Management of MP arthritis must begin in a conservative manner. Whether MP arthritis is a result of OA or inflammatory arthritis, a careful evaluation of the functional status of the patient must be performed. In patients who have OA, the goal of early management is aimed at pain relief and quick return to activities of daily living. As a result, early, nonsurgical treatment focuses primarily on lifestyle modification, nonsteroidal anti-inflammatory drugs (NSAIDS), and splinting. This form of treatment, although not necessarily curative, provides pain relief and return to activity, while slowing the progression of arthritis and buying time before invasive treatment will be necessary.
Management of the rheumatoid thumb is more challenging than the osteoarthritic thumb, and several additional factors must be considered. First, because of its relatively fast progression, treatment of RA must be initiated early and should be closely monitored as compared with OA, which usually has a more gradual progression. In one study , more than 80% of RA patients at 2 years showed evidence of joint space narrowing, and approximately 65% showed erosions. Second, thorough functional status of the MP joint as well as the rest of the thumb axis must be assessed, because the degree of involvement of other joints will dictate the treatment modality. Self-report questionnaires such as the Disorders of the Shoulder and Hand (DASH), the Arthritis Impact Measurement Scale (AIMS), and the Short-form 36 (SF-36), are adequate ways to assess the functional status of patients.
Because the progression of RA is relatively abrupt, early treatment with disease-modifying antirheumatic drugs (DMARDs) is recommended. Other early forms of treatment include:
(1) rest—because RA produces fatigue and subsequent difficulty in performing everyday tasks, rest can be beneficial in reducing inflammation;
(2) exercise—pain and swelling causes patients to stop using the joint, which leads to stiffness and loss of motion—by exercising, patients are able to maintain their range of motion and avoid stiffness, while strengthening the musculature, thereby providing better stability for the thumb; (3) physical therapy/occupational therapy—goals of PT and OT are not only to reduce pain and improve function, but in the case of OT, to educate the patient on joint protection and usage of assistive devices that will prolong the necessity to undergo corrective surgery .
Splinting provides immobilization of the involved joints, allowing for a reduction of inflammation and subsequent pain relief. Splinting may bring about temporary reduction of pain and return of function, while buying time before more invasive procedures are necessary.
When conservative treatment is unable to provide pain relief or the ability to return to activities of daily living, surgery is recommended.
Many surgical methods have been used over the years to treat MP arthritis of the thumb. The techniques implemented are dictated by the location and severity of the underlying joint pathology. Joint fusion has been the treatment of choice over the last 50 years for end-stage thumb MP osteoar-thritis. In the rheumatoid thumb, the treatments of choice have been synovectomy and reconstruction of extensor apparatus as a primary treatment of mild-to-moderate joint pathology, whereas ar-throdesis is the gold standard in the setting of extensive monoarticular disruption . When significant pathology exists in the other joints around the thumb axis, other treatment modalities have been proposed. Thumb arthroplasty, as pioneered by Brannon and Klein in 1959 [13,14], has brought a new form of treatment for patients who have considerable thumb arthritis extending beyond the MP joint.
Whether it is arthroplasty or arthrodesis that is considered for the MP joint, surgical treatment is aimed at four goals: (1) pain relief, (2) restoring function, (3) preventing further damage, and (4) providing cosmetic improvement [7,15,16]. In the case of the unstable rheumatoid thumb, surgical treatment is also aimed at correcting the instability about this joint.
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