Arthritis of the Hand and Fingers Thomas A. Wiedrich, MD 1 st Edition author: Donald H. Lee, MD

Etiology of Arthritis of the Hand and Fingers Osteoarthritis Inflammatory arthritis Systemic Lupus Erythematosus Psoriatic arthritis Scleroderma Gout Pseudogout Post-traumatic Post-infectious Arthritis – Hand & Fingers

Most commonly affected joints Distal interphalangeal joint (DIP) Thumb carpometacarpal joint (CMC) Proximal interphalangeal joint (PIP) Metacarpophalangeal (MP) joint rarely involved Incidence in > 65 year olds 78% of men / 99% of women Arthritis – Hand & Fingers

Interphalangeal Joint Arthritis Often painless Deformities Angular Rotatory Marginal osteophytes Distal interphalangeal joint Heberden’s nodes Proximal interphalangeal joint Bouchard’s nodes Essentials of Hand Surgery 2002

DIP Joint Arthritis Arthritis – Hand & Fingers

Osteoarthritis Long finger distal interphalangeal joint arthritis S/P fusion of index distal interphalangeal joint Arthritis – Hand & Fingers

Mucous Cysts May present with or without significant radiographic signs or arthitis Cyst emanating from joint Nail ridging may indicate more mature cyst May have dorsal skin attenuation Regional Review Course 1998 Arthritis – Hand & Fingers

Index finger mucous cyst Underlying distal interphalangeal joint osteophyte (arrow) Courtesy of Donald H. Lee, MD Arthritis – Hand & Fingers

Nonsurgical Treatment of Mucous Cysts Rest Activity restriction/modification Splinting Anti-inflammatory medications Aspiration/Injections Arthritis – Hand & Fingers

Surgical Indications Pain Deformity Painful instability Problematic mucous cyst Resistant to conservative measures Aspiration with ~ 40-50% recurrence Nail ridging Progressive enlargement Repeated local trauma Infection Arthritis – Hand & Fingers

Surgical Options- Mucous Cyst Dependent upon symptoms as well as amount of arthritic changes within joint Simple Mucous cyst excision Osteophyte excision Joint debridement Minimal surgical complications, nail ridging can resolve in ~5/6 of cases Joint significantly affected by arthritis Arthrodesis Arthritis – Hand & Fingers

Surgical Implant Options Tension band construct Intraosseous Kirschner wires (90-90 configuration Headless compression screw Position of arthrodesis Depends on fixation method and limitations with screw based on AP diameter of distal phalanx. Between 10-30° (0-10° more likely with screw, increasing flexion with K- wires) More flexion in ulnar digits Arthritis – Hand & Fingers

Surface Preparation And Shaping Cone and cup Chevron Flat angled resection Arthritis – Hand & Fingers Leibovic S et al, JHS, 2007

Kirschner wires used for distal interphalangeal joint fusion Courtesy of Donald H. Lee, MD Arthritis – Hand & Fingers

Time to clinical union ~ 6 weeks, protect with thermoplastic splint until that time Radiographic union in ~3 months Results Nonunion rates vary between 0 and 10% depending on joint fused (PIP vs DIP respectively) Infection rate <5% (minor infection, though osteomyelitis may occur) Soft tissue problems More common over DIP than PIP Avoid by not closing wound too tightly, noncompressive dressings Arthritis – Hand & Fingers

PIP Joint Arthritis Arthritis – Hand & Fingers

PIP Joint Arthritis Less frequently affected by primary OA Typically, Post traumatic Inflammatory (RA) Post infection Presentation PIP joints become painful and stiff with marked decreased range of motion Arthritic process can render PIP joint unstable due to attenuation of soft tissue stabilizers Courtesy of Donald H. Lee, MD Arthritis – Hand & Fingers

Regional Review Course 1998 Surgical Indications Pain Deformity Contracture Instability Surgical options Arthrodesis Arthroplasty Arthritis – Hand & Fingers

Surface Preparation and Shaping Cup and cone Allows rotational correction at time of fixation Chevron Angled resection Methods of fixation Kirschner wires Tension band construct Intraosseous screws/wires Plate and screws Position of arthrodesis More flexion as one goes ulnarly to mimic cascade Arthritis – Hand & Fingers Leibovic S et al, JHS, 2007

PIP Joint Arthrodesis With Headless Compression Screw Technical point Use rongeur to enlarge hole in middle phalanx to the size of proximal screw threads to prevent fracture of dorsal cortex! If dorsal cortex is breached, must use different method of fixation or supplement this fixation Arthritis – Hand & Fingers Leibovic S et al, JHS, 2007

