Hand and wrist OA is a common condition that affects patients of varying ages, most typically in middle to older age individuals. It is most commonly seen in patients older than 65 years, and incidence is much higher in women than in men. This gender difference is thought to be related to hormonal influences on the ligamentous support of joints leading to laxity and increased early joint wear. Of the population affected by OA, less than 2% are younger than 45 years, around 30% are between 45 and 64 years, with the remainder being older than 65 years. OA can be classified as either primary or secondary. Primary means idiopathic and is associated with genetic factors combined with cartilage aging secondary to mechanical forces. Secondary means there has been a causative factor which would be trauma, joint infection, or repetitive minor injury. These factors may lead to arthritis through joint instability, abnormal loading, or direct cartilage damage.1,2
2. Neogi T, Zhang Y. Epidemiology of osteoarthritis. Rheum Dis Clin North Am 2013;39(1):1–19 The pain experienced by patients with OA of the upper limb is variable. It can be constant or intermittent and ranges from a dull ache to a sharp pain. Pain typically occurs with joint loading and repetitive movement, and it is often better in the morning and worse at night after a day’s activities. This is in contrast to rheumatoid arthritis which tends to be more painful in the morning and associated with stiffness that improves as the day progresses. OA frequently affects sleep patterns, and this can be a key factor in determining when surgical intervention is warranted. Subjective weakness is common and may result from a combination of pain and reduced range of motion. OA symptoms such as weakness may be exacerbated by coexisting conditions: for example, many patients, particularly those with first carpometacarpal (CMC) joint arthritis, also have carpal tunnel syndrome.1
Although distal interphalangeal (DIP) joints are the joint most commonly affected by OA in the upper limb overall, the most commonly affected joint in the first ray is the CMC joint rather than the interphalangeal (IP) joint. When considering treatment for first CMC joint arthritis, it is important to look at the scaphoid–trapezium–trapezoid joint at the same time, because there may be disease between the scaphoid and trapezoid that could lead to persistent pain after trapeziectomy if it is not addressed.1 The first ray can be regarded as a column based on the radial aspect of the radius from scaphoid, through trapezium, into the metacarpal and phalanges. The midcarpal joint is adjacent to, rather than a component of, this column.
Heberden’s nodes are found at the DIP joint in patients with OA, while Bouchard’s nodes are located over the PIP joint. They both represent strong markers for underlying IP joint OA and are a familial trait. They were traditionally thought to represent osteophytes but may actually represent traction spurs due to repetitive loading. Heberden’s and Bouchard’s nodes are sometimes painful and can also be associated with ganglia and mucous cysts. Other characteristic findings in the osteoarthritic hand include swelling and deviation of the digits, particularly at the IP joints and less frequently at the MCP joints. There is usually a reduction in both active and passive joint motion which may be associated with ligament instability or pain.1 Nodules in the palm are more common with Dupuytren’s, trigger finger, or a flexor sheath ganglion. Nodules around the olecranon are associated with rheumatoid arthritis.
The classic radiographic features of OA are joint space narrowing, subchondral sclerosis, and osteophyte formation (see Fig. 99.1, Essentials of Plastic Surgery, third edition).1 However, the earliest sign is actually joint space widening secondary to inflammation causing an effusion. An example of how these stages are used in classifying osteoarthritic changes is in the Eaton–Littler classification of thumb CMC joint OA.2 In advanced cases, joint subluxation may occur. Periarticular erosions are associated with rheumatoid arthritis. Progressive subchondral sclerosis can lead to eburnation, which is the degeneration of bone into a hard, ivory-like mass as seen in OA. It explains why breaking up the trapezium during a trapeziectomy can sometimes seem to be disproportionately difficult.
For patients with suspected OA of the first CMC joint, plain radiographs of the hand and wrist in the anteroposterior (AP), lateral, and oblique planes are commonly ordered. Additional views can also be helpful1; for example, Robert’s view is a true AP view of the thumb and is taken with the hand in hyperpronation and the dorsum of the thumb against the cassette, which allows visualization of all four articulations of the trapezium. Eaton’s posteroanterior (PA) stress views are taken with the thumbs pressed together and may be useful to assess increased CMC joint laxity. Bett’s/Gedda’s view is a PA taken in pronation and flexion that gives a true lateral view of the trapeziometacarpal joint. The other trapezial articulations are also clearly demonstrated. Waters’ and Towne’s views are both craniofacial radiographs used in the assessment of facial trauma injuries.
