Deforming osteoarthritis of the interphalangeal joints of the hands

Among the many types of joint pathologies that eventually lead to a complete loss of cartilage tissue in the joint, deforming osteoarthritis of the interphalangeal joints of the hands is one of the most common. The frequency of such a disease increases with age, and the manifestations are quite different - from periodic moderate pain and stiffness to complete loss of hand function. In the early stages, the disease is not badly succumbed to drug therapy. [1]

Epidemiology

To date, the main source of pain in the joints of the fingers is considered to be deforming osteoarthritis. Pathology is predominantly found in men over 45 years of age and in women over 55 years of age. Women are more often affected (approximately twice as often).

In the post-Soviet countries, deforming osteoarthritis affects about 17-18% of the population.

The pathology affects primarily load-bearing joints, and therefore often becomes a major cause of early disability.

Most patients have multiple lesions of the interphalangeal joints. The disease manifests first in the metacarpal joint, and osteoarthritis of the index finger most often appears in the metacarpophalangeal and interphalangeal joints. [2]

The middle finger of the upper extremity is usually affected only at the interphalangeal joint, the ring finger at the metacarpal-wrist joint and the first interphalangeal joint, and the little finger at the first interphalangeal joint. [3]

Causes of the osteoarthritis of the interphalangeal joints of the hands

Deforming osteoarthritis of the interphalangeal joints of the hand is considered an age-related pathology, as it is found mainly in people over 55-65 years of age. Therefore, the probability of developing the disease increases significantly over the years. There is an assumption that the lesion of the interphalangeal joints of the hand occurs against the background of slowing down of metabolic processes due to natural age-related changes in the body. [4]

Cartilage structures of small interphalangeal joints begin to suffer from a lack of nutrients, moisture, and oxygen. Foci of erosions appear on the joint surfaces, the thickness of the cartilage layer decreases, the articular gap narrows. But the destruction of cartilage is the main, but not the only pathological process. Bone heads are subjected to destruction, the articulation is deformed, an inflammatory reaction joins. The development of the disease is facilitated by:

• frequent traumatic finger injuries;
• playing certain sports;
• congenital defects in joint structure;
• infections, endocrine and autoimmune diseases, gout;
• hypothermia of the hands;
• hormonal changes (especially often in women with the onset of menopause);
• severe stress.

The involvement of genetic traits is considered so far only as a theory. [5]

Risk factors

Factors in the development of deforming osteoarthritis of the hand joints may be as follows:

• Older age (55 years or more);
• occupational stresses on the upper extremities, hands and fingers;
• unfavorable working conditions, regular exposure to cold, vibration, etc..;
• Traumatic finger injuries, including fractures, dislocations, and contusions;
• Hereditary joint and connective tissue diseases;
• metabolic disorders;
• hormonal imbalance;
• chronic pathologies in the body, infectious and inflammatory processes, etc. [6]

Pathogenesis

One of the most valuable functions of cartilage is the adaptability of the articulation to mechanical friction and stress. In a healthy person, cartilage has two basic components: connective tissue matrix and chondrocytes, which maintain a balance between catabolic and anabolic reactions. With the development of deforming osteoarthritis, this balance is disturbed: catabolic reactions begin to dominate. Proinflammatory cytokines, which influence the production of proteolytic enzymes by chondrocytes and cause degeneration of proteoglycans and collagen, play a significant role in this process.

In addition, in deforming osteoarthritis, there is excessive production of cyclooxygenase-2. This is an enzyme that promotes the production of prostaglandins, which are involved in the development of inflammatory response.

These processes can be triggered by traumatic or inflammatory damage, dysplasia (congenital pathology). Some "contribution" is also made by such factors as unfavorable inheritance, obesity, old age, as well as peculiarities of profession and lifestyle. [7]

Symptoms of the osteoarthritis of the interphalangeal joints of the hands

The main first signs of developing deforming osteoarthritis of the interphalangeal joints of the hands are pain, curvature and stiffness in the fingers. Patients go to the doctor in most cases only after the appearance of severe and constant pain, although it is necessary to start treatment in the asymptomatic period, when there is only slight discomfort and "disobedience" of the fingers of the hand. Over time, the pain syndrome begins to bother not only after daytime physical activity, but also at rest - including at night.

In patients with deforming osteoarthritis of the interphalangeal joints, the pain syndrome is characterized by heterogeneity and may have different mechanisms of onset. Thus, discomfort can be caused by inflammatory reaction, osteophytes, ligament or bursa stretching, spasm of periarticular muscles, etc.

