When conservative arthritis treatments become less effective over time, there are two surgical options available: arthrodesis (joint fusion), or arthroplasty (joint reconstruction). Both are recognized as a successful treatment approach for chronic osteoarthritis, yet they each have their pros and cons. Here’s a closer look at what to consider before making the commitment to either type of hand surgery.
Considerations in Arthrodesis
Joint fusion surgery effectively immobilizes the affected joint, preventing further motion that would exacerbate the symptoms of arthritis. There are several approaches that may be taken:
- A bone autograft is typically the preferred option among surgeons, as harvesting donor bone material from the patient’s own body eliminates the rejection risks associated with allografts. Autografts also contain osteoblasts, promoting new bone formation for reinforcement.
- A bone allograft utilizes bone from a bone bank for joint fusion. The donor bone is first processed to reduce the likelihood of graft rejection and disease transmission. However, bone allograft still retains its osteoconductive qualities after processing.
- Synthetic substitutes for natural bone like hydroxyapatite can be used as an osteoconductive matrix.
- Structural implants in the form of metal wires, screws and plates can be used to maintain the affected joint in a closed position in such a way that the position becomes permanent.
Note that these options are not exclusive, and may be used in combination depending on the necessary course of treatment.
The process of joint fusion necessarily limits flexibility, which is a primary consideration of the surgery. However, the fused joint does become more stable and is better able to bear weight after the procedure; most importantly, the painful symptoms of arthritis are drastically reduced or eliminated. Joint deformity can also be resolved through fusion.
Considerations in Arthroplasty
Removing the degraded joint surface through joint replacement is the other option for surgical arthritis treatment, and is preferable when maintaining range of motion is essential to a positive outcome. Joint reconstruction begins by eliminating the surface degeneration and irregularities associated with advanced osteoarthritis. After the affected surface is excised, function is replaced through synthetic reconstruction.
Most commonly, new joints in the hand are crafted out of donor tissue from the patient’s body, usually a tendon, or synthetic material like silicone or pyrocarbon. Not all joints are good candidates for joint replacement. For example, the DIP joint is simply too small to effectively hold an implant; since overall hand function would be only minimally impacted through immobility, joint fusion in the DIP joint would be the better choice. Alternatively, fusion in the PIP joint could dramatically reduce hand function; reconstruction is recommended here instead.
As with any surgery, the unique needs of each individual patient remain the primary consideration in determining which approach will be most effective. However, speaking in larger generalizations, patients are typically broken down into candidacy based on age and activity level.
For younger, more active patients, joint reconstruction is generally not recommended. This may seem contradictory, considering the higher level of functionality that’s required for maintaining a more physical lifestyle and that could be limited by joint fusion. However, the realities of increased stress demand on joints under constant heavy use will very quickly wear out a less durable artificial joint.
Joint replacement surgery is more often indicated in older patients with a lower activity level, as well as those with rheumatoid arthritis. The activity level puts less strain on the artificial joint, while the pain relief provided through the surgery relieves pain enough to actually improve range of motion and functionality in the right candidates.