affected? The first CMC joint is a biconcave saddle joint that allows flexion, extension, and opposition at the thumb base. It has an important role in a number of key power grip functions. It is normally a very stable joint with 16 described ligaments supporting it. The most important of these are thought to be the dorsoradial and deep anterior oblique ligaments.1 The first CMC joint is very commonly affected by OA which can develop with advancing age, hormonal influences, or posttrauma.2 Key findings in the clinical history are pain with or without swelling, a weak lateral pinch (pulling pants up or holding large objects/book) and a weak grip (opening jars/door knobs). Physical examination will likely demonstrate thumb metacarpal adduction into the palm and dorsal subluxation of the CMC joint, with or without compensatory MCP joint hyperextension. Pain is typically induced by distraction and torque, or joint loading.
The presence of OA in the hand can present a number of problems for the patient. The most important of these, and the primary reason for undergoing surgery, is pain. This is also true of other joints such as the hip, knee, and shoulder. There may also be loss of function due to stiffness, deformity, and reduced range of joint motion. The overall aim of surgery is to gain a functional advantage for the patient; therefore, there should be a clear goal for each procedure. Two main approaches exist: arthrodesis and arthroplasty. Neither procedure will usually improve range of motion, although the relief of pain following surgery sometimes can increase the useful range at a joint (e.g., thumb base). At best, an arthroplasty will usually provide a similar amount of motion as presurgery but without pain, and arthrodesis will obviously limit movement but relieve pain. Aesthetics are down the list in terms of importance when compared with pain and function for most patients in relation to hand OA, although this is certainly not always the case.1–3
There are a number of nonsurgical interventions that may be useful in managing OA of the hand. DMARDS, such as methotrexate, leflunomide, and sulphasalazine, have not been shown to offer any significant improvement in pain in this patient group. DMARDS are best reserved for other hand conditions such as rheumatoid arthritis. First-line treatment for hand OA is rest and heat. Heat is typically applied by placing the hand in water or wax twice daily, usually initially guided by a hand therapist. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, or meloxicam can be useful for managing the symptoms of OA; however, caution should be exercised in those with peptic ulcers or asthma, and in the older population where comorbidities may mean NSAIDs are contraindicated. Both topical and systemic NSAIDs have a role. Opioid medications should be minimized where at all possible due to their addictive properties and side effects. Splinting at night can be beneficial for some patients to offload involved joints and relieve sleep disturbance due to painful joint movements. Range-of-motion exercises must be maintained to optimize the movement in associated joints and to avoid deconditioning of muscles. Intra-articular steroid injections can reduce pain in OA and these are often delivered with radiological guidance. Other treatments that have been tried include autologous fat injections and hyaluronic acid injection. There is some limited evidence of the effectiveness of these interventions.1,2
This woman has radiographically advanced disease according to Eaton’s classification, and is likely to need surgical intervention at some point in the future. However, symptoms do not always correlate with radiologic findings, and nonoperative measures should be explored fully in the first instance. The next step in her management is to trial one or more intra-articular steroid injections. Image guidance can be very helpful in ensuring accurate steroid placement (particularly in the presence of subluxation and osteophyte formation). Eaton’s classification may be used to grade the radiographic changes observed in OA and originally included four grades (Table 99.1). Grade IV disease involves degenerative destruction of both the first CMC joint and the ST joint. In this scenario, surgery that only addresses the CMC joint will not resolve the patient’s symptoms; therefore, neither CMC joint arthroplasty nor CMC joint fusion is appropriate for this woman. The likely surgical procedure of choice would be a trapeziectomy, and if this is performed, the remaining interface between the scaphoid and trapezoid must be inspected, since there is a likelihood of arthritic changes here too that can lead to persistent pain if left untreated. There is no consistent evidence that LRTI is superior to simple trapeziectomy alone in general. However, there are scenarios where one is more appropriate than the other and most surgeons base their choice upon factors such as functional demands of the patient, best results in that surgeon’s hands, and intraoperative instability of the metacarpal following trapeziectomy alone.1,2 Table 99.1 Eaton’s Radiographic Stages of CMC Joint Degeneration1 Stage Radiographic Findings I Normal articulations with widening of joint space suggestive of an effusion, less than one-third CMC joint subluxation II Slight narrowing of the thumb CMC joint, minimal subchondral sclerosis, debris/osteophytes <2 mm diameter, more than a third of CMC joint subluxation III As per stage II, increased sclerosis, subchondral cysts, debris/osteophytes >2 mm diameter IV As per stage III, with narrowed ST joint demonstrating sclerosis and cysts V Pantrapezial arthritis CMC, carpometacarpal; ST, scaphotrapezial.
