MP joints when exercising
    • If the MP joints become stiff or loose, a range of flexion glove may be required
  • Beyond 6 weeks
    • Wean patients off the dynamic splint entirely, and instruct them to only wear the static splint at night for a total of 3 months after surgery
    • Consider outfitting the patient in a metacarpal ulnar deviation splint for function it appears to be necessary
    • Initiate combined MP and IP joint flexion exercises to help patients attain composite grip
    • Initiate light functional activities when the patient has regained adequate strength and ROM
    • Instruct patients to avoid power grip, heavy lifting (12 lbs. maximum), and positions and activities that promote ulnar drift
    • Continue to emphasize joint protection and edema and scar management
Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Be sure to monitor the incision and inspect the skin for pressure areas at each visit
  • The most stable joints are those achieving approximately 60–70° of motion, as motion beyond this results in less stability and offers little to no functional advantage.
  • High-quality research on the efficacy of various splinting and exercise regimens following MP joint arthroplasty is lacking, as most evidence consists of case series and case studies. One poor quality trial suggests that continuous passive motion alone is not recommended for increasing ROM or strength after MP arthroplasty, but additional research is needed on this topic.3
References
  1. Vahvanen V, Viljakka T. Silicone rubber implant arthroplasty of the metacarpophalangeal joint in rheumatoid arthritis: a follow-up study of 32 patients. J Hand Surg Am 1986;11(3):333-339. PMID: 3711605
  2. Srnec JJ, Wagner ER, Rizzo M. Implant Arthroplasty for Proximal Interphalangeal, Metacarpophalangeal, and Trapeziometacarpal Joint Degeneration. J Hand Surg Am 2017;42(10):817-825. PMID: 28869061
  3. Massy-Westropp N, Johnston RV, Hill C. Post-operative therapy for metacarpophalangeal arthroplasty. Cochrane Database Syst Rev 2008(1):CD003522. PMID: 18254021
  4. Massy-Westropp N, Krishnan J. Postoperative therapy after metacarpophalangeal arthroplasty. J Hand Ther 2003;16(4):311-314. PMID: 14605648
  5. Escott BG, Ronald K, Judd MG, Bogoch ER. NeuFlex and Swanson metacarpophalangeal implants for rheumatoid arthritis: prospective randomized, controlled clinical trial. J Hand Surg Am 2010;35(1):44-51. PMID: 20117307
  6. Chang M, Jung NH. Comparison of Task Performance, Hand Power, and Dexterity with and without a Cock-up Splint. J Phys Ther Sci 2013;25(11):1429-1431. PMID: 24396204
  7. Becker SJ, Bot AG, Curley SE, Jupiter JB, Ring D. A prospective randomized comparison of neoprene vs thermoplast hand-based thumb spica splinting for trapeziometacarpal arthrosis. Osteoarthritis Cartilage 2013;21(5):668-675. PMID: 23458785
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