OSTEOARTHRITIS IN THE HAND. Dr.Maneesh Sinha St.Richard s Hospital,Chichester.
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1 OSTEOARTHRITIS IN THE HAND. Dr.Maneesh Sinha St.Richard s Hospital,Chichester.
2 Osteoarthritis: Diarthrodial joints. Focal degeneration of cartilage. Simultaneous repair & remodeling.
3 Osteoarthritis: Primary (idiopathic) Secondary -trauma. -mechanical derangement. -metabolic disease. -prev. articular lesion.
4 Primary osteoarthritis: Exact etiology unknown. Interplay of various factors. GENETIC FACTORS. MECHANICAL FACTORS. (MICRO-/ MACRO-TRAUMA.) CHEMICAL CHANGES. (LYSOSOMAL ENZYMES.)
5 Osteoarthritis in hand: What are those little hard knobs,about the size of a pea,which are frequently seen upon the fingers,a little below the top,near the joint.they have no connection with the gout, being found in persons who never had it;they continue for life; and being hardly ever attended with pain, or disposed to become sores,are rather unsightly than inconvenient, though they must be some little hinderance to the free use of the fingers. William Heberden ( ) Commentaries.History & cure of diseases.london,1802.
6 Osteoarthritis in hand: More commonly affects females. Post-menopausal. Hereditary predisposition. Increased prevalence with increasing age. Associated O.A of spine/hip/knee.
7 Topographical characteristics of basal joint of thumb & it s variations: In women-- smaller contact area; -- less congruent; -- more contact stresses for similar activities of daily living involving similar loads. (Xu,L. et al; J.Hand Surg.,Am.,1998,May.)
8 Genetic predisposition: 130 identical & 120 non-identical female twins aged yrs. Demonstrate clear genetic effect for radiographic OA. of hand & knee, ranging from 39%-65%,. (Spector,TD. et al; BMJ April.)
9 Is HRT. protective? 606 post-menopausal women from the Chingford study: For current users (n=72), inverse association with OA.knee suggestive of protective effect. No clear effect on OA. of hand joints. (Spector, TD. et al;ann.rheum.dis. 1997,July)
10 Effect of age : Left hand wrist x-rays of 386 participants of Baltimore longitudinal study of aging : Prevalence increases ; progression faster in individuals over 60 yrs. (Busby, J. et al.annals of Human Biology, 1991 Sept.
11 Obesity as a risk factor: 9%-13% increase in risk (per kg. increase in body weight.), of OA. of knee & hand. (Spector, TD. et al; J.Rheumatol July.)
12 Patterns of joint involvement: Symmetry in the involvement of joints of hand. 4 different patterns: -- predominantly DIP. jt. -- DIP & PIP jts. -- Basal jt. of thumb. -- equal involvement of thumb & finger jts. (Swanson & Swanson;Symposium on osteoarthritis, Disabling osteoarthritis in the hand & it s treatment.1976.)
13 Patterns of joint involvement: Incidence of OA. changes around trapezium in OA. of carpometacarpal jt. of thumb: Total excision of trapezium necessary in most cases to eliminate all pain. (Swanson & Swanson; 1976) 1st. MET. 100% TRAPEZIUM SCAPHOID 48% 2nd. MET. 86% TRAPEZOID 35%.
14 Patterns of jt. Involvement : Predominantly DIP. jt. involvement.
15 Patterns of jt. Involvement: Basal jt. of thumb + Peri-trapezial arthritis
16 Patterns of joint involvement: Clustering of OA. at different sites in the hand (967 peri- & post-menopausal women.) : 3 major determinants:- - symmetry. - clustering by row. - clustering by ray. (Egger, P. et.al. The Chingford study; J.Rheumatol Aug.
17 Clinical features: May be extremely benign course - May be very striking - indolent progression of joint swelling & deformity, minimal pain, minimal inflammation. abrupt onset of painful jts., swelling, marked inflammation.
