METACARPOPHALANGEAL JOINT IMPLANT ARTHROPLASTY

DECEMBER 1994, VOL 60, NO 6

Home Study Program MmACARPOPHAiANGEAL

JOINT IMPLANT ARTHROPLASTY

T he article “Metacarpophalangeal joint implant arthroplasty” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, FW, BSN, CNOR, clinical editor, with consul- tation from Susan Bakewell, RN, MS(N), education coordinator,

Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is

necessary to earn two contact hours for this independent study. Partic- ipants receive feedback on incorrect answers. Each applicant who suc- cessfully completes this study will receive a certificate of completion. The deadline for submitting this study is May 31, 1995.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service c/o Home Study Program

2 170 S Parker Rd, Suite 300 Denver, CO 80231-571 1

BEHAVIORAL OBJECTIVES After reading and studying the article on metacarpophalangeal

joint (MCPJ) implant arthroplasty, the nurse will be able to (1) discuss the pathophysiology of rheumatoid arthritis (RA), (2) discuss the medical and surgical management of patients with RA, (3) describe the perioperative care of patients undergoing MCPJ

implant arthroplasty, and (4) discuss the perioperative nurse’s role when caring for patients

undergoing MCPJ implant arthroplasty.

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DECEMBER 1994, VOL 60, NO 6 Roth

Metacarpophalangeal Joint Implant Arthroplasty

T he crippling effects of rheumatoid arthritis (RA) can destroy an individual's productivity and severely limit his or her activities of daily living (ADL). Rheumatoid arthritis is a chronic, inflammatory disease with unknown

etiology that primarily attacks the peripheral joints. Patients may experience constant, escalating pain or spontaneous remissions and unpredictable exacerba- tions with decreased ability to perform even the simplest ADL.

Metacarpophalangeal joint (MCPJ) implant arthroplasty is one treatment modality for patients with severe finger joint malformation from RA. The use of a silicone joint implant in combination with resection arthroplasty of the MCPJ may achieve

pain relief, correction of finger joint deformity, . improved joint stability, and increased range of motion

Modern silicone joint implants were developed in the 1960s to maintain the alignment and spacing of reconstructed joints. Silicone implants are flexible and allow early postoperative motion of reconstructed joints. As silicone implants become encapsulated in the finger joints, they function as molds and spacers to alleviate friction caused by finger joint bone-on-bone rubbing. The stability of the reconstructed joint is achieved by reshaping the soft-

(ROM).

I

A B S T R

tissue systems (ie, ligaments, muscles, tendons) around the encapsulated silicone implant.

INCIDENCE AND CAUSES Rheumatoid arthritis occurs in 6.5 million men,

women, and children worldwide, striking women three times more often than men. Although RA can occur at any age, most patients are women between the ages of 20 and 60 years with the peak onset pen- od between 35 and 45 years of age. Rheumatoid

arthritis disability affects more than 2.1 million people (ie, 1.5 million women, 600,000 men) in A C T

Rheumatoid arthritis (RA) usually requires lifelong treatment and sometimes surgery. Metacarpophalangeal joint (MCPJ) implant arthroplasty is one surgical treatment for patients with severe RA malformation of the finger joints. Although not a cure, MCPJ implant arthroplasty can enhance patients' quality of life by improving their performance of independent activities of daily living. The silicone implant acts as a spacer until tendons and connective tissues are able to control the joint's functions. Comprehensive preoperative and postoperative patient teaching and aggressive physical therapy are needed to achieve optimal outcomes in patients who undergo this surgical procedure. AORN J 60 (Dec 1994) 929-942.

the United States today. The most commonly affected areas are the peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels. There are more than 100 diverse rheumatic disor- ders that are bound together by musculoskeletal symptoms of pain, stiffness, weakness, and loss of motion; variable symptoms of disability; and occasional sys- temic symptoms such as fatigue, fever, and weight loss.'

Recent studies suggest RA susceptibility results from genetic defects that impair the autoimmune system. Theoretically, impaired autoimmune defenses lead to the creation of antigen- antibody complexes that cause the body to attack healthy joint tissue, resulting in inflammation and subsequent joint damage. Most people diagnosed with RA have synovial infiltrates (ie, activated

929 AORN JOURNAL

DECEMBER 1994, VOL 60, NO 6 Roth *

Figure 1 X-ray film of hand with rheumatoid arthritis.

T-cells and macrophages bearing the HLA-DR4 genetic marker) that correlate positively with the severity of RA disease process.2 It is important to note that with few exceptions, the exact cause of RA is unknown, and a cure is not available.

PAlWOPHYSIOLOGY Rheumatoid arthritis attacks the body systemati-

cally through four destructive stages. First, the body’s autoimmune response to RA causes synovial (ie, membrane lining the joint) hypertrophy, which in turn causes pain, stiffness, warmth, redness, and swelling. The inflamed joint lining then invades and damages bone and cartilage. In the second stage, the thickened synovial membranes cause decreased joint mobility and pannus formation (ie, thickened layers of granulation tissue developed from destroyed synovial membrane, small blood vessels, collagen). Pan- nus covers and invades cartilage and eventually destroys the joint capsule and bone. The joint then becomes stiff, enlarged, and so painful that even ROM exercises cannot stop the patient’s declining ability to perform ADL.

