Medical Minute 7-29: Knuckle Knockout: Rebuilding Arthritic Fingers

By: Vanessa Welch Email
By: Vanessa Welch Email

Ginamarie Russo doesn't wear the gloves, but she writes about the boxers who do.

"It just fascinates me. I started going down to the gym … ringside fights," said Ginamarie Russo, has juvenile arthritis.

Like a lot of these guys, she knows what it feels like to get hit hard. At just 12, she got a diagnosis that would affect her for the rest of her life.

"It started in one of my wrists -- shooting, shooting pain that wouldn't go away. It just completely took over my hand. I couldn't function anymore."

Diagnosed with juvenile arthritis, Ginamarie's identical twin watched as her sister's right hand became crippled.

"I would hold the toothbrush, everything. The fork, I would help her eat," said Annamarie Russo, Ginamarie's sister.

"I thank God for my twin sister. She's my right hand. Still is!"

Beth Israel's orthopedic hand surgeon Charles Melone watched Ginamarie's hand deteriorate. This is an X-ray of her hand before -- and a year and a half later. You can see what happened.

"By the time I saw her, she could barely write," said Charles Melone, M.D., Chief of Hand Surgery, Department of Orthopedic Surgery at Beth Israel Medical Center, New York, NY.

Doctor Melone replaced four of the knuckles in Ginamarie's right hand with silicone implants and realigned her tendons.

"You remove this part of the joint here, here, and here, and realign the bone, and then, you replace the joint. This would be placed in the joint here."

Ginamarie's hand went from this, to this. And now, after five months of therapy, including using a hand out-rigger, she's back in the gym.

"I was so excited for my new hand. No pain, and I'm back to writing again."

And her next article is sure to be a knock out!

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: Juvenile arthritis is a disease that targets thousands of children in the United States. It’s often a crippling pain that can prevent mobility by the time children reach adulthood, causing them to be unable to move their knees, shoulders, and hands.

CAUSES: It is not known exactly what causes juvenile arthritis in children, but research has indicated that it is an autoimmune disease. In autoimmune diseases, white blood cells lose the ability to tell the difference between the body’s own healthy cells and harmful invaders such as bacteria and viruses. This causes the immune system to release chemicals that can damage healthy tissues, causing inflammation and pain.

SPOTTING JUVENILE ARTHRITIS: In order to effectively manage and minimize the effects of arthritis, an early diagnosis is critical. By understanding the symptoms and characteristics of juvenile arthritis, children can maintain productive lifestyles. Early signs of arthritis can be subtle including limping or sore wrists, fingers, or knees. Joints may suddenly become inflamed and remain enlarged. Stiffness in joints located in the neck and hips may also occur as well as the sudden appearance and disappearance of rashes on the body. In many cases, juvenile arthritis can be treated with a combination of medicine, physical therapy, and exercise. In specific situations, children may also require specific injections into the joints or surgery. The goals of treatment are to relieve pain and inflammation, slow down or prevent the destruction of joints, and restore use and functionality of joints.

ONE PATIENT'S STORY: Ginamarie Russo suffered from juvenile arthritis. At just 12 years old, she began feeling constant shooting pain in her wrist before it completely took over her hand, making it nonfunctional. Charles Melone, M.D., an orthopedic hand surgeon at the Beth Israel Medical Center in New York, replaced four of the knuckles in Ginamarie’s right hand with silicone implants and realigned her tendons. This surgery, followed by five months of physical therapy, has allowed Ginamarie to regain function in her hand and go back to doing the things she loves.

FOR MORE INFORMATION, PLEASE CONTACT:
Joanne H. Nicholas
Director, Public Affairs
Continuum Health Partners
(212) 523-7772
JNicholas2@chpnet.org

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THE FOLLOWING IS AN IN-DEPTH INTERVIEW WITH THE DOCTOR FROM THE STORY ABOVE:

Charles Melone, MD, Chief of Hand Surgery, the Department of Orthopedic Surgery at Beth Israel Medical Center in New York, NY, discusses juvenile arthritis and new ways to relieve hand pain.

Are knuckle replacements common for patients with juvenile arthritis?
Dr. Charles Paul Melone, Jr.: The onset of arthritis is variable. It started when she was about twelve or thirteen years old, but the arthritis that she has is now more typical of adult arthritis. In other words, many patients with juvenile arthritis will undergo remission whereas others continually progress. Her arthritis progressed, and over a ten-year period, she experienced increasing pain, stiffness of the joints, more deformity, as well as a major limitation in function. By the time that I saw her she could barely write. She was a very active and intelligent young lady who loves to write.