18 Clinical features: Natural history. Waxing & waning over 5-10 years. Increasing deformity. Ankylosis. Burn out.
19 Clinical features: Symptoms Pain. Crepitus Stiffness Loss of strength Grind test helpful in localising complaints.
20 Clinical features: Interphalangeal joints: Angular deformities.(usually lateral deviation.) Flexion deformities. Limited motion / ankylosis. Bony enlargements - dorsally & laterally. (Heberden s nodes, Bouchard s nodes)
21 Interphalangeal joints: Soft tissues. Periarticular soft tissue & tendinous attachments. Ligamentous destruction. Contracture. Mucous cysts ; ridging of nails.
22 Radiological features: Interphalangeal joints: Initially - jt. space narrowing. Advanced - subchondral sclerosis, marginal osteophytes. Cyst formation, erosions. Angulation ; subluxation/dislocation.
23 Interphalangeal joints:
24 Clinical features: Basal joint of thumb: Pain at base of thumb ; thenar eminence. Loss of strength in grasp & pinch. Diminished metacarpal motion. Grind test - produces pain, crepitus.
25 Clinical features: Basal joint of thumb: Advanced - subluxation in a dorsal + radial direction. Secondary compensatory deformityhyperextension of MP. jt. Hypermobile MP. jt. Arthritic MP. jt.
26 Radiological features: Basal joint of thumb: Initially - instability on stress views. Advanced - jt. space narrowing. Subchondral cysts, sclerosis, marginal spurs. Dorsoradial subluxation.
27 Basal joint of thumb:
28 Metacarpophalangeal joints. Rare. Index / middle fingers. Locking of MP. Jt.
29 Associated conditions: Carpal tunnel syndrome. De Quervain s tenosynovitis. Stenosing flexor tenosynovitis. Volar ganglion.
30 Classification (Clinical): American College of Rheumatology criteria a. hard tissue enlargement in >1 of 10 jts. b. swelling of <3 MP. jts. c. hard tissue enlargement in >1 DIP. jts. d. deformity in at least 1 of 10 jts. The 10 selected joints:- 2nd ; 3rd DIP, 2nd ; 3rd PIP, CMC. Jt. of thumb in both hands. Altman R., et al. Arthritis & Rheumat Nov.
31 Radiological Grading: Kellgren & Lawrence: Five grades: 0: None. 1: Doubtful 2: Minimal 3: Moderate 4: Severe Kellgren JH, Lawrence JS. Ann.Rheum.Dis. (1957)
32 Radiological grading: Swanson & Swanson: Grade 1 Minimal Joint narrowing. Grade 2 Minimal to + subchondral sclerosis; moderate hypertrophic nodes. Grade 3 Moderate + erosions. Grade 4 Moderate to + cysts ; deviation. severe Grade5 Severe + dislocation.
33 Sensitivity of radiographic features. 32 patients with OA. hand, screened at 6 monthly intervals, over 18 months. Most sensitive radiographic features were : - osteophytes, - subchondral sclerosis, - juxta-articular radiolucencies. contd.
34 Scintigraphic imaging. Specificity of Tc99m bone scanning, studied. Scan features did not correlate with any of the radiographic features other than the osteophyte size. Buckland - Wright JC, European J Nuclear Med. (Sep.1991)
35 Osteoarthritis in the hand. Management of OA. in hand. Non-operative management. Operative management. Rest ; splinting. Physical therapy. Arthrodesis. Osteotomy. Medical measures ; Corticosteroids. Arthroplasty. Soft tissue. Interpositional materials. Joint replacements.
36 Management of OA. in hand. Non-operative management. Goals : Pain relief. Preservation of function. Prevention of deformities. Patient education.
37 Non-operative management: Rest. Splinting & physical measures. Active excercises. Medical therapy. Corticosteroid injections.
38 Operative treatment: Trapeziometacarpal osteoarthritis: - Arthrodesis. - Arthroplasty. - Metacarpal osteotomy.
39 Operative treatment: Arthrodesis of basal thumb jt. Favoured in patients under 50 yrs. involved in heavy labour. Isolated symptomatic arthritis of basal jt. of thumb. No peritrapezial OA. No adduction contracture of 1st met. or MP.jt. stiffness.