Specialists distinguish several types of pain syndrome in deforming osteoarthritis:

• Mechanical pain appears as a result of daytime physical activity and subsides during a quiet state. This phenomenon is caused by a decrease in the shock-absorbing properties of cartilage and other involved structures.
• Continuous dull night pain is due to venous stasis in the subchondral bone segment and increased intraosseous pressure.
• Short-lasting "starting" pain (10-20 minutes) appears immediately after starting movements after a prolonged quiet period (e.g., after sleeping), and subsequently subsides. This phenomenon is due to friction of joint surfaces, on which bone and cartilage destructive particles linger.
• Persistent pain is associated with reflex spasticity of nearby muscle structures and the formation of reactive synovitis.

Deforming osteoarthritis of the distal interphalangeal joints (so-called Heberden's nodules) is characterized by the formation of pea-sized bony marginal growths. Osteophytes are found from the first to the third fingers of the hand on the outer-lateral articular surface. Pathological manifestations usually start with an inflammatory reaction, patients talk about pain, the appearance of thickening, usurations.

Deforming osteoarthritis of the proximal interphalangeal joints (so-called Bouchard's nodules) is accompanied by osteophytic growths localized on the lateral joint parts, which gives the fingers a characteristic spindle-shaped configuration. This pathology is often mistaken for rheumatoid arthritis.

The erosive form of osteoarthritis of the proximal and distal interphalangeal joints develops somewhat less frequently.

Stages

To date, they speak of three stages of the course of the disease.

• Deforming osteoarthritis of the hands of the 1st degree is not accompanied by any significant morphological disruption of the articular structures. The problem affects only the functionality of the synovial membrane and the biochemical composition of the intra-articular fluid that nourishes cartilage tissue and menisci. It is noted that the joints gradually begin to lose the ability to withstand the load placed on it. Adaptation of the articulation is disturbed, overloads occur, an inflammatory reaction develops, and the first pains appear.
• Grade 2 deforming osteoarthritis of the hands is characterized by initial manifestations of menisci and cartilage destruction. The bone structure "responds" to the resulting overload by forming marginal growths - osteophytes, which further aggravates the impairment of function and pain syndrome.
• Deforming osteoarthritis of the hands of the 3rd degree is manifested by increasingly pronounced deformation of the articular surfaces, changes in the axis of the fingers. Ligaments become incomplete, shortened, joints acquire pathological mobility, and when the density of bursa increases, contractures - sharp motor limitations - occur.

Complications and consequences

Deforming osteoarthritis of the interphalangeal joints of the hand progresses constantly, but relatively slowly. If you contact doctors in time and fulfill all their appointments, the course of the disease can often be significantly slowed down, preserving the mobility of the fingers for many years. If you ignore treatment, then it is possible to form irreversible changes:

• a severe curvature of the fingers;
• reduction of motor capacity to complete ankylosis of the interphalangeal joints of the hand;
• shortening of the hand, deformities.

If we take into account that in most cases, not one but several joints are affected, the functions of the upper limbs are severely limited.

Diagnostics of the osteoarthritis of the interphalangeal joints of the hands

The diagnosis of deforming osteoarthritis of the interphalangeal joints of the hand is confirmed by a characteristic X-ray picture:

• asymmetrical narrowing of the articular spaces;
• The presence of marginal bone growths and subchondral cysts;
• subchondral sclerosis;
• occasionally a curvature of the bony epiphyses.

However, not all instrumental diagnostics is indicative. For example, X-rays and CT scans do not show the cartilage itself, the disturbance in which causes the pathology. The state of cartilage tissue is assessed only with the help of MRI. Magnetic resonance imaging is informative at any stage of the disease, even in the early stages, when radiological signs are absent, but the symptoms are already present.

However, arthroscopy is undoubtedly the most informative diagnostic method. Using a microscope and a special probe, the surgeon accurately determines the extent of cartilage damage:

• Grade 1 - softening of the cartilage when touched with a probe is noted;
• Grade 2 - small cracks and lesions on the cartilage surface are visualized;
• Degree 3 - cartilage tissue particles sag 2-3 mm;
• Grade 4 - the cartilage layer is completely absent, the bony surface is unprotected.

Laboratory tests do not carry any significant informative load in the detection of deforming osteoarthritis of the interphalangeal joints of the hand, but can be prescribed as part of the differential diagnosis.