How common are knuckle replacements?
Dr. Charles Paul Melone, Jr.: In my practice, I specialize in hand surgery, and one of the most prominent areas of my practice is arthritis. So here it is quite common. About four million people in the United States suffer from rheumatoid arthritis; about forty million suffer from all types of arthritis. A large percentage of these people require hand surgery, because the hand is one of the most common areas for arthritic involvement. You are talking about rather large numbers of afflicted persons.

How long have you been performing these procedures?
Dr. Charles Paul Melone, Jr.: I have been performing variations of this procedure for over twenty-five years.

How has it developed and progressed over those twenty-five years?
Dr. Charles Paul Melone, Jr.: The design of the implants and the medical management of the patients is far better now. In most cases, you expect to do this operation and that’s it. You don’t expect to revise this because they have a flare up in the disease process with recurrence of deformity. Obviously that can occur. We have found that the operations that we do can last for up to fifteen years.

Is this a last resort for patients?
Dr. Charles Paul Melone, Jr.: I think that when you go to joint replacement, that means that the joints are irreversibly destroyed, and you see this in all forms of arthritis. The medical management for rheumatoid arthritis has improved dramatically, so we are seeing a lesser number of individuals that require this type of invasive procedure.

Can you discuss the time that it took for the Ginamarie's hand to make this transformation?
Dr. Charles Paul Melone, Jr.: Well, this was over a period of about fourteen months.

Do you usually see that kind of rapid progression?
Dr. Charles Paul Melone, Jr.: It is variable. Once the joints have become unstable you may or may not see deformity right away. Since she is a very active lady, she incessantly uses and puts stress on these joints, so yes this can happen frequently in her particular age group.

What are those joint replacements made out of?
Dr. Charles Paul Melone, Jr.: This is a high-grade silicone implant, which is still the most frequently used joint replacement for rheumatoid arthritis of the hand.

How long will they last?
Dr. Charles Paul Melone, Jr.: The survivorship of these implants in my experience may exceed fifteen years. In most cases that have been documented, there is a ninety percent chance that these can last for up to ten years. That is comparable to the major joints, such as the hip as well as the knee. I think that it is a very reliable implant to use.

When you are able to help someone like Ginamarie who is so young and depends on her hands, it must be exceptionally rewarding for you to see the progress and improvements that she has made thanks to your expertise.
Dr. Charles Paul Melone, Jr.: It is very rewarding; just to see the happy expression on her face because of the improvements is extremely gratifying. When you first meet a patient, obviously they have a lot of anxiety because we talk about surgery. When people hear the word ‘surgery,’ they automatically think ‘defeat and that their arthritis is so bad that the only chance of regaining some normalcy is through surgery. Often they don’t realize, that surgery can be a positive step. So many people come into this office and say, “I didn’t know that you could do something surgically for the hand when it’s afflicted with arthritis.” There is a lot that we can do, and not just this operation, but operations on the thumb as well as the wrist. This is when you sit down and begin to talk about the myriad of available treatments and operations that can be done to help them. After a while, I think that she felt more relaxed and better understood what could be done for her. We have several photographs that we show the patient of what a hand looks like before and what it looks like after, which is exactly what you are seeing right here.

Hands are so imperative for everyday activities, and when you don’t have the means to use them it can ultimately affect your quality of life.
Dr. Charles Paul Melone, Jr.: The two most commonly exposed parts of our body are the face and the hands. Constant and unpaired use of our hands is critical to quality of life.

What do people who are considering this route of treatment need to be aware of before they make the decision?
Dr. Charles Paul Melone, Jr.: Before they go into surgery, they really have to be informed about the critical importance of postoperative hand therapy.

How long does the postoperative therapy for this procedure last?
Dr. Charles Paul Melone, Jr.: They start five days following the surgery. It is a very specialized therapy to maintain correction of the deformity, and to regain mobility as rapidly as possible. Formal splinting is used for about four weeks subsequent to the procedure (not fulltime but a decent part of the day) – you can take it off anytime that you want. There is a night extension splint for another six weeks. So the entire therapy program should between ten weeks to three months. I cannot stress the importance of the postoperative therapy in regards to the benefits of the procedure itself.

Other than normal risks that come with any surgery, are there any additional dangers that patients should be aware of?
Dr. Charles Paul Melone, Jr.: I think that the major risks have to do with progression of the arthritic disease process. For example, with rheumatoid arthritis, you can develop arthritis in other joints that may compromise the results of the procedure. In regards to strictly postoperative risks, obviously anyone can get an infection although that is very unusual.


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