Osteoarthritis of the distal interphalangeal joint

Osteoarthritis occurs with the highest prevalence in the distal interphalangeal joint of the hand and has been divided into an erosive and a nonerosive form. The pathogenesis of the early stages of osteoarthritis is poorly understood, but considerable emphasis has been placed on the role of cartilage and subchondral bone as well as soft tissue structures such as collateral ligaments and tendons. Radiographic evaluation represents the most standardized method to quantify disease progression, with different systems having been developed for defining and grading radiographic features. This current concepts article examines the recent knowledge base regarding the etiology, pathogenesis, and evaluation of osteoarthritis of the distal interphalangeal joint.     

Hand osteoarthritis--a heterogeneous disorder

Hand osteoarthritis (OA) is a prevalent disorder. Hand OA is not one single disease, but a heterogeneous group of disorders. Radiographic signs of hand OA, such as osteophytes or joint space narrowing, can be found in up to 81% of the elderly population. Several hand OA subsets--such as nodal interphalangeal OA, thumb base OA and erosive OA--can be discriminated. Furthermore, the experience of symptoms and the course of the disease differ between patients. Studies that used well-defined study populations with longitudinal follow-up have shown that similarities and differences can be observed in the pathogenesis, epidemiology and risk factors of the various hand OA subsets. Erosive OA in particular, characterized by erosive lesions on radiographical images, has a higher clinical burden and worse outcome than nonerosive hand OA. Imaging modalities (such as ultrasonography) have increased our knowledge of the role of inflammation of the disease. Our understanding of the heterogeneous nature of hand OA can eventually lead to increased knowledge of the pathogenesis of, and ultimately new treatment modalities for, this complex disease.     

Intraoperative Fracture of a Pyrocarbon PIP Total Joint—A Case Report

Pain or dysfunction of the finger joints due to arthritis or traumatic injuries that fail medical management may necessitate arthroplasty or joint replacement. The goals of the finger joint implant arthroplasty are to relieve pain, to correct deformity, and to improve the function and appearance of the hand. Several prosthetic implants have been used for the replacement of the proximal interphalangeal (PIP) joint. Pyrocarbon materials, a form of pyrolytic carbon, a ceramic-like material, have proven to be strong, durable, resistant to wear and nonreactive in the body. The Ascension PIP pyrocarbon total joint is a bicondylar, anatomically shaped, articulating implant that allows joint flexion–extension, while providing some restriction of adduction–abduction motion. A review of the literature of pyrocarbon PIP prosthesis reveals little clinical data. The case of a 33-year-old man with posttraumatic arthritis proximal interphalangeal joint right long finger is reported. The case was treated surgically using the Ascension PIP total joint. During the insertion of the implant, the proximal component fractured at the sub-articular collar. The component was removed, and a new implant was inserted without complication. Critical evaluation revealed that there was an inadequate resection of the volar lip resulting in a stress riser on the implant during impaction. Careful attention to this technical point will hopefully minimize the occurrence of this complication as the availability and use of these implants increases.     

Distinguishing erosive osteoarthritis and calcium pyrophosphate deposition disease

Erosive osteoarthritis is a term utilized to describe a specific inflammatory condition of the interphalangeal and first carpal metacarpal joints of the hands. The term has become a part of medical philosophical semantics and paradigms, but the issue is actually more complicated. Even the term osteoarthritis (non-erosive) has been controversial, with some suggesting osteoarthrosis to be more appropriate in view of the perspective that it is a non-inflammatory process undeserving of the “itis” suffix. The term “erosion” has also been a source of confusion in osteoarthritis, as it has been used to describe cartilage, not bone lesions. Inflammation in individuals with osteoarthritis actually appears to be related to complicating phenomena, such as calcium pyrophosphate and hydroxyapatite crystal deposition producing arthritis. Erosive osteoarthritis is the contentious term. It is used to describe a specific form of joint damage to specific joints. The damage has been termed erosions and the distribution of the damage is to the interphalangeal joints of the hand and first carpal metacarpal joint. Inflammation is recognized by joint redness and warmth, while X-rays reveal alteration of the articular surfaces, producing a smudged appearance. This ill-defined, joint damage has a crumbling appearance and is quite distinct from the sharply defined erosions of rheumatoid arthritis and spondyloarthropathy. The appearance is identical to those found with calcium pyrophosphate deposition disease, both in character and their unique responsiveness to hydroxychloroquine treatment. Low doses of the latter often resolve symptoms within weeks, in contrast to higher doses and the months required for response in other forms of inflammatory arthritis. Reconsidering erosive osteoarthritis as a form of calcium pyrophosphate deposition disease guides physicians to more effective therapeutic intervention.     

