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Osteoarthritis of the HandOsteoarthritis of the Hand
Andy BallantyneAndy Ballantyne
Edinburgh SpR RotationEdinburgh SpR Rotation
What is Osteoarthritis?What is Osteoarthritis?
OA is a disturbance of the normal OA is a disturbance of the normal balance of degradation and repair balance of degradation and repair of articular cartilage and of articular cartilage and subchondral bonesubchondral bone
40% Adult Population Affected40% Adult Population Affected 10% Require Medical Treatment10% Require Medical Treatment 1% Disabled1% Disabled
Multifactorial AetiologyMultifactorial Aetiology
AgeAge SexSex GeneticsGenetics TraumaTrauma Occupation Occupation RaceRace
Incidence of OA of the Incidence of OA of the HandHand
Commonest form of OACommonest form of OA <40 yrs - 50 new cases per 1000 <40 yrs - 50 new cases per 1000
person-years at risk person-years at risk 40 - 59 yrs - 65 new cases per 1000 40 - 59 yrs - 65 new cases per 1000
person-years at riskperson-years at risk >60 yrs - 110 new cases per 1000 >60 yrs - 110 new cases per 1000
person-years at riskperson-years at risk (Kallman et al. 1990, Arth Rheum 33,1323 - (Kallman et al. 1990, Arth Rheum 33,1323 -
1332)1332)
Pattern of Joint Pattern of Joint InvolvementInvolvement
Framingham OA Framingham OA StudyStudy, Boston - , Boston - 746 746 subjects, 1967 - 1993subjects, 1967 - 1993
Chingford StudyChingford Study - - 967 female subjects967 female subjects
Baltimore Baltimore Longitudinal Longitudinal Study of AgeingStudy of Ageing - - 177 male subjects, 177 male subjects, serial hand Xrsserial hand Xrs
Most commonly Most commonly affected jointsaffected joints
DIPJDIPJ 1st CMC1st CMC PIPJPIPJ MCPJMCPJ Others - Sesamoid, Others - Sesamoid,
Trapezial Trapezial Scaphoid/trapezoid, Scaphoid/trapezoid, Pisiform-triquetral OAPisiform-triquetral OA
Pattern of Joint Pattern of Joint InvolvementInvolvement
Generalised OA of the Hand - clustering of Generalised OA of the Hand - clustering of joint involvement joint involvement (Chaisson 1997, (Chaisson 1997, Framingham Study)Framingham Study)
Prevalent OA in one joint increased the incidence Prevalent OA in one joint increased the incidence risk of OA in :risk of OA in :
other joints in same rowother joints in same row other joints in same rayother joints in same ray
OA in DIPJ or PIPJ increased incidence risk of OA OA in DIPJ or PIPJ increased incidence risk of OA in any other hand joint. Thumb CMC not a in any other hand joint. Thumb CMC not a strong predictor of generalised diseasestrong predictor of generalised disease
Pattern of Joint Pattern of Joint InvolvementInvolvement
Polyarticular subset of hand OA Polyarticular subset of hand OA (Egger (Egger 1995, Chingford study)1995, Chingford study)
Major determinants of pattern of Major determinants of pattern of involvementinvolvement
symmetrysymmetry clustering by rowclustering by row clustering by rayclustering by ray
Clinical FeaturesClinical Features
FingersFingers Swelling around jointsSwelling around joints Lateral deformityLateral deformity Osteophytes/exostoses -Osteophytes/exostoses - Heberdens NodesHeberdens Nodes -” little -” little
hard knobs the size of a small hard knobs the size of a small pea, particularily a little below pea, particularily a little below the top, near the joint” the top, near the joint” (Heberden 1710-1801)(Heberden 1710-1801)
Bouchards NodesBouchards Nodes Mallet FingerMallet Finger Mucous Cysts/Ganglion - Mucous Cysts/Ganglion -
hyaluronic acid filled cystshyaluronic acid filled cysts
Clinical FeaturesClinical Features
Thumb CMCThumb CMC Subluxation of the Subluxation of the
CMC - CMC - metacarpal metacarpal base prominencebase prominence
Z-deformity - Z-deformity - bony bony collapse at the MC collapse at the MC base leads tobase leads to adduction of the MC adduction of the MC and hyperextension and hyperextension of the MCPof the MCP
ExaminationExamination
PIPJ/DIPJPIPJ/DIPJ Tenderness at joint lineTenderness at joint line Lateral InstabilityLateral Instability Pain on Axial Pain on Axial
CompressionCompression Crepitus on Axial Crepitus on Axial
CompressionCompression Reduced Range of Reduced Range of
MovementMovement
Thumb CMCThumb CMC Tenderness over 1stCMCTenderness over 1stCMC Pain and Crepitus on Axial Pain and Crepitus on Axial
