GRAND RAPIDS, Mich. — In just a few years, opening a door, grasping a pencil and buttoning a shirt had become nearly impossible for Claire Baumel. Rheumatoid arthritis had crippled her hands and left her in chronic pain.
In 1989, Baumel, 63, of North Andover, Mass., underwent surgery that replaced the diseased joints in her right hand with flexible hinges made of silicone. It corrected the deformities that had made her fingers swing out sideways, and restored almost all her manual dexterity.
It also erased the pain.
Artificial joints for hips and knees are relatively well known, but not hand-joint replacements, although Grand Rapids hand surgeon Alfred B. Swanson developed them nearly 30 years ago.
"The predominant surgery for orthopedic surgeons is with the hips and knees, because the first thing you want to do is restore mobility for the patient," said Gene Jakubczak, marketing director for silicone devices at Dow Corning Wright of Arlington, Tenn. The firm markets the small joint implants, which are manufactured at Dow Corning's plant in Hemlock, Mich.
Only about 10% of the approximately 10,000 orthopedic surgeons in the United States specialize in hand surgery and have specific knowledge of knuckle implants, Jakubczak said. Because arthritic patients commonly see general practitioners and orthopedic surgeons who don't specialize in the hand, they may never find out that such implants are available.
"Hand surgery is very complex," Jakubczak said. "Essentially, it's like doing five little knees."
About 16 million people in the United States suffer from osteoarthritis and 2.1 million have rheumatoid arthritis, the conditions for which the implants are designed. About 25% of these cases are severe enough to be considered for surgery, Swanson said.
Of the millions of Americans who potentially could benefit from small-joint implants, only about 200,000 have had the surgery, Swanson said.
The rubber-like artificial knuckles have been used in more than 1 million operations in 83 countries since Swanson performed the first surgery in 1964.
Osteoarthritis, which afflicts about half the population over 65, is caused by damage to cartilage. Rheumatoid arthritis, believed to involve the immune system, is inflammation of the linings of joints. As the cartilage and ligaments of the joint are destroyed and bone begins to rub against bone, pain becomes chronic.
Swanson is a surgery professor at Michigan State University and director of an orthopedic research and hand surgery fellowship at Blodgett Memorial Medical Center in Grand Rapids. He became interested in joint replacements in 1950. As a student at Indiana University, he assisted in the development of an artificial hip.
Two years later, as an Army surgeon, he hand-carved a model toe implant out of wood. He also tried, unsuccessfully, to replace destroyed toe joints with metal ones.
In 1961, Swanson heard about a medical-grade silicone developed by Dow Corning. He began experimenting with the implants on test machines and animals at Blodgett.
"The normal joint is so sophisticated and the ligaments around it so much in tune that you really can't simulate nature," Swanson said. "My idea was to make a functional joint, one that was pain-free and restored most of a person's mobility."
Previously, doctors would remove the diseased joint and leave a gap, hoping it would be filled with scar tissue that didn't cause as much pain. "It was totally unpredictable. My goal was to make it predictable," Swanson said.
After surgery, reconstructed tissues heal and surround the implant to function as ligaments while the bone around the implant improves. Relatively few complications have been reported, Swanson said.
The surgery does not cure arthritis, but most patients regain 50% to 75% of the hand's original mobility, he said.
Surgery on one hand generally costs about $2,000 and is covered by most insurance plans, he said.
Today, 27 years since his first operation on a human patient, the joint implant remains almost identical to Swanson's first design. The silicone used, however, has been toughened, and Swanson has developed a titanium shield to be placed on either side of the implant to protect the silicone from being damaged by sharp bone edges. He believes that innovation will make the implants last at least 30 years.
Swanson, whose desk displays samples of the various patented joints he's developed, also has made silicone implants for three wrist bones, as well as the shoulder and elbow.
"I think Dr. Swanson's development of the silicone implant has been a tremendous contribution," said Dr. James W. Strickland, president of the American Society for Surgery of the Hand and professor of orthopedic surgery at Indiana University Medical School. "They really have stood the test of time."
He agreed that there is insufficient awareness of the implants among many primary-care physicians, and perhaps a bit of reluctance among rheumatologists to refer patients for the surgery.
"There were cases in the early going, some 20 years ago, that didn't turn out so well and perhaps hand surgeons got a bad reputation," Strickland said. "But if that persists today it's unfortunate, because the results have been quite good."