Differential diagnosis

Diagnostic criteria in the diagnosis of deforming osteoarthritis of the interphalangeal joints of the hand:

1. Prolonged pain, motor stiffness.
2. Bony growths in two or more joints.
3. Less than two swellings at the metacarpophalangeal joints.
4. Bony growths including in two distal interphalangeal joints or more.
5. Distortion of one or more joints.

In patients with suspected deforming osteoarthritis of the interphalangeal joints of the hand, psoriatic arthritis, rheumatoid arthritis, hemochromatosis, and gout should be excluded. The conclusion is formed according to the typical symptom complex.

Treatment of the osteoarthritis of the interphalangeal joints of the hands

The main directions of therapeutic action in deforming osteoarthritis of interphalangeal joints of the hand:

• pain relief;
• improvement of performance of the affected joints, preservation of motor capabilities;
• inhibition of the aggravation of the pathological process, prevention of the development of complications.
• Comprehensive treatment involves the use of such methods:
• medications (non-steroidal anti-inflammatory drugs, Paracetamol, chondroprotectors);
• non-medication (physiotherapy, balneotherapy, physical therapy, massage, etc.);
• surgical methods (arthroplasty, etc.).

Medications

External preparations in the form of ointments and creams have analgesic and anti-inflammatory effect, help to get rid of intense clinical manifestations and improve the patient's condition. Most local remedies improve blood circulation, favor regenerative processes in tissues. With deforming osteoarthritis of the interphalangeal joints of the hand, the most commonly used external remedies are:

• Voltaren Emulgel - a preparation of diclofenac - relieves pain, eliminates swelling, increases mobility of the affected joint. Gel is applied to the affected interphalangeal joints of the hand up to 4 times a day, for no more than 14 consecutive days. Analog - external preparation Diclac-gel, Diclofenac gel.
• Viprosal B is an analgesic and anti-inflammatory agent based on viper venom. The ointment is used on externally intact skin, applied twice a day. Beforehand, it is necessary to check whether the patient is not allergic to the components of the drug.
• Naiz gel is an external preparation of nimesulide, reduces pain and morning stiffness. Frequency of use - up to 4 times a day, for two weeks. Possible side effects: itching, peeling, temporary discoloration of the skin (does not require withdrawal of the drug).
• Apizartron - ointment based on bee venom, used 2-3 times a day until persistent relief of symptoms. Contraindications: hypersensitivity reactions, allergy to bee products. Possible allergic reactions, skin irritation, contact dermatitis.
• Nikoflex - means with capsaicin, has a warming, vasodilating, distracting property. In the absence of allergy to the components of the ointment is applied to the affected fingers focally, once or twice a day. The duration of therapy is individual.
• Butadione - ointment with phenylbutazone, used for rubbing 2-3 times a day. It has no systemic action, may cause redness, rash on the skin in the area of application.

Additionally prescribe and oral medications that have anti-inflammatory, anti-edema and analgesic effect:

• Indomethacin - taken orally with food, without chewing, 25 mg 2-3 times a day (in the acute period - up to 50 mg three times a day). Side effects from the digestive system are possible, which is more typical for prolonged use.
• Ibuprofen - suitable for short-term use. It is taken in the amount of 20-30 mg/kg body weight per day (1-2 tablets every 6 hours), but not more than 6 tablets within 24 hours. If the dosage is exceeded, abdominal pain, dyspepsia, gastritis, ulcerative stomatitis, pancreatitis, perforation may occur.
• Ketorolac - taken orally, once or repeatedly (short-term) in the amount of 10 mg not more than 4 times a day. Possible side effects: headache, drowsiness, hyperactivity, psychosis, dizziness.
• Nimesulide - is prescribed based on the recommended dosage of 100 mg twice a day after meals. With prolonged use, it is possible to develop hepatotoxic manifestations - intrahepatic cholestasis, acute liver failure (incidence of development - 1 case per 10 thousand patients).
• Etoricoxib - taken orally, the dosage is determined by a doctor individually. The most probable side effects: edema, gastroenteritis, anxiety, appetite changes.

As auxiliary agents that promote the restoration of damaged structures of the interphalangeal joints, prescribe multivitamin complexes and chondroprotectors:

• Structum is a preparation of sodium chondroitin sulfate. It is taken 1 capsule (500 mg) twice a day for a long time (it has an accumulative effect). Among the likely side effects: dizziness, diarrhea, skin rash, edema.
• Teraflex is a complex remedy, which contains glucosamine sulfate, sodium chondroitin sulfate, ibuprofen. It is prescribed by a doctor according to an individually designed scheme.
• Dona is a preparation of glucosamine sulfate, with prolonged use promotes the restoration of cartilage tissue and the volume of intra-articular fluid. Dosage is individualized.