New frontiers in hand arthroscopy

This article covers new and emerging techniques in small joint arthroscopy in the hand. Recent improvement in the quality of small joint scopes and advancement in techniques have allowed for many new small joint arthroscopic procedures in the hand. The arthroscopic classification for thumb carpometacarpal (CMC) arthritis as well as treatment of each stage are described. Arthroscopic treatment of pantrapezial arthrosis is reviewed. Metacarpophalangeal arthroscopy for the treatment of synovitis, arthritis, fractures, and gamekeeper injuries are discussed, as is arthroscopy of the proximal interphalangeal, pisotriquetral, fourth and fifth CMC, and distal interphalangeal joints.     

Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations

PURPOSE: Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach. METHODS: A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws. RESULTS: A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity. CONCLUSIONS: Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Volar plate arthroplasty for osteoarthritis of the proximal interphalangeal joint: a preliminary report

Osteoarthritis of the hand, including involvement of the proximal interphalangeal joint, is common in the aging population. The purpose of this study is to provide a preliminary retrospective report on 12 volar plate arthroplasties in 9 patients who had volar plate advancement arthroplasty for osteoarthritis of the proximal interphalangeal joint. The average age of the patients was 67.6 years. All of the patients' data were obtained from office notes and hand therapy assessment sheets. The average time from surgery to follow-up evaluation was 36.5 months. All patients had significant pain relief. Range of motion was maintained; there was no significant difference between preoperative and final arc of motion values. Preoperative pinch and grip strengths did not differ significantly from the final values. Postoperative position was similar to preoperative angulation, with recognized lateral stability. Our results suggest that volar plate advancement arthroplasty represents a good primary surgical therapeutic option for the osteoarthritic proximal interphalangeal joint, providing pain relief while preserving motion, strength, and stability.     

A cross-sectional study of the association between Heberden's nodes, radiographic osteoarthritis of the hands, grip strength, disability and pain

OBJECTIVE: To describe the associations between hand osteoarthritis (OA), pain and disability in males and females and to further validate the Australian/Canadian OA hand index (AUSCAN LK3.0). DESIGN: Cross-sectional study of 522 subjects from 101 Tasmanian families (males N=174, females N=348). Hand OA was assessed by two observers using the Altman atlas for joint space narrowing and osteophytes at distal interphalangeal and first carpometacarpal joints as well as a score for Heberden's nodes based on hand photography. Hand pain and function were assessed by the AUSCAN LK3.0 and grip strength by dynamometry in both hands on two occasions. RESULTS: The prevalence of hand OA was high in this sample at 44-71% (depending on site). Pain and dysfunction increased with age while grip strength decreased (all P< 0.001). All three measures were markedly worse in women, even after taking the severity of arthritis into account. Hand OA explained 5.7-10% of the variation in function, grip strength and pain scores, even after adjustment for age and sex. Further adjustment suggested that the osteoarthritic associations with function and grip strength were largely mediated by pain. Severity of disease was more strongly associated with these scores than presence or absence. Lastly, the AUSCAN LK3.0 showed a comparable association to grip strength with structural damage providing further evidence of index validity. CONCLUSIONS: Hand OA at these two sites makes substantial contributions to hand function, strength and pain. The associations with function and strength measures appear mediated by pain. Gender differences in all three measures persist after adjustment for variation in age and OA severity indicating that factors apart from radiographic disease are responsible.     

Rehabilitation for proximal phalangeal fractures.

Proximal phalangeal fracture stability is crucial for the initiation of early and effective exercises designed to recover digital and especially proximal interphalangeal joint motion. Active digital flexion and extension exercises are implemented by synergistic wrist motion. Joint blocking exercises and active tendon gliding exercises in protective blocking splints are instrumental elements of early treatment. Dynamic splinting and serial finger casting are used in recalcitrant, severe, and late presenting cases. Surgical release is a last resort in regaining proximal interphalangeal joint motion. This measure is reserved for a failure of treatment when residual proximal interphalangeal joint contracture is persistent and severe enough to cause serious impairment of digital motion and hand function.     