Progression to the third stage is characterized by fibrous ankylosis (ie, adhesions between the joint surfaces), fibrous invasion of the pannus, and

scarring that occludes the joint space. Joint mis- alignment and bone atrophy cause visible hand deformities and disrupt the natural articulation of opposing bones, which leads to muscle atrophy and possible subluxations (eg, partial, complete). In the fourth stage, fibrous tissue calcifies, and the resulting bony ankylosis (ie, severe or complete loss of joint movement due to fusion of the bones) causes total immobility of the affected finger joint.3

DIAGNOSIS The RA disease process is individualized (ie,

onset can be slow, gradual, or rapid), and the course of the disease varies from person to person. When RA onset is slow and insidious, early diagnosis can be difficult. Physicians diagnose RA based on the overall pattern of a patient’s symptoms, medical history, physical examination findings, and laboratory and other test results. A family history is taken, although there is no proven familial trend in RA disease. The physician performs active and passive ROM tests on the patient and orders radiological films to search for joint destruction or degeneration (Figure 1). The presence of the rheumatoid factor is a positive indicator in 80% of adults with RA; however, the presence or absence of rheumatoid factor does not in itself indicate the presence of RA. The physician performs synovial taps to determine if joint or tissue breakdown (ie, pannus formation) is p re~en t .~

SIGNS AND SYMPTOMS

symptoms such as malaise and general fatigue, soreness and stiffness, joint aches and pain, anorexia and weight loss, and persistent and low-grade fever.

Misdiagnosis is possible because these vague signs and symptoms are common in a number of diseases, especially those related to aging.

Later, the patient develops specific, localized articular symptoms (eg, pain in the same joints on both sides of the body), primarily after inactivity. Nondiagnosed RA leads to visible joint deformity mainly in the hands or feet; however, RA may affect wrists, elbows, shoulders, neck, knees, hips, and ankles. If untreated, the pain, swelling, and joint deformity progressively continue until the patient is unable to perform even the simplest of daily routines.

Early in the disease, RA produces nonspecific

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Figure 2 X-ray film of the bones in a normal hand.

FINGER BONE ANATOMY AND PIIYSIOWGY The following is a description of finger bone

anatomy (Figure 2 ) and a discussion of the physiology associated with RA disease.

Anatomy. The skeletal structure of the finger consists of the distal phalanx connected to the middle phalanx at the distal interphalangeal joint (DIPJ). The middle phalanx is connected to the proximal phalanx at the proximal interphalangeal joint (PIPJ). The proximal phalanx is connected to the metacarpal at the MCPJ. The metacarpal is connected to one of the carpal bones that corresponds to the appropriate finger at the carpometacarpal joint.

The DIPJ controls the distal and middle phalanges, thus allowing them to extend and flex. The MCPJ controls the proximal phalanx and the metacarpal bones. The MCPJ, therefore, allows the fingers to abduct and adduct and controls extension and flexion of the proximal phalanx.

Dorsally, the soft-tissue structures surrounding the bones of the fingers consist of joint capsules and perionychium (ie, nail root and body, skin). Lying on the same plane as the joint capsule are the deep transverse metacarpal ligaments and the extensor tendons. On the palmar side of the hand, the soft-tis-

sue structures surrounding the bone consist of the joint capsule and the encompassing flexor tendons, synovial sheaths, and palmar ligament^.^

Physiology. The increased intrinsic muscle pulling associated with RA disabilities causes MCPJ flexion and interphalangeal extension. Hyperexten- sion and loss of extension of the distal phalanx forces the fingertips to drop. The PIPJs develop flexion deformities or become hyperextended. The MCPJs swell dorsally, and volar subluxation (ie, displacement of bone from metacarpal joints) and stretching of tendons pull the fingers to the ulnar side (ie, ulnar drift). Ulnar drift involves deviation of the ulna bone and a shift in the position of the proximal phalanx. The fingers may become fixed in a characteristic “swan neck” appearance (Figure 3). The hands appear shortened, and carpal tunnel syndrome (ie, compression of the median nerve within the carpal tunnel) causes tingling paresthesia in the fingers of the affected hand.

Extraarticular responses. The most common extraarticular response to RA is the gradual appearance of RA nodules (ie, subcutaneous, round or oval, nontender masses), usually on the elbows. Vasculitis can lead to skin lesions or leg ulcers. Peripheral neu- ropathy may cause numbness or tingling in the feet or weakness and loss of sensation in the fingers. Other extraarticular effects include pericarditis, pulmonary nodules or fibrosis, pleuritis, scleritis, and episcleritis.

Other responses. A less common complication of RA is degeneration of the odontoid process of the second cervical vertebrae. Spinal cord compression may occur, particularly in patients with long-term RA. Upper motor neuron signs (eg, positive Babins- ki’s sign, weakness) and temporomandibular disease

Figure 3 Preoperative photograph of right hand with rheumatoid arthritis before MCPJ implant arthroplasty.