In case of intense intra-articular changes and pronounced clinical symptoms, the use of antispasmodics and myorelaxants, as well as glucocorticosteroids is possible. [8]

Physiotherapy treatment

Physiotherapy procedures help to stop the development of inflammation, relieve swelling and improve the patient's well-being. Thanks to some procedures, it is also possible to activate the repair reactions of damaged cartilage and slow down further progression of osteoarthritis.

Often patients with deforming osteoarthritis of the interphalangeal joints are prescribed UHF therapy. The procedure involves exposure of the fingers to an artificial electric field, pulsed or continuous. During the therapeutic session, tissues are heated, blood circulation improves, trophism normalizes. The course is from 12 to 15 sessions, which contributes to a prolonged remission of osteoarthritis.

Another common method is laser therapy, which reduces swelling, eliminates pain, and prevents the formation of bone growths. The average duration of one session is up to 30 minutes. The therapeutic course includes up to 15 procedures.

Electrophoresis is successfully used to transport medications directly to the joint tissues. First, special pads are wetted in the appropriate medication solution, which are then applied to the affected joints. Further, with the help of electrodes, an electric field is created, adjusting the strength of the current. A course of treatment will require up to 15-20 sessions.

As part of spa treatment, it is possible to use radon, hydrogen sulfide, mud baths. An integrated approach allows to achieve a stable and prolonged remission. [9]

Herbal treatment

Phytotherapy is a good addition to the traditional treatment of deforming osteoarthritis of the interphalangeal joints. Medicinal plants have a unique therapeutic effect and enhance the effectiveness of many drugs. It is necessary to consult with the attending doctor beforehand.

A good effect is expected from compresses based on cabbage leaf. The leaf can be applied raw, or heated over steam and smeared with honey. The cabbage is fastened with cellophane or foil, fixed on top with a scarf or cloth, kept overnight. Duration of treatment - daily for several weeks (until persistent improvement of health).

No less effective ointment based on cabbage juice, honey, mustard and alcohol. All components are mixed in equal proportions. The prepared ointment is carefully treated with the affected articulations, insulated and kept for several hours (you can make bandages at night).

You can apply fresh horseradish leaves by wrapping each affected finger with them.

Surgical treatment

Endoprosthesis placement of the interphalangeal joints of the hand is indicated for patients who have severe deforming osteoarthritis.

Contraindications to surgery include:

• systemic or local pathologies in the acute phase;
• osteoporosis, bone destruction preventing reliable fixation of the prosthesis;
• muscle atrophy in the area of the intended intervention;
• severe blood disorders in the hand.

The surgical intervention involves two stages:

1. The surgeon restores the normal length of the finger, eliminates dislocation or subluxation (if present), scar tissue, etc.
2. The specialist performs the endoprosthesis by making an arc-shaped or wavy incision on the outer lateral articular surface, opening the capsule longitudinally, and separating the end segments of the articulating phalanges. Next, he removes the head of the proximal bone and the base of the middle phalanx (when endoprosthetizing proximal interphalangeal joints). The prosthesis is inserted into the enlarged medullary canals.

The quality of the operation is determined by the qualification and level of the surgeon. The rehabilitation period lasts several months. [10]

Prevention

Preventive measures involve creating conditions that avoid traumatizing and overloading the musculoskeletal mechanism of the hands.

It is recommended to follow the rules of healthy eating, include in the daily diet of greens, berries, fruits and vegetables, seafood, cereals.

It is undesirable that in the diet there are large quantities of offal, red meat, alcoholic beverages.

If you are prone to joint pathologies, you need to regularly perform special exercises for fingers, avoid hypothermia, systematically visit doctors for routine examinations, timely treat any existing pathological processes that can have an adverse effect on the musculoskeletal system.

Forecast

Deforming osteoarthritis of interphalangeal joints has a long course, with gradual and irreversible aggravation of the clinical picture. However, the slow dynamics of the disease allows the patient to retain the ability to work for a long time. Severe cases of pathology are accompanied by complete destruction of the joints with loss of their motor capabilities: in most cases, ankylosis or neoarthrosis with unnatural mobility is formed.

Deforming osteoarthritis of the interphalangeal joints of the hand can lead to disability in the long term. Early medical attention can significantly improve the condition of the affected joints and reduce the rate of progression of the disease process.