The EULAR ( European League Against Rheumatism ) issued recommendations in 2006 for the treatment of Osteoarthritis of the hand. They refer to rhizo-Osteoarthritis and Osteoarthritis of the fingers.
The best approach combines pharmacological treatments with non-pharmacological treatments. However, the choice of treatments remains difficult due to the absence of good quality clinical trials and the low level of testing.
It is necessary, above all, to specify the patient's complaint to know if it refers more to the aesthetic repercussion, pain or disability. Individual treatment and self-management by the patient are paramount.
Non-pharmacological treatments, including ergotherapy, reeducation, the use of technical aids (orthosis or splints) occupy an important place in the recommendations.
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Non-pharmacological treatments
Re-education
The aim of reeducation is to limit joint tensions and maintain joint mobility.
Several techniques are used, such as analgesic massage, thermotherapy, ultrasound and gymnastics. It is important to fight joint stiffness through reeducation, since once installed, it is irreversible.
The local application of heat (hot bandages or paraffin wax) and ultrasound can provide antialgia in a short period, and are proposed before the exercises.
Ergotherapy
Ergonomic measures have to be taken. The patient must be advised to practice "joint savings". For example, you can write with a large diameter ballpoint pen, modify instruments that require a fine grip, etc.
Technical support orthosis thumb
Technical help
The splints can prevent stiffness in bad position, particularly at long fingers. At the level of the thumb, the fight against deformation is also important. It must be early, since progressive degradation of the joint results in an adductus thumb, a loss of mobility and an often important functional discomfort. The latter is aggravated by the atrophy of the thenar eminence against which you have to fight doing exercises.
The thumb orthosis stabilizes the thumb in the function position. It has an orthopedic function against deformation, but it is also analgesic. It can be worn continuously during acute painful periods, or only at night, outside of crises, when the pains are less disabling.
In practice, the orthoses molded to measure in the patient, allow a better adaptation, especially in case of rigidity already installed. Good compliance depends on a good tolerance of the orthosis by the patient.
Pharmacological treatments
With regard to pharmacological treatments, it is necessary to favor the molecule with the best benefit / risk ratio and to re-evaluate the indication regularly.
Local treatments are still preferable to systemic treatments.
Local treatments
Topical NSAIDs can be used with a good symptomatic effect.
Paracetamol
Paracetamol is the reference analgesic since it is effective and has a very good tolerance. You can take up to 3 grams a day.
NSAID and Coxibs orally
NSAIDs should be reserved as a 2nd option in case of failure of paracetamol and / or in case of inflammatory access.
They should always be prescribed and used at the lowest effective dose and for the shortest possible time.
- The choice of an NSAID should be made taking into account its safety profile and the individual risk factors of the patient.
- There is no need to prescribe conventional NSAIDs or coxibs in case of an evolutive peptic ulcer or gastro-intestinal bleeding, a history of digestive bleeding or perforation during NSAID treatment.
- NSAIDs are susceptible to induce an acute IR, it is necessary to remain particularly attentive with patients treated with diuretics, which present a risk of hypovolemia or impaired renal function.
- In patients suffering from confirmed ischemic heart disease, peripheral arterial disease and / or history of stroke (including transient ischemic attack), coxibs are contraindicated and non-selective anti-inflammatory drugs should be used with caution.
Infiltrations of corticosteroids
During painful accesses, intra-articular corticosteroid infiltrations may be proposed to patients. Eventually they can be radio-guided, as access to the joint is often difficult, due to joint pinching and the presence of osteophytes.
Surgical treatments
In case of persistent painful symptoms or a handicap with deformation despite optimal medical treatment, surgical treatment may be considered.
Joint excision consists of a resection of the osteophytic protrusions. This intervention does not modify the osteoarthritic evolution and allows pain and joint discomfort to persist. This surgery is carried out more on a psychological basis.
Digital centering osteotomies can help in the case of particularly disturbed off-center joints.
Arthrodesis aims to fuse the joint in a position of function. It allows a good relief and a centering, but it entails a loss of mobility.
It may be interesting for the distal interphalangeal.
The arthroplasties are used for the proximal interphalangeal ones, since at this level a conservation of the mobility is indispensable.
In the particular case of rhizo-osteoarthritis, there are 3 surgical possibilities:
- trapezectomy,
- the escafotrapezoidal arthrodesis,
- the trapezometacarpal prostheses.