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Updated: Oct 2 2024

MCP Joint Arthritis

MCP Joint Arthritis

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  • Summary
    • Metacarpophalangeal (MCP) Joint arthritis typically presents with pain, swelling, and limited motion. Inflammatory etiology is much more common than osteoarthritis
    • Diagnosis is made with a combination of physical exam and radiographs which may demonstrate ulnar deviation of the digits with possible volar subluxation of the proximal phalanx on the metacarpal head
    • Treatment occurs on a spectrum of non-operative and operative measures including observation, Disease-modifying antirheumatic drugs (DMARDs), silicone or pyrolytic carbon implants, and arthrodesis 
  • Epidemiology
    • Incidence
      • Less common than other joints of the hand
        • DIPJ > Thumb CMC > PIPJ > MCPJ
    • Prevalence
      • primarily affects patients with pre-existing inflammatory arthropathies
      • primary osteoarthritis (OA) is rare
        • 6.1% in males
        • 1.4% in females
      • post-traumatic arthritis is rare
    • Demographics
      • more likely to occur in the 4th or 5th decade of life
        • OA and post-traumatic arthritis more likely to occur in men at an earlier age 
        • inflammatory arthritis more frequently occurs in women
  • Anatomy
    • Arthrology
      • MCP joint consists of the proximal phalanx and the corresponding metacarpal
      • diarthrodial joint
        • convex head of the distal aspect of the metacarpal articulates with the concave proximal phalanx base
        • MCP joint contributes 77% of the total arc of finger flexion, although most functional daily activities can be performed with 35° or 50% of the normal range of motion
      • thumb MCP joint
        • volar aspect of the joint capsule has 2 sesamoid bones 
        • larger range of motion in comparison to other MCP joints 
    • Ligament
      • volar plate
        • increases overall joint congruence and prevents MCP joint hyperextension
      • volar accessory ligament 
        • attaches on the middle of the metacarpal head and extends to the volar plate and deep transverse metacarpal ligament, which tightens during finger extension
      • deep transverse metacarpal ligament
        • connects the 2nd to 5th metacarpal heads together at the volar plate
        • function to increase joint stability and aid in joint dynamics
  • Classification
      • Larsen Radiographic Scale for Grading Joint Involvement in RA
      • Grade 0
      • no change
      • Grade I
      • slight changes, including periarticular swelling
      • Grade II
      • erosions, with definitive joint-space narrowing
      • Grade III
      • medium destructive changes with erosions and joint spaces poorly defined
      • Grade IV
      • severe destructive changes and collapse with significant erosions
      • Grade V
      • mutilating changes, original articulating surfaces have disappeared, and there is gross bony deformation
  • Presentation
    • History
      • prior trauma 
      • past medical history of rheumatic disease or inflammatory arthritides
    • Symptoms
      • common symptoms of OA
        • pain
        • deformity
      • common symptoms of inflammatory arthritis
        • intermittent inflammatory episodes
        • waxing and waning clinical course 
        • other joint involvement 
  • Diagnosis
    • confirmed by history, physical exam and radiographs 
  • Techniques
    • Nonoperative
      • pros/cons
        • patients on DMARDs have higher risks of infection and delayed wound healing which can be avoided with nonoperative management 
        • long term NSAID use can lead to renal and gastrointestinal pathology 
    • Arthrodesis of finger MCP joint
      • indications
        • persistent symptoms, synovitis, or swelling despite a 3 to 6-month course of nonsurgical interventions
      • technique 
        • Long finger: 30 degrees of flexion
        • Ring finger: 35 degrees of flexion
        • Small finger:  40 degrees of flexion
    • Arthroplasty of thumb MCP joint
      • approach
        • dorsal incision, exploiting extensor interval longitudinally 
        • gain access to dorsal capsule
      • technique
        • silicone implants
        • pyrocarbon implants 
      • complications 
        • silicone MCP joint implants are associated with low rates of complications
        • most frequently reported complication was change in the bone surrounding the implant, found in 4% of silicone rubber implants
        • implant fracture rates average 2% 
        • infection is rare, seen in 0.1% to 1% of reported implants
    • Arthroplasty of finger MCP joint
      • indications
        • Patients with pain that have failed nonsurgical treatment measures such as nonsteroidal anti-inflammatory medications, injections, splinting, and hand therapy are candidates for surgery
      • approach
        • dorsal approach allows the surgeon to tailor the extensor hood and sagittal band split based on any finger deformity or planned concomitant tendon centralization procedure, as in the cases of RA
        • in patients with osteoarthritis, a tendon-splitting approach can be used.
        • in cases with metacarpal volar dislocation, the volar plate can be released after bony resection to allow for relocation of the joint with arthroplasty insertion 
        • the collateral ligaments are often tensioned on the radial side and may require release on the ulnar side, to help restore coronal plane alignment 
        • the capsule and sagittal band are repaired, and the extensor tendon is centralized if needed to prevent recurrent deformity
        •  intrinsic release or transfer will help restore alignment and correct potential distal swan neck deformity
  • Complications
    • Nonunion
      • risk factors
        • tension band fixation
        • smoking or nicotine use 
        • diabetes mellitus 
      • diagnosis
        • radiographs or CT scan
      • treatment
        • revision arthrodesis if symptomatic 
        • ipsilateral distal radius autograft or allograft can be utilized to increase fusion mass
    • Surgical Site Infections
      • incidence
        •  rare, seen in 0.1% to 1% of reported implants
        • Staphylococcus Aureus was the most common organism isolated
      • risk factors
        • DMARD therapy 
        • inflammatory arthritis 
        • comorbidities such as diabetes mellitus 
      • diagnosis
        • physical exam
        • inflammatory lab analysis 
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