Converts palmar pull of flexors from distration force of dorsal side to compression force at palmar side Courtesy of Donald H. Lee, MD K-wire tension band construct

Arthroplasty Indications Older population Primary or post traumatic arthritis Contraindications Infection Lack of flexor/extensors Severe periarticular bone stock loss Incompetent collateral ligaments Incompetent volar plate Poor soft tissue coverage Arthritis – Hand & Fingers

Approaches Dorsal (central slip at risk) Tendon splitting Chamay tendon reflecting approach Lateral (collateral ligaments at risk) Volar (volar plate/flexor tendons at risk) Arthritis – Hand & Fingers Bickel KD, JHS, 2007

Surface Replacement Arthroplasty Arthritis – Hand & Fingers Murray P, JHS, 2007

Postoperative regimen Must protect central slip/lateral band/volar plate depending upon approach for 6 weeks. Use appropriate splint for approach(ie dynamic extension splint with flexion block for dorsal approach) Results after either Resurfacing Arthroplasty or Silicone arthroplasty Can expect excellent pain relief No real increases in ROM Appearance may be better with resurfacing Complications Extensor lag, instability of joint, need for reoperation/loosening Squeeking with resurfacing arthroplasty Branam and co-authors found 8/19 squeeked! (but patients were still happy with outcome and would opt for the same procedure ) Arthritis – Hand & Fingers

Thumb Carpometacarpal (CMC) Joint Arthritis Arthritis – Hand & Fingers

Incidence Framingham cohort study showed symptomatic OA in 7% women and 5% of men > 70 yo (Zhang et al, Am J Epidemiology 2002) Prevalence of hand arthritis approaches 67% in women > 55 yo with 21%-36% occurring at the thumb CMC joint (Dahaghin et al, Ann Rheum Dis 2005)

Clinical Symptoms Pain Palmar sided Pain with pinch Deformity Subluxation of the metacarpal dorsoradially with attenuation of the volar beak ligament Thumb metacarpal assumes adducted position MP joint extended Arthritis – Hand & Fingers

Essentials of Hand Surgery 2002 Physical Examination Visual inspection Shoulder sign- subluxation of metacarpal dorsoradially MP joint may be hyperextended (thought to be compensatory, may be contributory to the process) Examine bulk of thenar musculature (association with carpal tunnel syndrome) Palpation/provocative maneuvers Grind test Examine mobility of MP joint May need to be addressed surgically at time of CMC procedure Examine for CTS Regional Review Course 1998 Arthritis – Hand & Fingers

Differential Diagnosis Radial sided pain Intersection syndrome- pain with wrist flexion and extension DeQuervain’s tenosynovitis- Finkelstein’s maneuver Radial impaction- pain with radial deviation Scaphoid injury acute/chronic- pain/swelling in snuffbox, over tuberosity Scapholunate ligament injury- dorsal sided wrist pain, scaphoid shift test Scaphoid-trapezium-trapezoid arthritis- tenderness to palpation just distal to scaphoid Stenosing tenosynovitis- volar sided pain at A1 pulley level, nodule. Arthritis – Hand & Fingers

Regional Review Course 1998 Eaton Classification of Thumb CMC Arthritis Stage 1 – Articular contours normal; joint space may be widened due to synovitis. Less than one-third subluxation on any view Stage 2 – Slight narrowing of the joint space with osteophytes < 2 mm in size. May have more than one-third subluxation of the joint surfaces Stage 3 –CMCJ narrowing with sclerotic or cystic changes, osteophytes > 2 mm. The STT joint remains intact Stage 4 – Pantrapezial arthrosis – CMCJ and STT joint severe articular degeneration Stage 3/4

Regional Review Course 1998 Non Operative Treatment Splints Hand or forearm based NSAID’s Must be selective in older patients Injections Randomized controlled study comparing placebo to corticosteroid injection found no difference. Bay et al- prospective trial of injection and splinting evaluated effectiveness of 1 steroid injection and splinting x 3 weeks. Effective in stage 1 disease, less effective in stage 2/3 and ineffective in stage 4 disease. Arthritis – Hand & Fingers

Regional Review Course 1998 Surgical Indications Pain Refractory to nonoperative treatment Interferes with pinch and grip Deformity Breadth of palm increases Base of the thumb is the most operated upon joint (for osteoarthritis) in the Western world. Shoulder sign MPJ hyperextended Arthritis – Hand & Fingers

Surgical Options Dependent upon stage of disease Stage I Ligament reconstruction Metacarpal extension osteotomy Stages II-IV Ligament reconstruction with or without tendon interposition CMC arthrodesis Arthritis – Hand & Fingers

