1. Osteoarthritis of the Hand Andy Ballantyne Edinburgh SpR Rotation

2. What is Osteoarthritis? n OA is a disturbance of the normal balance of degradation and repair of articular cartilage and subchondral bone n 40% Adult Population Affected n 10% Require Medical Treatment n 1% Disabled

3. Multifactorial Aetiology n Age n Sex n Genetics n Trauma n Occupation n Race

4. Incidence of OA of the Hand n Commonest form of OA n <40 yrs - 50 new cases per 1000 person- years at risk n 40 - 59 yrs - 65 new cases per 1000 person- years at risk n >60 yrs - 110 new cases per 1000 person- years at risk n (Kallman et al. 1990, Arth Rheum 33,1323 - 1332)

5. Pattern of Joint Involvement n Framingham OA Study, Boston - 746 subjects, 1967 - 1993 n Chingford Study - 967 female subjects n 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 : n other joints in same row n 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 n symmetry n clustering by row n clustering by ray

8. Clinical Features Fingers Swelling around joints Swelling around joints Lateral deformity Lateral deformity Osteophytes/exostoses - 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 Mallet Finger Mucous Cysts/Ganglion - hyaluronic acid filled cysts Mucous Cysts/Ganglion - hyaluronic acid filled cysts

9. Clinical Features Thumb CMC n Subluxation of the CMC - metacarpal base prominence n Z-deformity - bony collapse at the MC base leads to adduction of the MC and hyperextension of the MCP

10. Examination PIPJ/DIPJ n Tenderness at joint line n Lateral Instability n Pain on Axial Compression n Crepitus on Axial Compression n Reduced Range of Movement Thumb CMC n Tenderness over 1stCMC n Pain and Crepitus on Axial Compression - torque test n Decreased Pinch Strength n Subluxation - intermittent pressure to MC base while pat pinches Sesamoid Arthritis n Pain palmar plate at thumb MCP n Good joint space n Elicited by press. on palmar plate

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

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

13. Kellgren/Lawrence Scale (1957)

14. Kallman (1989)

15. Dell (1978)

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

17. Surgery for Hand OA n 1st CMC n DIPJ n PIPJ n MCPJ n other procedures

18. Surgery for the 1st CMC Anatomical considerations n Palmar/Ulnar collateral ligament n Dorsal intermetacarpal ligament Laxity leads to subluxation Congenital laxity - Ehlos Danlos early OA changes

19. Surgery for the 1st CMC Radiological Considerations Involvement of other trapezial joints 86% 2nd metacarpal 48% scaphoid 35% trapezoid Pattern of joint involvement influences choice of procedure

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

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

22. Arthroplasty of the 1st CMC Trapezium excision arthroplasty n ?fascia/tendon interposition n ?ligament reconstruction n ??silicone interposition arthroplasty Total Joint Arthro. Hemiarthroplasty

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

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

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

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

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

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

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

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

31. Summary of Surgical Treatment n 1st CMC - Trapezial excisional arthro. n DIPJ - Arthrodesis n PIPJ - unresolved n DIPJ - ?Silicone Interpositional Arthroplasty

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