Degenerative Disease of the Metacarpophalangeal and Proximal Interphalangeal Joints

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CHAPTER 32 Degenerative Disease of the Metacarpophalangeal and Proximal Interphalangeal Joints

Developments in the early 1970s enabled use of the arthroscope to resolve small joint problems, similar to its application in treating large joint pathology. Despite the availability of this technology for almost 30 years, arthroscopy remains underused for treating small joints. Limited scientific literature regarding techniques and outcomes, poor delineation of the indications, and lack of reports on its benefits have hindered the acceptance and exploitation of small joint arthroscopy.

The concept of small joint arthroscopy was first delineated by Young Chang Chen, who presented a broad treatise on arthroscopy of the wrist and finger joints at a symposium that was later published in the July 1979 issue of Orthopedic Clinics of North America.¹ Chen described cadaver arthroscopic anatomy and clinical cases involving the wrist, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints of the hand. The thumb trapeziometacarpal joint was not addressed. However, the smaller joint arthroscopy was described using a no. 24 Watanabe arthroscope, which was the precursor of the modern small joint arthroscope and micro-arthroscope.

The first clinical report of MCP joint arthroscopy was not published until 1985, when Vaupel and Andrews described diagnostic and operative arthroscopy of the thumb MCP joint in a professional golfer who had experienced 1 year of pain, swelling, and stiffness in his nondominant thumb.² The technique was briefly described, and the clinical indications and results were outlined as a case report.

Arthroscopy of the proximal PIP joint had been mentioned in a cursory fashion in many case reports, beginning as early as 1997 by Richard Berger, but it was not clearly outlined until 2002, when Thomsen and colleagues described the clinical indications and arthroscopic portals in “Arthroscopy of the Proximal Interphalangeal Joints of the Finger,” published in the British Journal of Hand Surgery.³ MCP joint and PIP joint arthroscopic techniques have remained little explored by the hand surgery community, and they are virtually unknown among general orthopedic surgeons.

ANATOMY

The MCP and PIP joints are condylar hinge joints with relatively straightforward anatomy. The joint is essentially a box, with the floor represented as the less pliable volar plate and the roof as the thin dorsal capsule covered by the extensor mechanism. On either side are the collateral ligaments, which run in a dorsal to ventral oblique direction and insert distally. The MCP joint, particularly in the thumb, has a better-defined accessory collateral ligament that is located ventrally. The arthroscopic anatomy is less well defined, because the volar plate is covered with capsule and synovium, and the undersurface of the extensor mechanism also cannot be clearly visualized. The collateral ligaments are seen as fibers that pass in the oblique direction. The lateral and medial recesses are seen as deep valleys sitting below the origin of the collateral ligaments. This arthroscopic anatomy is less succinct when significant synovitis is present.

Arthroscopy may be more advantageous within the small joints than the larger joints, because open management is inherently difficult without destabilizing the joint itself. Arthroscopic management of degenerative joint disease in the MCP and PIP joints represents a logical extension of arthroscopic technique.

Degenerative joint disease can be divided into post-traumatic disease, osteoarthritis, and inflammatory arthropathy, such as rheumatoid arthritis. In the MCP and PIP joints, the post-traumatic variant is most common, because these joints are frequently injured. However, rheumatoid arthritis also is a common indication, particularly in the MCP joint, which is a hallmark of rheumatoid disease in the hand. In 2002, Sisato Sekiya of Nagoya Medical School in Japan evaluated arthroscopic rheumatoid synovectomy in the PIP and MCP joints in Arthroscopy: The Journal of Arthroscopic and Related Surgery,⁴ but a review of degenerative joint disease in the MCP and PIP joints is lacking. This chapter outlines the indications and the operative technique for arthroscopy of these critical joints, addressing acute and chronic pathology.

METACARPOPHALANGEAL JOINT ARTHROSCOPY

Background

Primary indications for MCP arthroscopy include chronic pain, which likely suggests degenerative joint disease of these small joints, and treatment of acute fractures or ligamentous lesions. Although acute indications may be more common for certain joints, such as the frequently injured thumb MCP joint, the chronic degenerative conditions are ideally suited for arthroscopic management, particularly because there are few other treatment options. Implant joint arthroplasty can be considered only in advanced disease and for low-demand patients.

Chen was the first to formally describe the arthroscopic anatomy of the MCP joint ¹; in several case reports, he described the arthroscopic findings and their clinical relevance. He performed 90 arthroscopies in multiple joints encompassing 34 clinical cases and in two amputated arms from November 1973 to August 1978. In 1984, Vaupel and Andrews described a case at the annual meeting of the American Orthopaedic Society for Sports Medicine.² A professional golfer presented with a 1-year history of chronic painful synovitis within the thumb MCP joint. Six months after arthroscopic synovectomy and débridement of a small chondral defect, the patient was able to return to his sport and was essentially pain free at a follow-up examination after almost 2-years.. These results were published in the American Journal of Sports Medicine, but hand surgeons were not affected by this novel technique.