40 Operative treatment: Arthrodesis of basal thumb jt. Method: - Curvilinear incision. - Vertical arthrotomy. - Cup & Cone. - Correct position. - K wire + thumb spica for 6-8wks.
41 Operative treatment: Arthroplasty of basal thumb jt. Types :- 1. Resection (trapeziectomy) arthroplasty: with interposition - soft tissue / synthetic. without interposition, 2. Replacement : hemiarthroplasty. total.
42 Operative treatment: Arthroplasty. Indicated when mobility is desirable. Trapeziectomy +/- reconstruction ; interposition: - severe pantrapezial arthritis. - trapezium height, less than 7 mm. - younger age - intensive hand use.
43 Operative treatment: Arthroplasty. Trapeziometacarpal replacement a plasty. - No or mild peritrapezial arthritis. - older individuals. - less active use of hands.
44 Operative treatment. Arthroplasty. Excision +/- Interposition. Method : Incision - dorsovolar Sup. Radial nerve preserved. Trapezium excised. FCR. tendon harvested. Ligamentous reinforcement. Short arm cast.
45 Operative treatment. Arthroplasty. Silicone Rubber implant interposition following excision of Trapezium. Maintains joint space. Provides smooth articulation. Improves stability, mobility, strength.
46 Operative treatment. Replacement arthroplasty. For cases with no / mild peritrapezial arthritis. a.silicone convex condylar implants. b.titanium condylar implants. c.cemented total jt. replacement. d.uncemented total jt. replacement.
47 Operative treatment. Problems with arthroplasties. Silicone implants : Silicone synovitis. Instability. Implant breakage. Joint replacements : loosening stress shielding, bony resorption. material failure.
48 Operative treatment. Associated MP. Jt. problems : Hyperextension of the MP. Jt. & adduction of the 1st. Metacarpal. -If angle of abduction < 45 degrees - Add. Pollicis muscle should be released. -Hyperextension of MP. Jt. - palmar capsulodesis / arthrodesis, if severe. -Basal metacarpal osteotomy.
49 Operative treatment. Basal thumb jt. OA. : review of litt. Trapeziectomy: Gervis WH. JBJS Soft-tissue arthroplasties for CMC jt. : Froimson AI; Clin. Othop Burton RI, Pellegrini VD; J.Hand Surg Total joint replacement arthroplasties: de la Caffiniere; cemented replacement Ledoux; cementless (press fit) implant
50 CMC. Jt. Arthroplasty. Review of litt. : Comparison of different techniques of trt. of OA. of 1st CMC. Jt. (av. follow-up 5 yrs.). Lanzetta, M. J. Hand Surg. (1995, Feb.) ; retrospective study of 98 surgical procedures; Group 1 : Swanson s arthroplasty. Group 2 : Ashworth Blatt hemiarthroplasty. Group 3 : soft tissue arthroplasty. Results satisfactory with silicone & soft tissue a plasty, but not with hemia plasty.
51 CMC. Jt. Arthroplasty. Review of litt. 24 thumbs evaluated after lig.- recon. & interposition arthroplasty, at average of 9 years. (Tomaino, MM. et al. JBJS 95 Mar.) 21 (95%) patients - excellent relief of pain. 93% improvement of grip strength. 65% improvement of pinch strength. Provides stable & functional reconstruction of thumb.
52 CMC. jt. Arthroplasty. Review of litt. Trapeziectomy alone, or with ligament reconstruction / tendon interposition? (Davis, TR. et al. J. Hand Surg. 97 Dec.) Randomised prospective study; 76 women; 3 months & 1 year follow-up. Results indistinguishable in terms of pain relief, hand function & thumb strength.
53 CMC. jt. arthroplasty. Review of litt. Ligament reconstruction basal jt. arthroplasty, with or without tendon interposition? (Gerwin, M. et al. CORR. 1997, Aug.) Prospective randomised study ; 26 patients. 23 months follow-up. No difference in motion of thumb, grip strength, pinch strength, jt. space on lat. X-rays.