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that impairs chewing and causes earaches also may develop. Other responses to RA include infection and osteoporosis.

MEDICAL MANAGEMENT The goals of medical treatment are pain relief

and maintenance of existing ADL levels. Nonsurgi- cal treatment is most effective with early diagnosis. If the patient has crippling joint deformity, severe pain, or an inability to perform ADL, nonsurgical treatment is generally ineffective. Medical therapy usually consists of a combination of rest, exercise, and medication.

eight to 10 hours of sleep every night, frequent breaks between ADL, and splinting or traction to rest inflamed joints.

Exercise. Exercise is designed to maintain a full range of joint motion as well as to maintain muscle strength by exercising the joint through a limited, painless arc of motion. Frequent ROM exercises (eg, active, passive, flexion, extension, strengthening) and individualized physical therapy sessions slow the loss of joint function. Physical therapists teach patients how to use moist heat (eg, hot soaks, paraffin baths, whirlpool) for relief of chronic pain and ice packs for treatment of acute pain episodes.

Medication. Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) are the mainstay of RA therapy because they decrease inflammation and relieve joint pain. The NSAIDs include indo- methacin, fenoprofen, ibuprofen, and naproxen. Gold salts, antimalarials (ie, chloroquine, hydroxy- chloroquine), and penicillamine are indicated when treatment is not successful with aspirin or NSAIDs.

Corticosteroids (eg, prednisone) provide a third level of care for patients with RA. They can be used systemically for multiple joint involvement or general- ized disease or given locally by instillation into a sin- gle joint that is most symptomatic. Immunosuppres- sants (eg, cyclophosphamide, azathioprine) are the last level of drugs for patients with uncontrolled RA.

Rest. Support measures for rest include

SURGICAL " A G E M E U t There are three types of commonly performed

surgeries for RA of the fingers: arthrodesis, synovectomy, and arthroplasty.

Arthrodesis. Arthrodesis (ie, the surgical fusion of a joint) is achieved by removing cartilage and fix- ating adjacent bones by passing a stainless steel surgical wire through the distal phalanx, the joint, and

the proximal phalanx. Arthrodesis sacrifices joint mobility for stability and pain relief. a s procedure does not improve flexion of the finger, but it can alleviate some joint deformities. The finger is fixated in a position that allows the patient to perform ADL in the most effective manner.

Synovectomy. Synovectomy (ie, removal of destructive, proliferating synovium) removes the excess growth of the synovial membrane along the fiiger joints. The main purpose of this procedure is to alleviate pressure on the joint and decrease pain. The existing joint function is maintained but not improved.

Arthroplasty. Arthroplasty involves removal of the joint (eg, generally the MCPJ) and replacement of the finger joint with a silicone implant. This procedure strives to correct joint deformities and increase joint function. Indications for MCPJ implant arthroplasty are

a fixed or stiff MCPJ with decreased arc of motion of 40 degrees or less, pain localized to the MCPJ that is associated with radiographic changes, volar MCPJ subluxation or dislocation, an ulnar drift of 30 degrees or greater, and muscle or ligament contractions with pain.6

Contraindications are existing ulnar drifts of 35 degrees but ROM greater than 60 degrees (ie, possible loss of power and decreased arc of motion), open epiphyses, poor bone stock, vasculitis and serious skin changes, no measurable functional loss in the affected hand, and inability to complete a therapy program.'

Joint replacement is not the first choice of RA treatment. The rheumatoid process must be in optimal medical control before surgery is attempted. The MCPJ reconstruction procedure is a team effort involving the surgeon, rheumatologist, physical therapist, nurse, patient, and family members.%

ANESWES4 CHOICE A major consideration when a patient under-

goes a surgical procedure for RA management is the type of anesthesia. Two types of anesthesia can be used when performing a MCPJ implant arthroplasty: general anesthesia or brachial plexus block. General anesthesia is effective, but it has more associated risks. The patient needs to be evaluated

934 AORN JOURNAL


for possible cervical neck deformity that would be a contraindication for general anesthesia (eg, hyper- extension of the neck for induction).

The brachial plexus is a nerve bundle located in the neck and axilla and is composed of the lower four cervical and first thoracic nerves that control arm movement and sensation. A brachial plexus block is accessible from both the axillary and supraclavicular approaches, but an axillary brachial plexus block is easier to perform, and the anesthesia care provider is less likely to cause a pneumothorax with needle pla~ement.~

PREOPERATIVE PERIOD A comprehensive preoperative patient teaching

plan is necessary to prepare the patient and family members for MCPJ implant arthroplasty . The patient and family members need to be aware that this surgical procedure is not a cure for RA. A MCPJ implant arthroplasty is designed to

decrease pain, improve joint function, permit more flexibility, and improve independent performance of ADL.

Patient teaching. The patient is told preopera- tively that joint function improvements are not immediately apparent after surgery. There is a pro- longed period of postoperative physical therapy that requires the patient to be motivated and to perform exercises that are necessary for improvement in joint function. The patient also is told he or she will be placed in a splint in the immediate postoperative period, then placed in a dynamic extension splint for three to four weeks. The patient should view the prosthesis and splints used with MCPJ implant arthroplasty, and the preoperative nurse should demonstrate how the patient will function with these items in place after surgery.

