Osteoarthritis of the Hand

1
Osteoarthritis of the Hand

• Andy Ballantyne
• Edinburgh SpR Rotation

2
What is Osteoarthritis?

• OA is a disturbance of the normal balance of
  degradation and repair of articular cartilage and
  subchondral bone
• 40 Adult Population Affected
• 10 Require Medical Treatment
• 1 Disabled

3
Multifactorial Aetiology

• Age
• Sex
• Genetics
• Trauma
• Occupation
• Race

4
Incidence of OA of the Hand

• Commonest form of OA
• lt40 yrs - 50 new cases per 1000 person-years at
  risk
• 40 - 59 yrs - 65 new cases per 1000 person-years
  at risk
• gt60 yrs - 110 new cases per 1000 person-years at
  risk
• (Kallman et al. 1990, Arth Rheum 33,1323 - 1332)

5
Pattern of Joint Involvement

• Framingham OA Study, Boston - 746 subjects, 1967
  - 1993
• Chingford Study - 967 female subjects
• Baltimore Longitudinal Study of Ageing - 177 male
  subjects, serial hand Xrs

• Most commonly affected joints
• DIPJ
• 1st CMC
• PIPJ
• MCPJ
• Others - Sesamoid, Trapezial Scaphoid/trapezoid,
  Pisiform-triquetral OA

6
Pattern of Joint Involvement

• Generalised OA of the Hand - clustering of joint
  involvement (Chaisson 1997, Framingham Study)
• Prevalent OA in one joint increased the incidence
  risk of OA in
• other joints in same row
• other joints in same ray
• OA in DIPJ or PIPJ increased incidence risk of OA
  in any other hand joint. Thumb CMC not a strong
  predictor of generalised disease

7
Pattern of Joint Involvement

• Polyarticular subset of hand OA (Egger 1995,
  Chingford study)
• Major determinants of pattern of involvement
• symmetry
• clustering by row
• clustering by ray

8
Clinical Features

• Fingers
• Swelling around joints
• Lateral deformity
• Osteophytes/exostoses -
• Heberdens Nodes - little hard knobs the size of
  a small pea, particularily a little below the
  top, near the joint (Heberden 1710-1801)
• Bouchards Nodes
• Mallet Finger
• Mucous Cysts/Ganglion - hyaluronic acid filled
  cysts

9
Clinical Features

• Thumb CMC
• Subluxation of the CMC - metacarpal base
  prominence
• Z-deformity - bony collapse at the MC base leads
  to adduction of the MC and hyperextension of the
  MCP

10
Examination

• Thumb CMC
• Tenderness over 1stCMC
• Pain and Crepitus on Axial Compression - torque
  test
• Decreased Pinch Strength
• Subluxation - intermittent pressure to MC base
  while pat pinches
• Sesamoid Arthritis
• Pain palmar plate at thumb MCP
• Good joint space
• Elicited by press. on palmar plate

• PIPJ/DIPJ
• Tenderness at joint line
• Lateral Instability
• Pain on Axial Compression
• Crepitus on Axial Compression
• Reduced Range of Movement

11
Radiological Features

• 88 Joint Space Narrowing
• 81 Osteophytes
• 46 Subchondral Sclerosis
• 33 Bony Cysts
• lt20 Lateral Joint Deformity
• lt20 Cortical Collapse
• (Kallman 1989, Arth Rheum 32, 1584-1591)

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Radiological Classification

• Kellgren and Lawrence Scale (1957) Ann Rheum Dis
  16494 - 501
• Kallman (1989) Arth Rheum 321584 - 1591
• Dell (1978) - 1st CMC OA

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Kellgren/Lawrence Scale (1957)
14
Kallman (1989)
15
Dell (1978)
16
Treatment Options for OA of the Hand