First CMC joint instability can occur in young healthy females who may present with painless, but visible, joint subluxation on thumb loading. Radiographs at rest may be normal, but on pushing the thumbs together during imaging, the dynamic changes may be revealed. Sometimes pain can prevent good stress-view imaging in more severe cases. In first CMC joint laxity, reconstruction of the joint capsule and volar ligamentous support using a partial flexor carpi radialis (FCR) sling has shown good results in many patients, although the procedure is not recommended in the presence of Eaton’s grade II–IV arthritis, as the joint surface is not addressed.1 Some authors have also described good results in patients with early joint changes using extension osteotomy of the metacarpal to alter joint biomechanics.2 Patients with isolated first CMC joint degenerative changes can respond well to CMC joint fusion, but that would not be the first-line option in this case provided she has good articular surfaces when inspected. Likewise, a trapeziectomy is not warranted in this scenario as the degenerative process is too mild and there are less aggressive options available. When a trapeziectomy is performed, the degree of metacarpal collapse should be assessed after removal of the trapezium. If there is a good endpoint on loading the thumb axially without abutment against the scaphoid through a range of wrist movements, there is no definitive evidence that a ligament reconstruction with or without a tendon interposition procedure is likely to give additional benefit.3 Pyrocarbon hemi-arthroplasty is an option in some patients with severe isolated thumb CMC joint OA. Implant survival rates of 80% have been reported4 and favorable results in stage III and early-stage IV have also been described.5
The MCP joints of the fingers are not commonly affected by symptomatic OA unless, as in this case, the condition is secondary to trauma. The best surgical option is usually arthroplasty in order to preserve joint range of motion, in contrast to the thumb where arthrodesis is usually most successful and well-tolerated. Given that this patient is young, a pyrocarbon arthroplasty is preferable to a Silastic joint as it will have greater stability and should have more long-term component integrity. Silastic implants are usually reserved for older patients with poor soft-tissue stability and lower physical demands. They are most commonly used in rheumatoid arthritis. Steroid injection is only likely to give a very limited, short-term response for this patient, given the extent of his joint disease. A ray amputation would be less favorable in terms of both aesthetics and function in this scenario but might be more relevant if there were other additional problems with the ray related to the original injury.1,2
While arthrodesis and steroid injections are widely employed, arthroplasty for the PIP joint is less common. Patient selection and technical excellence are critical for successful PIP joint pyrocarbon arthroplasty and index finger disease is a good indication. A silicone/Silastic implant is unlikely to be able to withstand the lateral stresses through the dominant index finger during pinch and key grips. For these reasons, many surgeons would choose arthrodesis over arthroplasty for the border digits. Good results have been reported following denervation procedures for some small joint arthritis.1–3
The DIP joint is the most commonly affected joint in OA and if arthrodesis is performed, the joint is usually fixed in 0 to 10 degrees of flexion, although more angulation is sometimes preferred in the index finger and the angle selected should take into account individual functional demands (see Fig. 99.3, Essentials of Plastic Surgery, third edition). DIP joint angles of fusion are therefore generally less than those for the PIP joints, which are usually fused between 20 and 40 degrees of flexion, depending on the digit and functional requirements of the patient. In reality, the DIP joint is frequently asymptomatic in OA and clinical and radiological deformities are often unrelated to symptoms. As such, surgery is often not required. A cheilectomy is one surgical option that involves debridement of the osteophyte and joint preservation. Notta’s node refers to a nodule on the thumb of an infant causing triggering of the flexor tendon. It is accredited to the French physician Alphonse Notta who first described the condition of trigger finger. It is Heberden’s nodes that are associated with DIP joint OA. These bony swellings are commonly observed but do not usually require treatment. Nail deformity is often seen in DIP joint OA and is usually related to a mucous cyst. A mucous cyst is a small ganglion associated with DIP joint OA, and surgical excision may be warranted due to pain, impending rupture risking infection, or nail deformity. When this is performed, the use of an H-shaped or Y-shaped incision over the dorsum of the DIP joint can facilitate access to the full extent of the ganglion and debridement of osteophytes. When an area of skin loss is anticipated, a dorsal advancement flap may be useful.1–4