Other preoperative nursing care and teaching considerations include

explaining the steps of the surgical procedure (eg, prophylactic antibiotics, skin prep, anesthesia), teaching the patient to continuously elevate the postoperative surgical hand, and demonstrating isometric exercises and deep breathing and coughing exercises for patients undergoing general anesthesia.

Preoperative holding area. The patient is admitted through the same day surgery unit on the morning of surgery and discharged the same day from the postanesthesia care unit (PACU). The pre-

operative holding room nurse identifies the patient and reviews the patient's chart for a signed surgical consent form, medical history, physical assessment, current medications, and laboratory results. The nurse determines the patient's knowledge of the RA disease process and his or her understanding of the palliative nature of the surgery (ie, purpose is to increase independent performance of ADL, not cure the disease).

The circulating nurse reviews pertinent patient information with the preoperative holding room nurse and also interviews the patient. After the patient verbalizes a correct understanding of the surgical procedure, the circulating nurse reviews the surgical plan of care with the patient. The nurse then performs a total body assessment for signs and symptoms of deformity or impaired ROM. Close attention is given to the cervical spine because of the high incidence of cervical neck abnormalities in patients with RA. Although RA affects all age groups, the primary patient population is the elderly; therefore, any underlying disease processes that might affect the surgical outcome or patient positioning are accommodated. The circulating nurse bases intraoperative positioning on the patient's assessed ROM and comfort level. The anesthesia care provider then reviews the patient's chart, verifies the accuracy of the information, inserts an IV line, and gives a prophylactic antibiotic.

The scrub person is responsible for assembling the necessary surgical instruments before the patient is brought to the OR (Figures 4 and 5). Necessary equipment includes

soft-tissue instruments, small bone orthopedic instruments, the implant and its instrumentation, a tourniquet, a hand table with arm bolster for skin prep, and a power drill and saw with attachments.

The circulating nurse has warm blankets available and increases the OR temperature to 72" F (22.5' C) for patient comfort before the patient is transferred to the OR suite. The patient is transferred to the OR by the circulating nurse and the anesthesia care provider.

IMRAOPERATlVE PERlOD The OR team members (ie, circulating nurse,

anesthesia care provider, OR assistant) help the patient to a supine position on the OR bed. The circulating nurse accommodates the patient's comfort needs by using foam padding, pillows under the

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DECEMBER 1994, VOL 60, NO 6 Rorh

Figure 4 Mayo stand with partial instrumentation setup for MCPJ implant arthroplasty. (Clockwise from fop left.) Two curved hemostats, one curved mosquito clamp, two plain forceps, three straight bone curettes, one mallet, three bone rongeurs, six retractors, three bone awls, four osteotomes, three double-ended curettes, two toothed forceps, one curved scissors, one straight scissors, knife handle with #15 blade.

patient’s knees, and blankets. The circulating nurse places warm blankets on top of the patient and a safety strap across the patient’s mid-thigh area before anesthesia administration.

Patient preparation. The anesthesia care provider places an automatic blood pressure monitor, electrocardiogram monitor leads, and a pulse oxime- ter probe on the patient. The patient’s surgical arm is placed on an arm table, and a padded bolster is

Figure 5 Angled, large, and small bone awls; trial sizer; and bur used in MCPJ implant arthroplasty.

placed under the arm for prep- ping. The circulating nurse places an electrosurgical unit dispersive pad on the patient’s anterior thigh and tourniquet padding on the upper portion of the surgical arm before the surgeon places the tourniquet on the patient’s arm.

The circulating nurse preps the hand with povidone-iodine prep solution unless contraindi- cated. The surgical hand and arm are draped with an extremity sheet, cloth sheets, and towels. The incision line is marked with a sterile marker. A rubber compression bandage is applied to exsan- guinate the surgical arm and hand. A precalibrated tourniquet is inflated between 200 and 300

mm Hg. The surgical team members monitor tourniquet time in two-hour increments to avoid potential nerve and tissue damage. If the surgery exceeds two hours, the tourniquet is deflated for 10 minutes and then reinflated for the necessary surgery time. This surgical procedure usually requires two to three hours.

Surgical procedure. A transverse skin incision is made on the dorsal side of the hand over the metacarpal heads (Figure 6). The surgeon uses iris scissors to dissect through the subcutaneous tissue. He or she then applies small retractors and identifies the extensor-hood mechanism (ie, muscles and tendons that extend the phalanges) of each finger. The surgeon carefully releases the dorsal veins that lie between the MCPJ heads using blunt, longitudinal dissection to preserve the intermetacarpal venous drainage system.

The surgeon identifies the intrinsic ulnar muscle and then detaches the muscle at its insertion point to the hood (ie, top) of the extensor tendon. He or she exposes the extensor hood to the base of the proximal phalanx and then longitudinally cuts the extensor hood on the radial side of the extensor tendon. The hood fibers and joint capsule are carefully sepa- rated from the underlying synovial tissue. The surgeon takes meticulous care to preserve the support- ive structures so that a secondary, soft-tissue reconstruction can be performed with the arthroplasty. The surrounding tissues and synovium are often thickened (ie, pannus formation), and in extreme cases,

937 AORN JOURNAL

DECEMBER 1994, VOL 60, NO 6 Roth -

Figure 6 . Transverse skin incision across metacarpophalangeal joint.

