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