• Non surgical
• Splints
• NSAIDs
• Intraarticular Injections

• Surgical
• Stabilisation
• Arthrodesis
• Arthroplasty

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Surgery for Hand OA

• 1st CMC
• DIPJ
• PIPJ
• MCPJ
• other procedures

18
Surgery for the 1st CMC

• Anatomical considerations
• Palmar/Ulnar collateral ligament
• Dorsal intermetacarpal ligament
• Laxity leads to subluxation
• Congenital laxity - Ehlos Danlos early OA changes

19
Surgery for the 1st CMC

• Radiological ConsiderationsInvolvement of other
  trapezial joints86 2nd metacarpal48
  scaphoid35 trapezoid
• Pattern of joint involvement influences choice of
  procedure

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Indications for Surgical Intervention

• Failure of non-surgical methods
• pain
• instability - weakness in grip
• In the presence of OA change - Keelgren/Lawrence
  gt2

21
Arthrodesis of the 1st CMC

• Disease limited to CMC
• positioned 45o palmar and radial abduction
• cup and cone arthrodesis - 2-5 non-union

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Arthroplasty of the 1st CMC

• Trapezium excision arthroplasty
• ?fascia/tendon interposition
• ?ligament reconstruction
• ??silicone interposition arthroplasty
• Total Joint Arthro.
• Hemiarthroplasty

23
Soft Tissue interposition or Ligament
Reconstruction?

• Burton Pellegrini, 1986 (J Hand Surg) - Lig.
  recon and tendon interposition - improved grip
  strength and endurance
• Gerwin 1997 (Clin Orthop) -lig. recon. no tendon
  interposition - no requirement for tendon
  interposition
• Livesey 1996 (J Hand Surg) - lig. recon. produces
  stronger hand than trapezial excision alone,
  although slower recovery

24
Surgery for the DIPJ

• Indications
• Pain
• Instability
• Mucous Cyst
• Deformity
• 80 presenting are at a stage requiring surgery
  to alleviate symptoms

• Options
• Arthrodesis
• Arthroplasty
• Procedures for Symptom Relief

25
Arthrodesis of the DIPJ

• only treatment in the presence of significant
  bone destruction and instability
• multiple methods to obtain arthrodesis - cup and
  cone, K-wires
• 2 pseudoarthrosis (Carroll 1969, JBJS - 635
  joints)

26
Surgery for the DIPJ

• Interposition Arthroplasty
• silicone interposition - preserves motion and
  stability
• falling into disfavour
• Wilgis 1997 (Clin Orthop) - 38 digits, lt10
  implants removed

• Synovectomy and osteophytectomy - stable joint
  with good bone preservation
• Mucous Cyst Excision

27
Surgery for the PIPJ

• Indications
• Pain
• Instability
• Deformity
• In the presence of OA

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• Arthrodesis
• Arthroplasty
• cemented
• silicone interposition
• Pelligrini 1990, J Hand Surg - 24 pat
• Cemented Biomeric - failed average 2.25yrs
• Silicone - 35 showed bone resorption
• Arthrodesis - greatest improvement in lat grip

29

• MCP/IPJ Thumb
• Arthrodesis - either IPJ or MCP
• Interpositional Arthroplasty - MCP
• Cemented Steffee prosthesis -slotted component
• Swanson Silicone Rubber Arthroplasty
• Soft Tissue Arthroplasty - salvage procedures

30
Surgical Procedures for Other Joints

• MCPJ
• Soft tissue Arthroplasty
• Joint Replacement Arth. Steffee Prosthesis
• Ball and Socket joints

• Sesamoid OA
• excision of the sesamoid
• Pisotriquetral OA
• injection
• pisiform excision

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Summary of Surgical Treatment

• 1st CMC - Trapezial excisional arthro.
• DIPJ - Arthrodesis
• PIPJ - unresolved
• DIPJ - ?Silicone Interpositional Arthroplasty

32
Hand Osteoarthritis

• Common problem affecting elderly females
• Most commonly affects DIPJ 1st CMC
• Surgical Intervention for pain and instability
• Number of unresolved questions regarding surgical
  treatment - i.e.. Type of arthroplasty
• Outcome - painfree but with reduced ROM and
  decreased pinch strength