Figure 7 The surgeon exposes the metacarpophalangeal joint cavity.

the extensor tendons are subluxed. Articular destruction is commonly seen in these patients.

The surgeon performs a longitudinal incision across the MCPJ capsule and elevates the capsule and the collateral ligaments of the ulnar and radial mar- gins of the MCPJ head, using scissors and a periosteal elevator (Figure 7). Next, he or she uses a bone ronguer to remove excess synovia from the joint cavity and surrounding tissue. The surgeon identifies the MCPJ head and transects the neck of the MCPJ head with an osteotome and a saw blade attached to an air- powered saw. The MCPJ head and hypertrophied synovial material are removed from the joint cavity. Following the resection of the MCPJ head, osteophytes are resected by a bone ronguer and marginal osteophytes are cleaned out of the joint space.

Using a bone ronguer and a periosteal elevator, the surgeon removes the base of the proximal phalanx to prevent the recurrence of cartilage synovitis in the joint space. He or she prepares the metacarpal intramedullary canal using bone awls, curettes, and an air-powered drill with an attached bur. The surgeon uses the bone awls (ie, smallest size fist, then gradual increases to larger sizes) in a rectangular fashion until the desired canal size is obtained. He or she takes great care not to overream the metacarpal intramedullary canal because overreaming can lead to bone weakness, poor healing, and increased frac- ture potential of the phalanx. The surgeon further prepares the canal for the silicone implant by using an air-powered drill and a smooth, leader-point bur (Figure 8). The choice of bur is determined by the size of the canal.

Figure 8 . Air-powered drill used to prepare metacarpophalangeal joint.

After the metacarpal intramedullary canal has been prepared for the silicone implant, the surgeon uses trial implants to determine the appropriate size implant. He or she pulls the soft tissue around the trial implant and examines the patient's finger to assess the ROM that the implant will allow. The scrub person and the surgeon verify the size of the silicone implant needed before the circulating nurse opens the sterile implant on the sterile field (Figure 9). The silicone implant is placed in an antibiotic solution (ie, 500,000 U of polymyxin B and 50,000 U bacitracin in 500 mL of lactated Ringer's solution), and the surgeon reconstructs the soft tissue before inserting the silicone implant.

Implant insertion. The surgical wound is irrigated with copious amounts of the same antibiotic solution in which the implant has been soaking. The surgeon holds the silicone implant with nontraumatic or smooth forceps to prevent damage to the implant.

Figure 9 . Silicone implant used in MCPJ surgery.

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Figure 10 The surgeon

places silicone implant in the

metacarpophalangeal joint.

The implant first is inserted into the proximal section of the metacarpal intramedullary canal (Figure 10). The implant then is flexed and placed gently into the distal portion of the canal. After the surgeon releases the implant, he or she rechecks the bone alignment. It is essential that the implant fit snugly without obstructing the joint function.

The surgeon puts the MCPJ through a ROM evaluation to ensure that the proper size implant has been placed and that it functions appropriately. The collateral ligaments and radial capsule are repaired with 3-0 nonabsorbable, polyester-braided suture to correct the ulnar devia- tions. The proper balance of these structures is maintained by meticulous repair of the capsule, ligaments, muscle, and soft tissue. In cases where the deformities are too severe for soft-tissue repair, the surgeon places a stainless steel surgical pin in the patient's distal phalanx to correct alignment problems. He or she takes care to ensure there is no impingement on the joint space or the silicone implant.

Closure. The extensor hoods are repaired with the 3-0 nonabsorbable, polyester-braided suture (Figure 11). This is a very important stage of the surgery and must

be performed meticulously for best results. A deli- cate balance exists between the previously repaired soft tissue, capsule, ligaments, and muscle and the repair of the extensor hoods. This balance must be evaluated and carefully maintained to achieve the proper alignment.

The tourniquet is deflated, and the wound is irrigated again with a copious amount of antibiotic solution. The surgeon repairs the subcutaneous tissue with an interrupted stitch of 5-0 absorbable, braided suture. He or she closes the skin with an interrupted stitch of 5-0 nonabsorbable, monofila- ment suture.

Dressing. The surgeon and scrub person apply a bulky hand dressing consisting of fine mesh gauze, folded gauze sponges (ie, over the incision, in between the fingers, in the palm of the hand), and an abdominal pad for the final layer. The scrub person holds the surgical hand while the surgeon places a narrow splint on the palmar aspect of the surgical hand and a plaster splint around the dorsal dressing. A gauze roll is placed over the splinting material, and an elastic bandage is used to cover the entire dressing. The surgical hand is immediately and continuously elevated on pillows as the circulating nurse, surgeon, and anesthesia care provider transfer the patient to the PACU.Io

POSTOPERATIVE PERIOD The PACU nurses assess the circulation and

sensation of the patient's surgical hand. The dis- charge plan consists of the PACU nurse instructing

Figure 11 Postoperative photograph of the patient's right hand shown in Figure 3, one week after MCPJ implant arthroplasty.

