Metacarpal Phalangeal Joint Replacements

Metacarpalphalangeal Joint (MCJP) Arthroplasty

Traditionally MCPJ replacements have been of silicone construction inserted into patients with rheumatoid disease. However osteoarthritis (OA) either primary or secondary to trauma does occur. In these patients it has been shown that a more stable MCPJ replacement such as the Ascension Pyrocarbon type is more suited.

Rehabilitation for RA and OA is very different:

Post Operative Hand Therapy for RA:

Two protocols are available: -

Dynamic Regime
Static regime

The DYNAMIC REGIME is the preferred protocol, but the STATIC REGIME should be considered when there are justifiable circumstances.

Aims of treatment:

Improve function by:

Correcting deformity
Relieve pain
Altering arc of flexion / extension (most commonly it is extension that requires the greatest increase in movement but achieving this must not be at the expense of functional flexion).
Improved cosmesis is frequently achieved by this procedure and maintaining this is important to many individuals.

Immediate Post-operative Period:

Elevation
Antibiotics
Pain relief

Day 2:

Removal of post-op dressing
Wound inspection
Removal of silastic drain
Reapplication of volar supporting splint (post op POP if comfortable or custom made thermoplastic resting splint, see appendix 1)

Day 3-5:

Elevation of hand
Pain relief as appropriate
The patient may be discharged from hospital at this point if medical and social circumstances permit.

Day 5 Dynamic Regime:

If Outpatient re-admit to ward for over night stay or as day patient dependent on medical & social circumstances and distance from hospital.
Construction / Application of Outrigger / Commencement of exercise regime (see appendix 2&3)
Review / Application of Night Resting Splint

Day 6:

Review of outrigger and exercises as Inpatient or Outpatient.
ADL needs attended to in preparation for discharge.
If Inpatient normally patient is discharged home depending on medical & social circumstances.
Check patient follow-up details and arrange Therapy follow up as appropriate.

Day 14:

Removal of sutures in Outpatient
Review of skin condition
Review of Outrigger and Night resting Splint efficiency and comfort
Review of exercise programme and Range of Movement

Follow Up weeks 2-6:

Minimum weekly attendance in Therapy Department to ensure maximum efficiency of splints and patient exercise regime.
Scar care as appropriate
Introduction of additional exercises to increase flexion or extension or both.
Introduction of static flexor / extensor splints as appropriate.
Check patients follow up details and arrange Therapy follow-up as appropriate

Week 6:

Reviewed either in Outpatient Department by consultant.
If joints stable and good correction of ulnar deviation has been maintained cease the use of Outrigger splint
If there is poor correction of ulnar deviation and /or laxity of the joints the Outrigger can be retained for a further 2 weeks.
If the patient exercises more efficiently against the rubber band and resistance provided by the Outrigger the splint can be retained for a further 2 weeks for exercise only.
Joint protection advice
Commence light function applying joint protection principles
Ulnar Deviation protection splinting as appropriate to individual ROM / Deformity / ADL circumstances.

Follow-up Weeks 6-12:

Patient reviewed in Therapy as frequently as is dictated by the individuals needs.
Review appointment at 12 weeks for discharge.
STATIC REGIME This involves the use of 2 static splints. Figure 3

Splint 1

Wrist extension 30 degrees
MCPJs flexed, ideally 60-70 degrees
IPJs extended 0 degrees

Splint 2

Wrist extension 30 degrees
MCPJs extended 0 degrees
IPJs extended 0 degrees

The splints are alternated every 24 hours.
Splint removed hourly during the day for active exercise
Isolated MCP joint flexion
Isolated IP joint flexion
Mass flexion
Passive MCP joint extension
Active MCP joint extension
Radial finger walking

This protocol was prepared by: -

Lynda Gwilliam, Clinical Specialist Occupational Therapist, Wrightington Hospital Hand & Upper Limb Therapy. Reviewed with Ann Birch, Clinical Specialist Physiotherapist, Wrightington Hospital Hand & Upper Limb Therapy. August 2006

Appendix 1

Volar based hand/wrist static splint for MCP joint arthroplasties

The initial purpose of this splint is to support the MCP joints in maximum comfortable extension and to maintain the correction of MCP joint ulnar deviation obtained through surgery during the inflammatory phase of wound healing.

Immediately post –op, in theatre, this position is achieved by the application of a volar bases POP slab.

Upon dressing reduction (day 2) this POP slab can be reapplied if effective and comfortable or replaced with a custom made thermoplastic splint, which has the same clinical objectives.

For the first 5 days post-op the splint is worn 24 hours a day to support the MCP joints.

If the patient has retained the post-op POP for the first 5 days it is replaced with a thermoplastic splint on day 5 post-op.

The longer-term purpose of the splint (collagen formation) is to prevent the recurrence of MCP joint ulnar deviation and maintain /increase MCP joint extension during periods of daytime rest and during the night.

Occasionally, at 3 weeks post –op, if extension of the MCP joints is good but flexion poor the splint can be remoulded to encourage flexion of the MCP joints.

The position and efficacy of this splint should be reviewed at each follow-up visit.

To discourage recurrence of pre-operative deformity, and maintain optimal alignment and ROM of the MCP joint arthroplasties, this splint is retained at night during the tissue maturationphase of healing (3-6 months)

Appendix 2

Dynamic Extension Splint (DES or Outrigger)

The purpose of this splint is to: -

Protect the soft tissue reconstructions performed during surgery.
Prevent recurrence of pre-operative deformity.
Assist the relocated weak extensor tendons achieve maximum tissue excursion and movement of the MCP joints.
Correct any residual deformity.
Provide “bio feed back” to the flexor mechanisms of the MCP joints to assist with active flexion of the MCP joints.
Immobilise/stabilise the wrist joint to direct the most efficient flexor power to the MCP joints.

For the majority of patients this will be achieved via a low profile outrigger (if ulnar deviation of the MCP joints is still significant, or the patient has considerable difficulty achieving flexion of the joints a high profile outrigger or alternate regime should be considered).

Because most patients suffering from RA have very fragile skin the base of the splint must be well fitting at all times. This will require frequent monitoring and some alterations as oedema reduces and the arc of movement changes. The tension on the elastic should support the MCP at neutral and allow maximum MCP flexion.

Links:

Finger Replacement Surgery

Evidence:

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