Welcome to a series segment called Hands-On, where we'll focus on different parts of the hand from fingertip to wrist. You've probably heard of a knee or hip replacement, but did you know that there are replacement surgeries for joints as small as the knuckle? Tune in to learn more about the functionality of the knuckles, the kind of arthritis that affects them and how a knuckle replacement works.

We're going to talk about it today with Dr. Khurram Pervaiz, Orthopedic Surgeon, specializing in hand and upper extremity surgery for Orthopedic Associates of Central Maryland Division. Hello, I'm Prakash and I have Got A Bone to Fix With You. So doctor, my first question is what kind of arthritis affects the knuckles?

Dr. Pervaiz: Hand surgery has come a long way in terms of treatment for arthritis of the finger joints. So, in any one of the fingers in your hand, you've got the knuckle, which is the main joint, and then further going down towards the fingertip, you also have the smaller finger joints. We call them the interphalangeal joints.

So arthritis of these joints can be caused by age which is osteoarthritis, wear and tear arthritis. It can be caused by trauma. If you've had an injury, a fracture, you can develop arthritis, which is we call that post-traumatic arthritis. And then the other major type of arthritis that can affect the finger and the nuckle joints is rheumatoid arthritis or autoimmune disease. These conditions affect different joints in the body and can also affect the finger and the knuckle joints. So these are the most common three types of arthritis that affect the hand and finger joints.

Host: Understood. So, you know, when we talk about the knuckles, they seem like such a small joint in the hand. I'm curious as to how it affects functionality, strength, range of motion. What does it feel like when you have arthritis in your knuckles?

Dr. Pervaiz: You're absolutely correct. It can present with a variety of ways. I see patients sometimes come in complaining of just pain. Sometimes patients complain of loss of motion or not being able to have a strong grip. I had a patient today who her main complaint was can't open up bottle or a can if she wants to. She has a really hard time doing that, difficulty with daily tasks, difficulty with holding a pen or doing your job, or just taking care of yourself, you know?

It's amazing. The hand is our window to the world. That's how we interact with the world. And just a little bit of pain, in your dominant hand can be very disabling.

Host: Yeah, there's no question about it. And I guess a lay person question is, I used to always crack my knuckles when I was younger. I know my wife still does that today. Can that cause arthritis in the knuckles?

Dr. Pervaiz: Yeah. So, this is something you know, that I also was told as a kid, I used to crack my knuckles and I'm a hand surgeon and I still have a nervous habit of cracking my knuckles. This what actually studied. And it makes no difference.

Host: Okay, well, that is good to know. And I'm glad that I have that in my arsenal of information.

Dr. Pervaiz: Go ahead, crack away, it won't affect, your joints.

Host: Okay, fair enough. You know, when one person has knuckle arthritis, what are the modalities of treatments available to them?

Dr. Pervaiz: It depends on the severity of the arthritis and how far along their symptoms are. So well, so for instance, when I see somebody and they're coming in for the first time, I'll typically prescribe something simple. We have anti-inflammatory medication we'll use, we'll have anti-inflammatory creams, we'll prescribe home directed therapy and exercises, or we might have them see a hand therapist. You know that working with a therapist can improve range of motion and strength and function. Simple measures are not working, then we'll do more advanced treatment. Like we may do certain injections, certain medications can be injected in the joint to help lubricate the joint and help decrease pain and inflammation.

And when all these things, let's say patient, patients have tried all of these things and nothing is working, then the next step is to consider surgery.

Host: Okay. And so at what point does surgery get considered? Like have you been living with arthritis in the knuckle for a long time? Is this kind of a long discussion with an orthopedic surgeon like yourself, maybe talk about how that decision comes or unfolds.

Dr. Pervaiz: So it depends on their pain level and depends on what they've tried so far. So, if they've tried everything else and they've given it sufficient time and they feel that they're ready for surgery and they fully understand what that means and what the risks and benefits are. Obviously, this is all, we explain this to the patient because it's an mutual informed decision between the surgeon and the patient. And if they understand the risks and benefits and they're willing to go through the recovery process, then that's the time to consider surgery.

Host: So, you know, we're talking about knuckle replacement today, and that is something that just seems so crazy to me. So, maybe talk about the dynamics of how the surgery works and what the recovery time is like.