940 AORN JOURNAL

DECEMBER 1994, VOL 60, NO 6 * Roth *

the patient and family members on

pain control, continuous hand elevation, isometric exercises, and scheduled appointments.

The PACU nurse reminds the patient that the capsule and the joint space need time to heal and that early finger movement may inhibit the healing process and decrease the eventual function of the fingers. The return visit to the surgeon is approximately one week after surgery. The surgeon removes the bulky hand dressing during this visit and fits the patient with a dynamic extension splint (Figures 12 and 13). The patient wears the dynamic extension splint continuously for three to four weeks. During this time, the patient continues to elevate the surgical hand above the heart by using pillows or a sling.

Figure 12 Lateral view of the postoperative hand in a dynamic suspension splint.

Figure 13 View of the anterior surtace of the hand in a dynamic suspension splint.

The physical therapist meets with the patient at least once a week to teach ROM exercises (ie, flexion and extension of the MCPJ). The patient performs these ROM exercises four to six times a day but does not perform any other tasks with the surgical hand.

Four to six weeks after surgery, the patient is slowly weaned from the dynamic extension splint. The patient begins the weaning process by removing the splint for short periods of time while continuing to perform ROM exercises. The patient also begins to use the fingers to perform some light ADL. Finger use increases during the weaning process, and the patient continues physical therapy visits.' I

POSSIBLE COMPLICATIONS There is the potential for infection as with any

surgery, and there is the potential for joint dislocation after surgery. The most frequent difficulties following MCPJ implant arthroplasty are implant fractures, failure to correct or fully control ulnar drift, bone reaction to the surgical procedure, and gradual loss of motion.'? There have been rare instances of silicone synovitis that resulted in increased patient pain. Deterioration of the bone can occur at the joint space, possibly related to silicone synovitis or pannus formation from the arthritis. Implant fractures

are another complication that can have a major effect on the surgical outcome (eg, recurrence of deformity) and even require repeat surgery. The presence of persistent or recurrent ulnar drift can cause functional and cosmetic problems.

CONCLUSION Rheumatoid arthritis is a disease with no known

cause or cure. The crippling effects of this disease strike the finger joints, causing severe pain, contractures, swelling, and a decrease in performance of independent ADL. There are only palliative treat- ments, which range from medical management to MCPJ implant arthroplasty and always involve physical therapy. Silicone implants are not as proficient as natural joints, but they can alleviate some, if not all, of the incapacitating pain that patients with rheumatoid arthritis suffer.

Since the early 1990s, the US Food and Drug Administration (FDA) has restricted the use of silicone breast implants because of silicone ruptures and leaks into surrounding tissue. These silicone implant problems resulted in reports of silicone-induced adenopathy, lymphopathia, lymphoma, and autoimmune responses in numerous women. The FDA has not restricted the use of silicone implants in MCPJ implant arthroplasty because the finger implant is

941 AORN JOURNAL


composed of solid silicone, whereas silicone breast implants are liquid and can leak into surrounding tissues. Solid silicone implants for MCPJ implant mhroplasties have been used since the 1960s9 and thousands Of them have been placed in the finger Joints Of patients SUffenng from rheumatoid arthritis without controver~y.’~ These implants are considered safe and reliable for surgical procedures. A

Michael Roth, RN, BS, CNOR, is a level III staff nurse in the OR atBarnesHOsPita1, St Louis.

The author acknowledges Laura Steiner, RN, assistant head nurse of orthopedic surgery, Barnes Hospital, St Louis; and H, Mirley, MD, orthopedic fellow at the time this article was written, Washington University Medical School, Barnes Hospital, St Louis.

NOTES 1. Arthritis Foundation, Rheuma-

toid Arthritis Facts (Atlanta: Arthritis Foundation, 1994).

2. Ibid. 3. D T Sowa, A J Weiland,

“Metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis,” Complications in Orthope- dics 11 (MarcWApril 1990) 58-64; A B Swanson, “Flexible implant arthroplasty for arthritic finger joints: Rationale, technique, and results of treatment,” Journal of Bone and Joint Surgery 54 (April

4. R L Wilson, E R Carlblom, “The rheumatoid metacarpophalangeal joint,” Hand Clinics 5 (May 1989) 223-237; H R Schumacher, ed, Primer on the Rheumatic Dis- eases, 10th ed (Atlanta: Arthritis Foundation, 1993); R W Harris, “The pathophysiology of rheumatoid hand deformities,” Orthopaedic

1972) 435-455.

Review 13 (February 1981) 33-46; V E Wood, D R Ichterz, H Yahiku, “Soft tissue metacarpophalangeal reconstruction for treatment of rheumatoid hand deformity,” Jour- nal of Hand Surgery 14A (March 1989) 163-174.

5. P Williams, R Warwick, eds, Gray’s Anatomy, 36th ed (New York City: Churchill Livingstone, Inc, 1980); Wilson, Carlblom, “The rheumatoid metacarpophalangeal joint,” 223-237.