Stage I Ligament reconstruction 30 degree metacarpal extension osteotomy Shifts forces dorsally away from arthritic changes on volar surface Koff MF et al, JHS, 2006

Many options for Stage II-IV disease Some interpose tissue within the trapezial space, others use “hematoma arthroplasty” All are predicated on reconstruction of the volar beak ligament Arthritis – Hand & Fingers Mo JH et al, JHS, 2004

Trapeziectomy Appearance of excised trapezium Courtesy of Donald H. Lee, MD

Thumb MCPJ Hyperextension Deformity < 10 degrees Leave alone > 10 degrees K-wire fixation in 10 degrees of flexion (6 weeks) Extensor pollicis brevis tenotomy and tenodesis to APL (removes deforming force from thumb proximal phalanx) and K-wire fixation Volar capsulodesis MP arthrodesis (arthritis) Arthritis – Hand & Fingers

Clinical Outcomes After Treatment Of Thumb CMC Arthritis Ligament reconstruction Eaton et al reported 100% good/excellent results for stage I, 91% for stage II with 7 year follow up Metacarpal osteotomy Hobby et al reported good to excellent results in 95% of patients with low rate of complications Meta-analysis by Martou found no significant benefit to ligament reconstruction Latest Cochrane review shows trapiezectomy alone to be efficacious and safe Thumb CMC arthrodesis Younger patients with higher demands? Perhaps stronger pinch Relatively high rate of nonunion- asymptomatic Arthritis – Hand & Fingers

Inflammatory Arthritis Systemic disorder Skin rashes and ulcers Organ dysfunction Cardiac, pulmonary, renal, vascular, ocular, GI Hematological disorders Raynaud’s phenomenon More common disorders Rheumatoid arthritis Systemic lupus erythematosus Psoriatic arthritis Scleroderma Arthritis – Hand & Fingers

Rheumatoid Arthritis Systemic autoimmune disorder Chronic systemic erosive synovitis Deformities secondary to hypertrophied synovial tissue Prevalence increases with age Women:men ratio – 2.5:1 Metacarpophalangeal joint most commonly involved Wrist and other upper extremity joints Arthritis – Hand & Fingers

Rheumatoid Arthritis Metacarpophalangeal joints – most commonly affected Clinical findings Morning stiffness Digital and wrist synovitis Ulnar drift of fingers Radial deviation of wrist Regional Review Course 1998 Arthritis – Hand & Fingers

Rheumatoid Hand Deformities Digital and wrist synovitis Ulnar drift of fingers Volar subluxation / dislocation of MP joints Swan neck deformity Boutonniere deformity Radial deviation of wrist Trigger fingers Carpal tunnel syndrome Ulnar drift of the digits and radial deviation of the wrist Regional Review Course 1998 Arthritis – Hand & Fingers

Rheumatoid Arthritis Volar subluxation of MP joints and swan neck deformities of the digits Regional Review Course 1998

Stages of Rheumatoid Joint Involvement Stage I - Synovitis without deformity Stage II - Synovitis with passively correctable deformity Stage III - Fixed deformity without joint changes Stage IV - Articular destruction Arthritis – Hand & Fingers

RA - Non-operative treatment Medical management NSAIDs Disease remitting agents Rest Controlled exercises Splints Finger Resting hand splints Steroid injections Patient education Resting hand splint Regional Review Course 1998

RA - Surgical Indications Pain relief Restoration/improvement of function Prevention of deformities Improvement of appearance Arthritis – Hand & Fingers

MCP Joint Synovectomy Joint realignment Centralization of extensor tendon Ulnar collateral ligament and intrinsic release Reefing of radial collateral ligament Cross intrinsic tendon transfers Implant arthroplasty Arthritis – Hand & Fingers

RA – Implant arthroplasty - Indications Pain with arthritis Ulnar drift with loss of function Marked flexion contractures Decreased arc of motion (< 40 deg.) Contraindications Poor bone stock Vasculitis Poor skin condition Arthritis – Hand & Fingers

Summary Osteoarthritis commonly involves the hand, especially the distal and proximal interphalangeal and thumb carpometacarpal joints Rheumatoid arthritis commonly involves the metacarpophalangeal joints Arthritis – Hand & Fingers

Summary Non-operative treatment includes the use of antinflammatory medications, splints and therapeutic modalities Surgical treatment includes soft tissue reconstruction, arthroplasty and arthrodesis Arthritis – Hand & Fingers

Thank you Questions?