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1

Define osteoarthritis

·   Degenerative osteoarthritis of the hand/wrist can involves all of the tissues around the synovial joint, including the articular cartilage, joint capsule, ligaments, subchondral bone, metaphyseal bone, and the muscles acting across the joint

·   Principle pathological change --> loss of articular cartilage.

2

Describe the pathophysiology of osteoarthritis

  • Changes to articular cartilage
    • Biochemical: cytokine release --> cellular response, cartilage damage
    • Biomechanical: loss of proteoglycans, increase vascular ingrowth, increased water - cartilage becomes soft (chrondromalacia)
    • Structural changes: chondrocytes respond to mechanical forces and cartilage develops fibrillations on surface, clefts, fractures, decrease thickness
  • Changes to subchrondral bone
    • sclerosis (increased bone density where exposed), cysts, osteophyte formation
  • Changes to peri-articular structures
    • inflamed synovium, swelling, stiffness

3

how do you classify osteoarthritis?

  • Primary vs. secondary:
  • Primary – idiopathic (combo of genetics, joint shape/anatomy, endocrine changes)
  • Secondary – Antecendent event or underlying etiology that accelerates loss of cartilage
    • Mechanical – change to joint architecture – trauma, infection
    • Metabolic – gout, cppd, Wilson’s disease, hemochromatosis (MCPJ, 2nd & 3rd)
    • Inflammatory – rheumatoid / inflammatory arthopathy
    • Endocrinopathy: DM (neuropathic joint), acromegaly, hyperparathyroidism
    • Miscellaneous (AVN, genetic skeletal disorders)
  • Non-Erosive (classic OA) vs. Erosive – features of inflammatory OA, often post-menopausal & hereditary; PIPJ
  • By joint & disease stage (see below)

4

list findings on physical exam for OA hand

 

THUMB OA

  • dorsal subluxation
  • MCPJ hyperextension
  • adduction contracture*
  • tenderness*
  • pain and/or crepitus with axial loading (and/or traction)*
  • decreased a/pROM*

rest of hand see * above and:

  • heberden's nodes (DIPJ)
  • Bouchard's nodes (PIPJ)
  • mucous cyst formation
  • instability
  • decreased grip strength

5

xray findings of OA

o  joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes

6

what are goals for treatment of OA

 (in order) – control pain, improve function, correct deformity, improve appearance

7

outline a general treatment approach to OA

  • Conservative: all patients start here; often intra-articular steroid after other modalities first (unless severe)
  • NSAIDS, Tylenol, splinting, activity modification, steroid injection (triamcinalone), mechanical assists (PT/OT)
  • Surgical management – Indications à intractable functional pain, deformity impacting function after non-operative trial
  • Options: arthrodesis, arthroplasty (including tenoplasty, ligamentoplasty)

8

why is the volar beak ligament important? how does its pathology contribute to thumb CMC OA?

  • volar oblique ligament is most important stabilizing structure (pinch produces a dorsal force)

  • volar beak of bone on MC base ® trapezial tuberosity (controls pronation & prevents radial translation)

pathology

  • volar beak ligament attrition --> ligamentous laxity --> abnormal joint position and loading --> abnormal transmission of force across joint surface --> biomechanical change and loss of articular cartilage

9

why does the thumb assume a hyperextension posture at MCP w/ CMC OA?

  • Lateral/dorsal subluxation d/t capsular / intermetacarpal ligamentous laxity, hypertrophic medial spurs, pull of APL ® compensatory MPJ hyperextension & thumb adduction

10

what is the differential diagnosis for thumb cmc oa?

·   Tendonitis/tenosynovitis: FCR; de Quervain’s (1st dorsal compartment); intersection syndrome (2nd compartment)

·   Inflammatory arthritis: RA

·   Crystal arthropathy: gout, cppd

·   Ligamentous: Chronic UCL injury (Gamekeeper’s thumb)

·   Neuropathy: Radial sensory neuritis (Wartenberg); CTS

·   Arthritis at other joint: SLAC wrist; isolated STT arthritis; radiocarpal, MCP

·   Scaphoid trauma

11

in addition to usual views on XR, what additional imaging would you want for thumb cmc oa?

  • X-rays:  Stress view – PA at 30° (shows MC base lateral subluxation); Roberts view – AP of hyperpronated hand (all 4 trapezial articulations)

12

describe eaton classification for thumb cmc oa

Stage I

  • Normal X-ray, joint space may be wide

Stage II

  • Joint space narrow, minimal subchondral sclerosis, debris<2mm, STTJ normal

Stage III

  • ++narrow, cystic changes/sclerosis/debris>2mm, variable subluxation. STTJ normal

Stage IV

  • Pantrapezial arthritis, large osteophytes, ++ subchondral sclerosis, STTJ arthritis

13

list surgical options for thumb cmc oa?