6. Wilson, Carlblom, “The rheumatoid metacarpophalangeal joint,” 223-237.

7. Ibid. 8. D P Green, Operative Hand

Surgery (New York City: Churchill Livingstone, Inc, 1982).

Anaesthesia, E Eriksson, ed (Philadelphia: W B Saunders, Co, 1980).

10. Swanson. “Flexible implant

9. Illustrated Handbook in Local

arthroplasty for arthritic finger joints: Rationale, technique, and results of treatment,” 435-453.

1 1. Washington University Med- ical School, M P Arthroplasty Postop- erative Treatment Guidelines (St Louis: Irene Walter Johnson Rehabil- itation Institute, September 1989).

12. Wilson, Carlblom, “The rheumatoid metacarpophalangeal joint,” 234-235.

13. G D Groff, A R Schned, T H Taylor, “Silicone-induced adenopathy eight years after metacarpophalangeal arthroplasty,” Arthritis and Rheumatism 24 (December 1981) 1578-1581; L A Murakata, A F Rangwala, “Silicone lymphadenopathy with concomitant malignant lymphoma,” Journal of Rheumatology 16 (July 1989) 1480-1483; T Kircher, “Silicone lymphadenopathy: A complication of silicone elastomer fiiger joint prostheses,” Human Parhology 11 (May 1980) 240-244.

AORN is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center‘s Commission on Accreditation. AORN recognizes this activiw as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentioling Center‘s commission on Accreditation approves or endorses any product included in the activiw.

AORN mointains the following provider numbers: Alabama ABNP0075, California BRNOO667, Florida 27F0177, Iowa 103. AORN is approved 0s a provider of continuing nursing

education by the Kansas State Board of Nursing. This course offering is approved for two contoct hours. The Kansas State Board of Nursing approved provider number is LTOll4-03 16.

Professional nurses are invited to submit manuscripts for the Home Study Program. Manuscripts or queries should be sent to the Editor, AORN Journal, 21 70 S Parker Rd, Suite 300, Denver, CO 8023 I-57 I 7 . As with all manuscripts sent to the Journal, papers submitted for Home Study Programs should not have been previously published or submitted simultaneously to any other publication.

942 AORN JOURNAL


Examination MLTACARPOPHAIANGEAL

JOINT IMPLANT ARTHROPLASTY

1 .The use of a silicone joint implant in combination with resection arthroplasty of the metacarpophalangeal joint (MCPJ) may achieve a. a cure for rheumatoid arthritis (RA) b. correction of finger joint deformities c. remission of RA disease symptoms d. relief from all joint contractures and swelling

2.The US Food and Drug Administration has restricted the use of silicone implants for MCPJ implant arthroplasties because of silicone ruptures and leaks into surrounding tissue. a. true b. false

&Rheumatoid arthritis strikes women three times more often than men, and the exact cause of RA is unknown. a. true b. false

4. Early in the disease, RA produces nonspecific symptoms such as 1. anorexia and weight loss 2. soreness and stiffness 3. malaise and general fatigue 4. persistent, low-grade fever

a. 1,2, and 3 b. 2,3, and 4 c. none of the above d. all of the above

5.The increased intrinsic muscle pulling associated with RA disabilities causes a. carpal tunnel syndrome b. nodules and vasculitis c. MCPJ flexion and interphalangeal extension d. infection and osteoporosis

6. Comprehensive medical therapy for RA usually consists of a combination of a. surgery, splints, and physical therapy b. implants, paraffin baths, and whirlpool c. rest, exercise, and medication

d. aspirin, gold salts, and corticosteroids

7. What are the most common types of surgeries performed for RA of the fingers? a. open reduction with internal fixation of joint b. arthrolysis and reconstruction of the joint c. arthroscopy and carpal tunnel release d. arthrodesis, synovectomy, and arthroplasty

%.The types of anesthesia used when performing MCPJ implant surgery include a. general anesthesia or brachial plexus block b. local anesthesia or Bier block c. regional or spinal anestheisa d. axillary block or epidural anesthesia

%The preoperative nurse’s teaching care plan includes discussions with the patient and family members on 1. physical therapy and exercise after surgery 2. postoperative splints and continuous elevation

3. steps of the surgical procedure 4. postoperative monitoring equipment used in

of the surgical hand above the heart

the intensive care unit a. 1,2, and 4 b. 1,2, and 3 c. 2,3, and4 d. all of the above

10.The preoperative holding room nurse determines the patient’s knowledge of the RA disease process and his or her understanding of the palliative nature of the MCPJ implant surgery. a. true b. false

11.The circulating nurse bases intraoperative patient positioning for MCPJ implant surgery on a. location of the electrosurgical unit b. assessed range of motion (ROM) and comfort

c. patient and surgeon’s special requests d. length of necessary tourniquet time

level of the patient

943 AORN JOURNAL


1 1 T h e surgical team members monitor tourniquet inflation time in three-hour increments to avoid potential nerve and tissue damage. a. true b. false

1S.What medications are the mainstay of RA therapy? a. antibiotics, anthelmintics b. corticosteroids, immunosuppressants c. aspirin, nonsteroidal antiinflammatory drugs d. gold salts, antimalarials

