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Osteoarthritis of the Hand

Osteoarthritis of the Hand. Andy Ballantyne Edinburgh SpR Rotation. 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.

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Osteoarthritis of the Hand

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  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 • <40 yrs - 50 new cases per 1000 person-years at risk • 40 - 59 yrs - 65 new cases per 1000 person-years at risk • >60 yrs - 110 new cases per 1000 person-years at risk • (Kallman et al. 1990, Arth Rheum 33,1323 - 1332)

  5. 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 Pattern of Joint Involvement

  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 toadduction of the MC and hyperextension of the MCP

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

  11. Radiological Features • 88% Joint Space Narrowing • 81% Osteophytes • 46% Subchondral Sclerosis • 33% Bony Cysts • <20% Lateral Joint Deformity • <20% Cortical Collapse • (Kallman 1989, Arth Rheum 32, 1584-1591)

  12. Radiological Classification • Kellgren and Lawrence Scale (1957) Ann Rheum Dis 16:494 - 501 • Kallman (1989) Arth Rheum 32:1584 - 1591 • Dell (1978) - 1st CMC OA

  13. Kellgren/Lawrence Scale (1957)

  14. Kallman (1989)

  15. Dell (1978)

  16. Non surgical Splints NSAIDs Intraarticular Injections Surgical Stabilisation Arthrodesis Arthroplasty Treatment Options for OA of the Hand

  17. 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

  20. Indications for Surgical Intervention • Failure of non-surgical methods • pain • instability - weakness in grip In the presence of OA change - Keelgren/Lawrence >2

  21. Arthrodesis of the 1st CMC • Disease limited to CMC • positioned 45o palmar and radial abduction • cup and cone arthrodesis - 2-5% non-union

  22. 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. Indications Pain Instability Mucous Cyst Deformity ~80% presenting are at a stage requiring surgery to alleviate symptoms Options Arthrodesis Arthroplasty Procedures for Symptom Relief Surgery for the DIPJ

  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. Interposition Arthroplasty silicone interposition - preserves motion and stability falling into disfavour Wilgis 1997 (Clin Orthop) - 38 digits, <10% implants removed Synovectomy and osteophytectomy - stable joint with good bone preservation Mucous Cyst Excision Surgery for the DIPJ

  27. Surgery for the PIPJ Indications • Pain • Instability • Deformity In the presence of OA

  28. 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. MCPJ Soft tissue Arthroplasty Joint Replacement Arth. Steffee Prosthesis Ball and Socket joints Sesamoid OA excision of the sesamoid Pisotriquetral OA injection pisiform excision Surgical Procedures for Other Joints

  31. 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

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