Stage 1

  1. Palmar/volar oblique ligament reconstruction
  2. MC osteotomy

Stages 2-4

 

  1. Trapeziectomy ± hematoma/distraction arthroplasty
  2. Trapeziectomy w/ interposition graft
  3. Trapeziectomy, LR(±TI)
  4. Arthrodesis
  5. Arthroplasty

14

describe MC osteotomy for thumb CMC OA

  • Designed to restore abduction and extension
  • 4 cm longitudinal incision over radial border of 1st metacarpal
  • Resect radially based 20-30o wedge within 2 cm of joint
  • Distal MC extended and compressed through wedge excision; fixation K wires, intraosseus loops, plate
  • Advantages: pain relief, improved function (increased grip & pinch @ 2 yrs)
  • Nonunion up to 50%

15

describe trapeziectomy and LRTI

  • Trapeziectomy & LRTI
  • Incise: rad bord 1st MC, dissect between APL/EPB or EPL / EPB
  • Trapezial resection (in quadrants) -  FCR tendon is at base
  • drill hole through base of MC in line with nail plate, and out through base of MC
  • FCR harvest (1/2 or all) through 2 transverse volar forearm incisions, pull into joint
  • Pass FCR through base of MC, sutured onto itself (as tight as possible), interpose into joint, (± Kwire)
  • Alternative = APL à one slip harvested, passed through base 1st MC (or around FCR), through 2nd MC (radial/volar à dorsal ulnar), free end woven through ECRB and secured to itself (± Kwire)
  • Capsular & wound closures
  • Postop: cast for 4 weeks, splint for 4 weeks, normal function at 12 weeks
  • Advantage: most common, durable/reliable outcome, pain relief, increased grip/pinch
  • Disadvantage: loss of trapezial space height; no advantage over trapeziectomy alone (PRS 2011 Thoma, Sys. Rev)

16

describe considerations for management of MCPJ hyperextension during thumb cmc oa operations

  • Degree of hyperextension
    • <20 - no Rx
    • 20-30 deg - EPB tenotomy à transfer to base of MC to augment APL; K-wire x 4/52
    • >30° – fusion vs. volar capsulodesis MPJ + EPB tenotomy vs. sesamoid arthrodesis vs. palmaris longus volar plate reconstruction (No evidence of approach superior to another, no long term comparative prospective studies)
  • Non-operative management – figure of 8 splint

17

describe use of arthroplasty for pipj oa

  • Arthroplasty – less active patients with stiff, painful joints, flex/ext arc 60-80⁰ --> ½ pre-op ROM expected
  • Volar plate arthroplasty (limited use)
  • Silastic arthroplasty: joint spacer  (RA pt), pain relief, less stable, limited ROM
    • dorsal, volar or lateral approach; must preserve central slip insertion
    • oblique osteotomies, remove minimal bone
  • Surface replacement arthroplasty
    • constrained prosthesis, chromium-cobalt alloy, pyrocarbons
    • PP head and articular base of MP (looks like a mini total knee)
    • Greater stability, likely higher complications, higher cost, ? long-term durability
  • Immobilize x 2/52, then limited ROM x 2/52 more (can be more aggressive with constrained implants
  • Advantages: preserve ROM (avg ROM post-op: 40’-60’ TAM)
  • Disadvantages: not full ROM/ ROM may deteriorate; compliance w/ therapy, implant failure, instability, deformity

18

describe use of arthrodesis for pipj oa

  • Arthrodesis – young, high demand patient, significant loss of bone, symptom relief, stability (preference for D2/3
  • Dorsal approach, splint extensor tendon and joint capsule; cup & cone vs osteotomies/rongeur
  • Plating is best. Alternatives – K-wire, screw, Fig of 8 tension band
  • Best for index +/- small (pinch, stability)
  • Advantage stable and reliable
  • Distadvantage: PIPJ contributes 85% to finger ROM and ~ 25% to hand flexion, loss of grip, NU/DU/MU

 

19

what is your differential for mono- arthritis of joints in hand?

MONOARTHRITIS

  • Crystal induced
  • Infection (acute, chronic)
  • Trauma, hemarthrosis
  • Osteoarthritis
  • Foreign body
  • Pigmented villonodular synovitis
  • Joint neoplasms
  • Aseptic necrosis
  • Osteochondritis dissecans
  • Mechanical internal derangement
  • Sarcoidosis
  • Neuropathic (Charcot) joint
  • Onset of polyarthritis

 

20

describe XR finding in psoriatic arthritis

  • Imagingosteolysis, pencil in cup (typically DIP), arthritis mutilans (osteolysis hand with collapse), ankyloses
  • Distal to joint = bone proliferation; proximal side joint = bone wasting

21

what is presentation for psoriatic arthritis?