Compression - Compression - torque testtorque test Decreased Pinch StrengthDecreased Pinch Strength Subluxation - Subluxation - intermittent intermittent
pressure to MC base while pat pressure to MC base while pat pinchespinches
Sesamoid ArthritisSesamoid Arthritis Pain palmar plate at thumb Pain palmar plate at thumb
MCPMCP Good joint spaceGood joint space Elicited by press. on Elicited by press. on
palmar platepalmar plate
Radiological FeaturesRadiological Features 88% Joint Space 88% Joint Space
Narrowing Narrowing 81% Osteophytes 81% Osteophytes 46% Subchondral 46% Subchondral
SclerosisSclerosis 33% Bony Cysts33% Bony Cysts <20% Lateral Joint <20% Lateral Joint
DeformityDeformity <20% Cortical Collapse<20% Cortical Collapse (Kallman 1989, Arth Rheum (Kallman 1989, Arth Rheum
32, 1584-1591)32, 1584-1591)
Radiological ClassificationRadiological Classification
Kellgren and Lawrence Scale Kellgren and Lawrence Scale (1957) (1957) Ann Rheum Dis 16:494 - 501Ann Rheum Dis 16:494 - 501
Kallman (1989) Kallman (1989) Arth Rheum 32:1584 - Arth Rheum 32:1584 - 15911591
Dell (1978) - 1st CMC OA Dell (1978) - 1st CMC OA
Kellgren/Lawrence Scale Kellgren/Lawrence Scale (1957)(1957)
0 No Osteophytes
1 Doubtful osteophytes
2 Minimal osteophytes, possibly withnarrowing,cysts and sclerosis
3 Moderate or definite osteophytes withmoderate joint space narrowing
4 Severe with large osteophytes and definitejoint space narrowing
Kallman (1989)Kallman (1989)
Osteophytes 0 = none1 = small2 = moderate3 = large
Joint space narrowing 0 = none1 = definitely narrowed2 = severely narrowed3 = joint fusion
Subchondral sclerosis 0 = absent1 = present
Subchondral cysts 0 = absent1 = present
Lateral deformity 0 = absent1 = present
Collapse of Central joint CorticalBone
0 = absent1 = present
Dell (1978)Dell (1978)
Stage I Mild joint narrowing or subchondral sclerosis. Mildjoint effusion or ligament laxity. No subluxation orosteophyte formation
Stage II Narrowing the CMC and sclerosis. Ulnar osteophytes.Subluxation radially and dorsally
Stage III Further narrowing, cystic change and sclerosis. Passivereduction of subluxation not possible. Scaphotrapezialjoint may show arthrosis
Stage IV As above, more severe. CMC may be immobile andpain free
Treatment Options forTreatment Options for OA of the Hand OA of the Hand
Non surgicalNon surgical SplintsSplints NSAIDsNSAIDs Intraarticular Intraarticular
InjectionsInjections
SurgicalSurgical StabilisationStabilisation ArthrodesisArthrodesis ArthroplastyArthroplasty
Surgery for Hand OASurgery for Hand OA
1st CMC1st CMC DIPJDIPJ PIPJPIPJ MCPJMCPJ other proceduresother procedures
Surgery for the 1st CMCSurgery for the 1st CMC
Anatomical considerationsAnatomical considerations Palmar/Ulnar collateral ligamentPalmar/Ulnar collateral ligament Dorsal intermetacarpal ligamentDorsal intermetacarpal ligament
Laxity leads to subluxationLaxity leads to subluxation
Congenital laxity - Ehlos Danlos early OA Congenital laxity - Ehlos Danlos early OA changeschanges
Surgery for the 1st CMCSurgery for the 1st CMC
Radiological Radiological ConsiderationsConsiderationsInvolvement of other Involvement of other trapezial jointstrapezial joints86% 2nd metacarpal86% 2nd metacarpal48% scaphoid48% scaphoid35% trapezoid35% trapezoid
Pattern of joint Pattern of joint involvement involvement influences choice of influences choice of procedureprocedure
Indications for Surgical Indications for Surgical InterventionIntervention
Failure of non-surgical methodsFailure of non-surgical methods painpain instability - weakness in gripinstability - weakness in grip
In the presence of OA change - In the presence of OA change - Keelgren/Lawrence >2Keelgren/Lawrence >2
Arthrodesis of the 1st CMCArthrodesis of the 1st CMC
Disease limited to Disease limited to CMCCMC
positioned 45positioned 45oo palmar and radial palmar and radial abductionabduction
cup and cone cup and cone arthrodesis - 2-5% arthrodesis - 2-5% non-unionnon-union
Arthroplasty of the 1st Arthroplasty of the 1st CMCCMC
Trapezium excision Trapezium excision arthroplastyarthroplasty
?fascia/tendon interposition?fascia/tendon interposition ?ligament reconstruction?ligament reconstruction ??silicone interposition ??silicone interposition
arthroplastyarthroplasty
Total Joint Arthro.Total Joint Arthro.
HemiarthroplastyHemiarthroplasty
Soft Tissue interposition or Soft Tissue interposition or Ligament Reconstruction?Ligament Reconstruction?