Treatment of Symptomatic Distal Interphalangeal Joint Arthritis with Percutaneous Arthrodesis: a Novel Technique in Select Patients

Arthrodesis of the distal interphalangeal (DIP) joint is a reliable means of achieving pain relief in a symptomatic DIP joint afflicted by a variety of degenerative, inflammatory, or posttraumatic conditions. Successful arthrodesis is more reproducible when rigid compression of the joint is achieved. The emergence of an increasing number of commercially available headless or variable pitch compression screws reflects the growing trend among hand surgeons to utilize rigid stabilization of the DIP joint so that motion at more proximal levels can be initiated immediately without affecting arthrodesis rates. Successful closed percutaneous DIP arthrodesis can be achieved in a patient with hypertrophic osteoarthropathy, passively correctable deformity, and patients at increased risk for perioperative soft tissue complications associated with open arthrodesis. We present a novel percutaneous DIP fusion technique utilizing a cannulated headless compression screw in a select group of patients. The sagittal plane diameters of the distal and middle phalanges are templated. Cannulated headless compression screws, 2.4 and 3.0 mm, with short or long terminal threads at the leading end of the screw are selected based upon patient-specific anatomic considerations. Pain-free status and radiographic fusion were achieved in both patients (gout arthropathy, n = 1; posttraumatic arthritis, n = 1) at an average of 6 weeks postoperatively. Our current indications, along with pearls and pitfalls with this technique, are reviewed. In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques.     

Osteoarthritis--epidemiology, economics and quality of life

Osteoarthritis (OA) is the most common form of arthritis and the most common indication for total hip and total knee replacement. It is an ageing-disorder which mostly affects distal interphalangeal joints, proximal interphalangeal joints, trapezo-metacarpal joints of the thumbs, knees and hips. Risk factors for the development and/or progression of OA identified in epidemiological studies can be broadly divided into systemic factors that increase the susceptibility to the disease and local biomechanical factors that influence the development of OA at the particular joint. It is estimated that costs associated with OA exceed 2% of the gross national product in developed countries. When it involves the hip and/or knee, OA accounts for more functional limitations and physical disability than any other chronic disease among adults.     

Manifestations articulaires associées à la présence de l’anticorps anti-Jo-1

Anti-Jo-1 antibody is associated with an overlap syndrome usually described as the association of idiopathic inflammatory myopathy, pulmonary fibrosis and polyarthritis. We report three observations illustrating different aspects of arthropathy associated with anti-Jo-1 antibody. Two patients presented with a deforming and erosive arthritis affecting the hands, periarticular calcifications and dislocation of the interphalangeal (IP) joint of the thumb. The third patient, who had a short disease course, presented only with a mild non erosive polyarthritis of both hands, metacarpophalangeal joint narrowing and periarticular calcifications. All the patients had interstitial pulmonary syndrome. Only two of them had myositis. An arthropathy characterized by erosive arthritis of the fingers, with dislocation of IP joint of the thumb and periarticular calcifications, seems to be specifically associated with anti-Jo-1 antibody.     

Proximal interphalangeal joint arthrodesis using the tension band technique

Arthritis and instability of the proximal interphalangeal (PIP) joints of the hand leads to chronic pain and decreased hand function. Proximal interphalangeal joint arthrodesis is an effective means of restoring hand function. The tension band technique is a reliable and cost-effective means of stabilizing the arthrodesis while allowing early hand motion. The dorsal tension band causes compression at the arthrodesis site during active motion, further facilitating healing. The technique is cost effective, using inexpensive pins and a wire. Complications include delayed union, pin protrusion from the bone, and painful hardware.     

Arthropathy associated with anti-Jo-1 antibody

Anti-Jo-1 antibody is associated with an overlap syndrome usually described as the association of idiopathic inflammatory myopathy, pulmonary fibrosis and polyarthritis. We report three observations illustrating different aspects of arthropathy associated with anti-Jo-1 antibody. Two patients presented with a deforming and erosive arthritis affecting the hands, periarticular calcifications and dislocation of the interphalangeal (IP) joint of the thumb. The third patient, who had a short disease course, presented only with a mild non-erosive polyarthritis of both hands, metacarpophalangeal joint narrowing and periarticular calcifications. All the patients had interstitial pulmonary syndrome. Only two of them had myositis. An arthropathy characterized by erosive arthritis of the fingers, with dislocation of the IP joint of the thumb and periarticular calcifications, seems to be specifically associated with anti-Jo-1 antibody.     

Instructional Course Lecture. Arthrodesis of the interphalangeal joints with headless compression screws

Interphalangeal arthrodesis is a reliable method of pain relief for arthritic proximal and distal interphalangeal joints in the fingers. Indications include osteoarthritis, acute trauma, chronic reconstruction for trauma, rheumatoid and other inflammatory arthritides, and at the distal interphalangeal joint, chronic mallet finger deformity and unreconstructible flexor tendon defects. Solid arthrodesis imparts stability to the digital skeleton. Headless compression screws can be reproducibly inserted and are a good method to provide fixation adequate to accomplish interphalangeal arthrodesis. Surgical technique involves a dorsal incision and preparing the skeleton for good bony apposition. Exact technique for screw insertion depends on the specific screw used. Union rates range from 85% to 100% in published studies, with time to union of 7 to 10 weeks.     