  • Presentation – psoriasis, joint pain/stiffness >30 mins in AM, relieved with activity
  • Classic PE – psoriatic plaque, distal & asymmetric, nail lesions (pitting, onycholysis); PIPJ 95% (flexion deformity, no boutonniere), polyarthritis 25%, DIP 5%
  • Associated features: enthesitis, dactylitis (fusiform), pitting edema, uveitis

22

what is your treatment approach to psoriatic arthritis?

  • Medical – NSAIDS, steroids (systemic), DMARDs (MTX, penicillamine)
  • Surgical (rare) – synovectomy/tenosynovectomy, tendon release/repair/transfer (DIP usually autofuses; PIP fusion, MCP arthroplasty, fusion/bone graft arthritis mutilans to maintain length

23

what is the classic presentation and diagnostic criteria for lupus arthritis

  • Presentation – F>>M, onset 15-25yo, black>white, morning stiffness, pain, +/- Raynaud’s
  • Classic PE – Erythematous maculopapular eruption fingers & palm, symmetric joint swelling & pain, tenosynovitis
  • Joint deformities – see below (ligamentous and volar plate laxity, tendon subluxation
  • 11 criteria: Serositis, oral ulcers, arthritis, photosensitivity, blood (pancytopenia), renal disorder (proteinuria), ANA+, immunologic (anti-dsDNA, anti-Smith, APLA), neurologic (seizures, psychosis), malar rash, discoid rash

24

discuss treatment approach to lupus arthritis

Treatment

o  Medical – Rheum/Medicine, NSAIDS, steroids, hand therapy & splints (to delay surgery)

o  Surgical – soft tissue procedures (extensor tendon relocation & tenodesis) – do not provide long-term results; selective arthrodesis is often the best choice

 

Wrist

MCP

PIP

DIP

Thumb

Deformity

Caput unlna

- SL dissoc.

- Radial dev

- Ulnar trans carpus

- Dorsal sublux ulna

- Ulnar deviation PP

- Volar subluxation PP

- Ulnar subluxation EDC

- Hyperextension

- Flexion

- Lateral deformity

- Hyperextension

- Flexion

- Lateral deformity

- MP hyperextension

- Lateral subluxation at distal joint

- Subluxation of extensor tendons

Mgmt.

- Limited & total wrist fusion

- (Darrach w/ ECU stabilization)

- Swanson arthroplasty

- Extensor tendon relocation

- Early – soft tissue re-alignment

- Late – arthrodesis

- Early – soft tissue re-alignment

- Late – arthrodesis

- EPL rerouting

- Arthrodesis in 15-20° flexion

25

describe classic presentation of gout

  • Presentation – M>>F, ↑ with age
  • Classic PE – MTP great toe most common (acute monoarticular inflammatory condition), exquisitely tender, tophi
  • DDx – sept arth, suppur tenosynovitis, RA, cancer
  • Labs – CBC, serum urate, Xray, urine (crytals), Joint aspirate --> gout = negatively birefringent crystals (polarized light)
  • Imaging – early – no change; late = punched out erosions or lytic areas with overhanging edges

26

describe classic presentation of scleroderma

  • Presentation – F>M, CREST --> Calcinosis, Raynaud’s, Esophageal dysfunction, Sclerodactyly, Telangiectasia
  • Classic PE – progressive PIPJ contracture, hyperextension MCPJ, 1st web contracture, extensor tendon rupture, soft tissue breakdown/ulcers/gangrene with exposed tendon/bone/joint

27

describe approach to treatment of scleroderma arthritis and hand problems

 Treatment

o  Medical – Rheum, D-penicillamine, MTX, interferon

o  Surgical – Avoid GA and tourniquet

§ Wound management to minimize infection

§ Optimize: vascularity, function, cosmesis, improve pain

 

DIP

PIP

MCP

1st Web

Deformity

Gangrene, tuft resorption

Fixed flexion deformity

Hyperextension

Contracture

Mgmt.

  • Fusion
  • Amputation if gangrenous, infected, osteomyelitis
  • Fusion: angle depends on MCPJ ROM

 

 

  • Resection of joint to overcome contractures
  • ± Arthroplasty
  • Release of thumb adductor, FTSG
  • Standard web release techniques

28

what is hypothenar hammar syndrome and classic presentation?

  • Thrombembolic occlusion or aneurysm UA à digital ischemia
  • Repetitive blunt palmar or hypothenar trauma
  • PE – Pain, cold sensitivity, sensory disturbances, hypothenar mass, dig ischemia, ulceration, abnormal Allen’s test

29

what is your approach to treatment of hypothenar hammar syndrome?

  • Conservative/Medical – vasodilation for acute ischemia (warm room, compresses, lidocaine plain injections, CCB, nitroglycerin paste; ↓ sympathetic tone (pain control, rest)
  • activity modification, cold protection, CCBs, quit smoking
  • Operative/interventional: thrombolysis, excision & ligation, excision & vein grafting

30