In 1987, L.L. Wilkes, an orthopedic surgeon, presented the first series of rheumatoid pathology treated by arthroscopic means in the MCP joint.⁵ Arthroscopic rheumatoid synovectomy was performed on 13 joints in five patients with chronic rheumatoid arthritis. The patients lacked significant joint deformity, or even ulnar drift, but they did have significant synovitis within the recesses of the collateral ligament origins. Close clinical follow-up for 4 years demonstrated recurrence of pain and suggested that this technique altered progression of disease at the rheumatoid MCP joint only minimally. However, the transient pain relief and minimally invasive nature of the procedure led the investigator to conclude that it was a worthwhile procedure warranting further refinement. This innovative paper was published in the Journal of the Medical Association of Georgia but still did not influence the field of hand surgery.

This technique reached a broad audience of hand surgeons in 1994 through publication of a case report in the Journal of Hand Surgery (British edition).⁶ The patient was a young man who presented with swelling and recurrent locking of the MCP joints of the index and middle fingers bilaterally. This is a typical presentation for hemochromatosis, a rarely seen hematologic condition that is treated with phlebotomy and for which the joint manifestations are poorly understood. Until that time, the treatment of arthropathy was osteotomy, arthroplasty, and occasionally joint arthrodesis. Arthroscopy was an excellent alternative to open surgery, with better visualization of the joint, facilitating treatment of the synovitis, and more rapid recovery aided by its minimally invasive nature. The emphasis of the case report was on the condition itself, and no further recommendations were given beyond the suggestion that arthroscopic surgery was “of value.” Probably because the arthroscopic treatment was overshadowed by the unusual pathology being treated, the common clinical application of this technology was still not clear.

In 1995, Ryu and Fagan presented their series on treatment of the ulnar collateral ligament Stener lesion, which offered a common clinical application for this new technology.⁷ Their retrospective series study described arthroscopic reduction of Stener lesions in eight thumbs, with an average follow-up period of slightly more than 3 years. The technique involved reduction of the Stener lesion into the joint so that the avulsed ligament was juxtaposed to its insertion site on the base of the proximal phalanx. Previously, the ligament had been sitting outside the adductor aponeurosis and could not heal in appropriate position. After the reduction, the ligament ends were débrided and the joint pinned for stability. On removal of the cast, a brief course of therapy was introduced, and at follow-up no patient reported any pain or functional limitation. Range of motion was excellent, and strength parameters were equal to or greater than those of the thumb on the unaffected side. The only complication was a pin tract infection. These results indicated that an arthroscopic reduction of a Stener lesion could obviate the need for open repair with its inherent complications, such as prolonged recovery, stiffness, and dysesthetic scar. This series represented the first broad clinical indication for arthroscopic management of a small joint lesion. However, there was no mention of bony gamekeeper’s lesions and no comparative analysis with the open technique.

The primary benefit of this article was that it was published in a widely read journal and introduced the concept of small joint arthroscopic surgery to the broader hand surgery community. Although the paper was published a decade ago, the technique remains at the periphery, and few clinical series have been published since then.

In April of 1999, Rozmaryn and Wei presented the first paper on the practical aspects of MCP arthroscopy, with amplification of the possible indications and advantages of this still new technique.⁸ This was not a clinical series discussing outcomes; rather they addressed the sentiment that the MCP joint is too small for arthroscopic procedures and provided a summary of the broad indications that could be treated with this procedure. They specifically mentioned joint synovectomies, débridement, and biopsies and supported the possibility of collateral ligament débridement and true ligament repair. They also reviewed removal of loose bodies, treatment of osteochondral lesions, management of periarticular lesions, and treatment of articular fractures. Although their article reviewed technical aspects and further delineated anatomic landmarks not discussed since Chen’s description 20 years earlier, it had little influence on field of hand surgery. They predicted, however, that the advantages of arthroscopic techniques and the indications would evolve over time.

Later in 1999, Slade and Gutow published a review paper, “Arthroscopy of the Metacarpophalangeal Joint,” in Hand Clinics.⁹ For the first time, a description of the technique was presented, including the surgical procedure, indications, and some typical cases. The investigators touched on complications and their management. They emphasized that small joint arthroscopy required small but resilient instrumentation and good knowledge of the anatomy of these joints. Their experience revealed broad indications for this methodology, although the treatment of degenerative joint disease was not discussed in any depth. Much more detailed surgical techniques were described, mainly regarding the management of intra-articular fractures, with supporting case studies. A challenging and innovative technique was described in which arthroscopy was combined with the application of small bone anchors for reattachment of injured collateral ligaments.

Slade and Gutlow ⁹ pointed to the advantages of arthroscopy (e.g., rheumatoid synovectomy), as communicated by Patrick Ansah in Heidelberg. Ansah had begun comparing arthroscopic synovectomies and open procedures in joints of rheumatoid patients. In all of his cases, the surgeon and patient were impressed by the diminished postoperative swelling and improved rehabilitation with earlier return to activity provided by arthroscopic treatment. This unpublished series is an early illustration of the benefits of arthroscopic management of small joint degenerative disease. Coincidentally, a rheumatology paper published that same year discussed the use of mini-arthroscopy in MCP joints to stage the inflammatory arthropathy and to assist as a biopsy tool. This paper emphasized its clinical utility in the assessment of synovitis in rheumatoid patients but offered little discussion of the operative technique.¹⁰ The investigators commented that micro-arthroscopy provided the rheumatologist an objective technique for joint evaluation and visual guidance of synovial biopsy with increased accuracy and decreased risk of sampling errors. General anesthesia was not necessary, and the procedure could be done on an outpatient basis.

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