Ligament reconstruction and tendon interposition for advanced posttraumatic arthritis of the proximal interphalangeal joint: 3 case reports

Although prosthetic replacement of the proximal interphalangeal (PIP) joint can restore function, it is associated with high rates of complications and is considered unsuitable for active young patients. Resection arthroplasty of the PIP joint offers an alternative, but it requires adequate soft tissue integrity and cannot correct lateral instability. The authors present an alternative resection arthroplasty technique for the PIP joint, which includes collateral ligament reconstruction and tendon interposition using a free tendon graft. This procedure can be performed in advanced posttraumatic arthritis of the PIP joint and provides acceptable motion and adequate lateral stability.     

Ultrasonographic criteria for the diagnosis of erosive rheumatoid arthritis using osteoarthritic patients as controls compared to validated radiographic criteria

ObjectivesThe aims of this study were to compare characteristics of radiography (RX) and ultrasound (US) erosive lesions in rheumatoid arthritis (RA) and osteoarthritis (OA) patients (prevalence, topography and severity), to determine thresholds for the diagnosis of erosive RA based on US and to evaluate the performance of US and RX to establish a diagnosis of erosive RA differentiated from hand OA.MethodsPatients fulfilling ACR 1987 and/or ACR/EULAR 2010 criteria for RA or ACR hand OA criteria were prospectively included. A modified Sharp erosion score was assessed by two blinded readers and one adjudicator for discordant cases (number of eroded joints ≤ three). Erosions in US were scored on six bilateral joints (MCP2-3, 5; MTP2-3, 5) with a four-grade scale to calculate total US score for erosions (USSe).ResultsA total of 168 patients were included: 122 RA (32 early RA < 2 years; 90 late RA ≥ 2 years); 46 OA patients. On RX: 42 RA patients (6 early; 36 late) and 5 OA patients were eroded according to EULAR 2013 definition criteria with sensitivity at 34.4% and specificity at 89.1%. On US, 95 RA patients (21 early; 74 late) and 12 OA patients were eroded. Considering at least two joint facets eroded or at least one joint facet eroded at grade 2 on US, sensitivities were good (68–72.1%) and specificities excellent (89.1–100%). Agreement between RX and US was excellent (90–92%). The positive and negative likehood ratios were respectively 3.16 and 0.73 for radiography and 6.64 and 0.31 for US (for two facets eroded).ConclusionUSSe can differentiate RA from OA in erosive disease and detect two times more patients with erosive RA than RX with excellent specificity and agreement.     

Implant arthroplasty of the metacarpophalangeal joint of the thumb

Thumb metacarpophalangeal arthritis may affect overall hand function more than expected because pain and instability compromise pinch and grip strength. Implant arthroplasty represents one option in the treatment of deformity, destruction, and instability at the metacarpophalangeal joint level. Appropriate use of implant arthroplasty requires careful evaluation of the overall deformity and the status of the interphalangeal joint. If the interphalangeal joint is likely to require fusion--either simultaneous with metacarpophalangeal surgery or subsequently--then implant arthroplasty may be the best treatment option for the metacarpophalangeal joint.     

Hand osteoarthritis and bone mineral density in postmenopausal women; clinical relevance to hand function, pain and disability

OBJECTIVE: The aim of the present study was to assess phalangeal bone mineral density (BMD) in postmenopausal females with hand osteoarthritis (OA) and to correlate the measured levels with the radiographic OA grade, pain, function and disability of the hand. METHODS: The study group constituted 40 postmenopausal women with hand OA (range; 45-83 years). Socio-demographic data were collected. They underwent a comprehensive clinical examination of joint status and health outcome measure including Australian Canadian (AUSCAN) OA hand index. Hand radiographs were quantified and graded according to Kellgren and Lawrence (K-L) scoring system. Bone mineral content (BMC) and BMD of the third finger were measured using the accuDEXA (Schick, New York, NY). Twenty females matched for age and years of menopause were studied as a control group. RESULTS: Phalangeal BMC and BMD were significantly reduced in women with hand OA compared to controls and related to radiological erosive OA. The AUSCAN pain and function subscales were worse in proportion to the severity of hand OA. OA X-ray score was significantly associated with reduced right grip strength, pain, and function scales while, decreased BMD was related to Ritchie index and pain scale. CONCLUSION: Postmenopausal women with clinical and radiological hand erosive OA are at risk of development of hand osteoporosis (OP). Phalangeal bone densitometry is an objective reproducible investigation. Poor physical function due to increased pain associated with increasing severity of radiographic hand OA leads to worse BMD results.