1S.What specific instruments does the surgeon use to prepare the metacarpal intramedullary canal for placement of the silicone implant? a. bone ronguers and periosteal elevators b. intramedullary reamers, osteotomes, mallet c. bone awls, curettes, drill with bur d. self-retaining retractors and tenotomy scissors

=The advantages of performing an axillary versus a supraclavicular brachial plexus block are a. cost containment, patient comfort b. no preoperative patient teaching necessary c. decreased neck pain, no spinal headaches d. performance ease, needle placement less like-

ly to cause a pneumothorax

1 A T h e surgeon permanently seats the silicone implant in the distal phalanx. a. true b. false

1 L T h e postoperative nurse reminds the patient that the MCPJ capsule and joint space need time to heal and that early fiiger movement a. is the responsibility of the patient and family

b. may increase the healing process and increase

c. is encouraged by the surgeon and physical

d. may inhibit the healing process and decrease

members

the eventual function of the fingers

therapist

the eventual function of the fingers

16.The postoperative patient wears a dynamic extension splint for a. 1 week b. 2 to 3 months c. 3 to 4 weeks d. 5 to 6 months

17.The most frequent difficulties following MCPJ implant arthroplasty are a. implant fractures, failure to correct ulna drift b. silicone synovitis, increased patient pain c. pannus formation, carpal tunnel syndrome d. silicone adenopathy, lymphoma formation

18.The most common extraarticular response to RA is the gradual appearance of a. spinal cord compression b. temporomandibular disease c. infection and osteoporosis d. subcutaneous nodules, usually on the elbows

21.Necessary surgical equipment for a MCPJ implant arthroplasty includes a. tourniquet, hand table, implant, power drill b. bone plates and screws, bone gouges, reamers c. bone-holding and tendon-passing forceps, car-

d. rubber compression bandage, suction/irriga- tilage stripper, rake retractor

tion device, IV pole with finger traps

=Comprehensive preoperative and postoperative patient teaching and aggressive physical therapy are needed to achieve optimal outcomes in patients who undergo MCPJ implant surgery. a. true b. false

23Studies suggest RA susceptibility results from a. radiation exposure in the OR b. activated D-cells and free radicals c. genetic defects that impair autoimmune defenses d. HIV, methyl methacrylate exposure

=Physicians diagnose RA based primarily on the patient’s family history. a. true b. false

=After reviewing the surgical plan of care with the patient, the circulating nurse performs a total body assessment for signs and symptoms of a. previous surgeries or pregnancy b. hearing loss or impaired vision c. deformity or impaired ROM d. scoliosis or clubfoot

944 AORN JOURNAL


Answer Sheet MEeACARPOPHALANGEAL

lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: P AORN Customer Service

c/o Home Study Program 2170 S Parker Rd, Suite 300

Denver, CO 8023 1-571 1

Session # 25 13 Event # 955006

Program offered December 1994.

The deadline for this program is May 3 1, 1995.

1. Record your identification number in the appropriate section below. 2 . Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program

5. Enclose fee: Members $7; Nonmembers $14.

AORN (ID) # Name Address City State Zip RN license # State Phone number ( If nonmember, please provide Social Security number

Fee enclosed or bill the credit card indicated 0 Mastercard 0 Visa 0 American Express Card #

Expiration date Signature

(for credit card authorization)

Mark only one answer per question.

I

2

3

4

5

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9

I 0

11

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16

I 7

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945 AORN JOURNAL


Learner Evaluation MEeACARPOPHALANGEAL

JOINT IMPLANT ARTHROPIASN

The following evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate the following items on a scale of 1 to 5.

OBJECTIVES

Home Study Program achieved? To what extent were the following objectives of this (LOW) (High)

(1) Discuss the pathophysiology of rheumatoid

(2) Discuss the medical and surgical manage-

(3) Describe the perioperative care of patients undergoing metacarpophalangeal joint

(4) Discuss the perioperative nurse's role when caring for patients undergoing MCPJ implant

arthritis (RA). (1) (2) (3) (4) (5 )

ment of patients with RA. (1) ( 2 ) (3) (4) (5 )

(MCPJ) implant arthroplasty. (1 ) (2) (3) (4) (5 1

arthroplasty. (1) (2) ( 3 ) (4) (3

C0MEN-l (1) Did this article increase your knowledge of

the subject matter? (1) (2) (3) (4) (5 1 (2) Was the content clear and organized? (1) (2) (3) (4) (5 1 (3) Did this article facilitate learning? (1) (2) (3) (4) (5 ) (4) Were your individual objectives met? (1) (2) (3) (4) (5 1

objectives? (1) (2) (3) (4) (5 1 (5) Was the content of the article relevant to the

TEST OUESnONSlANSWERS ( I ) Were they reflective of the content? (1) (2) (3) (4) ( 5 ) ( 2 ) Were they easy to understand? ( 1 ) (2) (3) (4) (5 1 ( 3 ) Did they address important points? (1) (2) (3) (4) ( 5 )

4. What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic (s):

Author names and addresses:

946 AORN JOURNAL

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