Burton & Pellegrini, 1986 (J Hand Surg) - Burton & Pellegrini, 1986 (J Hand Surg) - Lig. recon and tendon interposition - improved Lig. recon and tendon interposition - improved grip strength and endurancegrip strength and endurance
Gerwin 1997 (Clin Orthop) -Gerwin 1997 (Clin Orthop) -lig. recon. no lig. recon. no tendon interposition - no requirement for tendon interposition - no requirement for tendon interpositiontendon interposition
Livesey 1996 (J Hand Surg) - Livesey 1996 (J Hand Surg) - lig. recon. lig. recon. produces stronger hand than trapezial excision produces stronger hand than trapezial excision alone, although slower recoveryalone, although slower recovery
Surgery for the DIPJSurgery for the DIPJ
IndicationsIndications Pain Pain InstabilityInstability Mucous CystMucous Cyst DeformityDeformity
~80% presenting are at a ~80% presenting are at a stage requiring surgery stage requiring surgery to alleviate symptomsto alleviate symptoms
OptionsOptions
ArthrodesisArthrodesis
ArthroplastyArthroplasty
Procedures for Procedures for Symptom ReliefSymptom Relief
Arthrodesis of the DIPJArthrodesis of the DIPJ
only treatment in the only treatment in the presence of presence of significant bone significant bone destruction and destruction and instabilityinstability
multiple methods to multiple methods to obtain arthrodesis - obtain arthrodesis - cup and cone, K-wirescup and cone, K-wires
2% pseudoarthrosis 2% pseudoarthrosis (Carroll 1969, JBJS - 635 (Carroll 1969, JBJS - 635 joints)joints)
Surgery for the DIPJSurgery for the DIPJ
Interposition Interposition ArthroplastyArthroplasty
silicone interposition silicone interposition - preserves motion - preserves motion and stabilityand stability
falling into disfavourfalling into disfavour Wilgis 1997 (Clin Wilgis 1997 (Clin
Orthop) - 38 digits, Orthop) - 38 digits, <10% implants <10% implants removedremoved
Synovectomy and Synovectomy and osteophytectomy osteophytectomy - stable joint with - stable joint with good bone good bone preservationpreservation
Mucous Cyst Mucous Cyst ExcisionExcision
Surgery for the PIPJSurgery for the PIPJ
IndicationsIndications PainPain InstabilityInstability Deformity Deformity
In the presence of OAIn the presence of OA
ArthrodesisArthrodesis
ArthroplastyArthroplasty cementedcemented silicone silicone
interpositioninterpositionPelligrini 1990, J Hand Surg Pelligrini 1990, J Hand Surg
- 24 pat- 24 pat Cemented Biomeric - Cemented Biomeric -
failed average 2.25yrsfailed average 2.25yrs Silicone - 35% showed Silicone - 35% showed
bone resorptionbone resorption Arthrodesis - greatest Arthrodesis - greatest
improvement in lat gripimprovement in lat grip
MCP/IPJ ThumbMCP/IPJ Thumb Arthrodesis - Arthrodesis - either either
IPJ or MCPIPJ or MCP Interpositional Interpositional
ArthroplastyArthroplasty - MCP - MCP Cemented Steffee Cemented Steffee
prosthesis -slotted prosthesis -slotted componentcomponent
Swanson Silicone Rubber Swanson Silicone Rubber ArthroplastyArthroplasty
Soft Tissue Arthroplasty - Soft Tissue Arthroplasty - salvage proceduressalvage procedures
Surgical Procedures for Surgical Procedures for Other JointsOther Joints
MCPJMCPJ Soft tissue ArthroplastySoft tissue Arthroplasty Joint Replacement Arth. Joint Replacement Arth.
Steffee Prosthesis Steffee Prosthesis Ball and Socket jointsBall and Socket joints
Sesamoid OASesamoid OA excision of the excision of the
sesamoidsesamoid
Pisotriquetral OAPisotriquetral OA injectioninjection pisiform excisionpisiform excision
Summary of Surgical Summary of Surgical TreatmentTreatment
1st CMC - Trapezial excisional 1st CMC - Trapezial excisional arthro.arthro.
DIPJ - ArthrodesisDIPJ - Arthrodesis PIPJ - unresolvedPIPJ - unresolved DIPJ - ?Silicone Interpositional DIPJ - ?Silicone Interpositional
Arthroplasty Arthroplasty
Hand OsteoarthritisHand Osteoarthritis
Common problem affecting elderly females Common problem affecting elderly females Most commonly affects DIPJ & 1st CMCMost commonly affects DIPJ & 1st CMC Surgical Intervention for pain and Surgical Intervention for pain and
instabilityinstability Number of unresolved questions regarding Number of unresolved questions regarding
surgical treatment - i.e.. Type of surgical treatment - i.e.. Type of arthroplastyarthroplasty
Outcome - painfree but with reduced ROM Outcome - painfree but with reduced ROM and decreased pinch strengthand decreased pinch strength