Dr. Pervaiz: Right. So obviously, you know, this is why surgery like this, which is by the way, highly specialized surgery, it's done by Fellowship trained, Board Certified Hand Surgeons and hand surgeons like myself. We are Orthopedic Surgeons that gets subspecialty training in hand surgery, And it's delicate work. It's a little bit different than replacing a hip or a knee, which are much bigger joints.

So, here you know, it's much more delicate work and we're working with smaller bones and smaller joints. So, you have to be extra careful, obviously, not that hip and knee surgery is not careful either, but you know, it's a different level of skill that's needed here. So what does the surgery look like? We make incisions on the joint.

We protect the surrounding structures. There's a lot of tendons, and nerves and blood vessels around the finger joints, we protect them. And then we go in and we remove the arthritic joint and we replace it with an artificial joint. Now, these artificial joints for the knuckles and the finger joints are made up of different types of materials.

Historically, these joints were made up of a rubber type of material made of silicone, so it's a single implant that goes in on both sides of the joint, into the bone and in the middle it's connected and it allows the patient to just bend their finger. Then we came up with implants, made up of pyrocarbon, those worked for a while, but then also had some failures and historically, so, and now the latest innovation, a metal and plastic articulation, similar to what we use in the hip and the shoulder and the knee. And that's the more recent advancement in finger joint replacement. So, what type of implant to use will be based on your type of arthritis and your activity level and your discussion with your hand surgeon.

So your hand surgeon will be able to advise you on what type of implant exactly you will need, and they will be able to tell you that. And then the recovery is, these surgeries are typically done outpatient. Patients go home the same day. They're immobilized in a permanent splint for a couple of weeks.

And then we switch them to a removable splint and we start hand therapy and patients are in therapy typically for three months. The recovery is anywhere from three to six months. I typically tell my patients that give it about three to six months to get enough function, to return to a normal life.

Host: And is this surgery typically for pain relief or does it actually address some of the things that you talked about earlier? Like being able to pick up a pen or open a bottle? Talk a little bit about that.

Dr. Pervaiz: Oh, yeah, it can. It can address just about all of those symptoms. You know, patients for this surgery, if they have a good outcome, barring obviously no complications which can rarely happen, but usually don't, patients can expect improvement in pain. If patients are diligent with their therapy, they can sometimes also have improvement in their range of motion.

And then definitely they'll have improvement in the functional use of their hand. They'll have better grip strength, better use because once the arthritic joint is gone and the pain is gone and the artificial joint is functioning well, there's just overall have a much better function in the hand.

Host: Yeah, that sounds absolutely amazing. So, you know, just taking a step back I guess a more basic question is one around just being proactive with making sure that you do everything that you possibly can, obviously not to need that knuckle replacement. What do you recommend to your patients that aren't necessarily experiencing any pain yet, but want to be proactive about their hand or their knuckle health?

Dr. Pervaiz: Well, main thing is to stay active, you know, there's a lot of data on now nutrition and a lot of different things affecting just your overall joint health. So stay active, eat healthy. Be well. If you have a family history of arthritis and you're having any issues, might be a good idea to go see a hand specialist. Certainly if you have a trauma, don't ignore it. I do see not too uncommonly, patients who had a minor injury and they chaulked it off to just a sprain and I see them a month later and it was a displaced fracture, broken bone and then it's a much harder injury to fix then definitely if it's ignored, it's going to lead to premature arthritis.

So if you have an injury, definitely go and have it looked at, have it x-rayed even at an urgent care and they can advise you on if you need to see a specialist. And then if you're having issues then pain, you might want to have somebody take a look at it so that they can help you address it appropriately and prevent future issues.

Host: Well, Dr. Pervais I think this has been a great conversation and the perfect place to end. Is there anything else that you wanted to share with our audience before we close here today?

Dr. Pervaiz: Yeah, thank you for listening to the podcast and please come and see us at Orthopedic Associates. We specialize in all orthopedic issues. We have all specialties in-house and come and see us so we can help make your pain better.

Host: Absolutely. Well, Dr. Pervaiz, thank you again for your time.

Dr. Pervaiz: Thank you Prakash.

Host: That's Dr. Khurram Pervaiz, Orthopedic Surgeon, specializing in hand and upper extremity surgery for Orthopedic Associates of Central Maryland Division. For more information, you can head to MDbonedocs.com. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

That's all for today, I'm Prakash Chandran and that Was a Bone That's Fixed.