54 CMC. Jt. Arthroplasty. Review of litt. Titanium implant hemi-arthroplasty. ( Swanson, AB. et al. CORR Sept.) 105 Titanium metacarpal implants reviewed ; Av. Follow-up of 5 years. Improvement of index tip pinch (64%), grip strength and key pinch.height of trapezium preserved. No peritrapezial arthritis.
55 CMC. jt. Arthroplasty. Review of litt. de la Caffiniere thumb CMC arthroplasty. ( Chakrabarti, AJ.et al. J. Hand Surg. 97 Dec.) Results of 93 cemented replacements reviewed between 6 & 16 years. 11 joints required revision, commonest cause was loosening of trapezial component. Failure rate higher in working men; caution against use in men younger than 65 yrs.
56 CMC. Jt. Arthroplasty. Review of litt. Cemented & non-cemented replacements of the trapeziometacarpal joints. Wachtl SW. JBJS. Jan cementless Ledoux implants. 43 cemented de la Caffiniere ; 61 prostheses survived. 51 reviewed clinically. Contd.
57 Survival rate : Ledoux prostheses : 58.9% at 16 months. de la Caffiniere prostheses : 66.4% at 68 months. Loosening - 24% cemented stems. - 28% cemented cups. - 15% cementless stems. - 46% cementless cups. Normally - 1st met. lies lateral to trapezium. Colinear axis disturbs joint kinematics. Constrained prosthesis with fixed centre of rotation not suitable.
58 Thumb CMC. Jt. Arthritis. 1st Metacarpal osteotomy. Wilson JN. Br. J. Surg. (1973) Hobby JL et al JBJS (May 98) 41 thumbs ; mean f.u. 6.8 yrs. Good pain relief in 80%, and 82% had normal pinch & grip strength, with restored abduction. Poor results with advanced peritrapezial arthritis. Corrects thumb adduction contracture, improves opposition.
59 Operative treatment Interphalangeal joints. Distal I.P. joint : Pain usually abates ; mild to moderate deformities ; hand function not severely compromised. Arthrodesis, therefore the preferred treatment. If pain associated with need for motion - as in thumb or index finger, flexible silicone implants may be used.
60 Operative treatment Interphalangeal joints. Artrhodesis of DIP. Jts. : - transverse incision directly over the joint. - extensor tendon attachments divided. - osteophytes resected. - cup & cone. - K wire fixation.
61 Operative treatment Interphalangeal joints. Silicone arthroplasties for DIP. Jt. : Useful substitute to arthrodesis in some cases. - Distally based y-shaped incision. - Division of extensor tendon 0.5 proximal to joint. - Medullary reaming to accept stems. - Repair of extensor tendon.
62 Operative treament. Interphalangeal joints. Proximal I.P. joints. For severely destroyed joints, particularly of the index digit, arthrodesis may be indicated. Flexion of the PIP. jts. of ring, little fingers is important for grasp, therefore flexible implant arthroplasty is more suitable.
63 Operative treatment Review of literature: Interphalangeal joints. DIP. Jt. Silicone arthroplasty. Wilgis EF. CORR Sept. 38 procedures ; average age 58.3 yrs. Follow-up 10 yrs. Average flexion- 33 degrees. Average loss of extension < 10 degrees. Less than 10 % implants had to be removed.
64 Operative treatment Interphalangeal joints. Review of literature : Proximal interphalangeal joint surface replacement arthroplasty. Linscheid RL et al. J Hand Surg. 97 Mar. Chromium-Cobalt + UHMWPE prostheses for PIP jts. Used in 66 jts. Mean follow - up of 4.5 yrs. Good results in 32, fair in 19, poor in 15. Poor results in fingers with previous injury ; static deformity.
65 Operative treatment Metacarpophalangeal joints. Not very common. Seen usually in index finger Functionally, Arthrodesis at MP. Jt. can be very limiting, therefore the procedure of choice is arthroplasty with or without implants.
66 Thank you!
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