Dr EG Penserga discusses developments in hand osteoarthritis - from disease mechanisms to treatment propositions. Presented during the Joint RA OA SIG Symposium held at the F1 Hotel last 28 Nov 2014.

1. Osteoarthritis as a multifocal
originating disease represents the
traditional ‘joint decompensation’
model for OA
and entails a strong degree of
therapeutic nihilism,
with the exception of joint
replacement strategies.
J Anat March 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829386/#

2. Osteoarthritis is an end stage organ
failure
Osteoarthritis is a heterogenous
disease

3. Handling Hand OA
Ester Z. Gonzales-Penserga MD

4. Hand OA: the “forgotten” disease
• Objectives : TO DISCUSS
– Concepts of mechanisms of disease in hand OA
– Clinical burden of disease
– treatment propositions

5. Traditional classification of osteoarthritis (OA)
• Primary or idiopathic
Localized
Hands: e.g. nodal OA, erosive OA, first CMC joint OA
Feet: e.g. hallux valgus, hallux rigidus, talonavicular OA
Knee: e.g. patello-femoral syndrome, medial/lateral compartment OA
Hip: e.g. diffuse, superior, concentric
Spine: e.g. DISH, spondylosis, intervertebral joints, apophyseal joints
Other: wrist, glenohumoral, acromioclavicular, temporomandibular
Generalized Includes three or more areas listed above
•Secondary
Post-traumatic e.g. fracture, infection, joint surgery
Congenital disorders e.g. congenital hip dislocation, chondral dysplasia
Metabolic Calcium crystal deposition
Haemochromatosis
Acromegaly
Paget's disease
Ochronosis
Inflammatory Any inflammatory arthritis, e.g. rheumatoid arthritis
Septic arthritis
Other bone and joint disorders
Avascular necrosis, neuropathic charcot joints

6. Site-specific pathogenic classification of osteoarthritis (OA)
Type of OA Recognized causes
Chondrogenic Traumatic cartilage injury
Hereditary genetic disorder
chondrodysplasias
Ligamentogenic (enthesogenic) Trauma, e.g. ACL rupture
Generalized nodal OA – hand OA
Cervical spondylosis
Lumbar spondylosis
DISH
Meniscogenic Primary meniscal degeneration
Meniscal extrusion
Root horn tears
Synoviogenic Inflammatory, e.g. CPPD-, MSU,-BCP-
Secondary to inflammatory arthritis
Osteogenic Neuropathic joint disease
Avascular necrosis
Bony dysplasia
Joint fracture
Paget's disease
Mixed pattern –‘multifocal’ Proportion of age-related disease with serial
insults to different joint structures
Anat March 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829386/#

7. McGonagle D et al. Rheumatology 2008;47:1278-1285
© The Author 2008. Published by Oxford University Press on behalf of the British Society for
Rheumatology. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
What is known of generalized OA
including HOA
• Joints that are
commonly affected
by GOA, including
large synovial joints
like hips and knees;
small synovial joints-
DIP, PIP and CMC
joints and 1st MTP

8. What is known of HOA
• Prevalent disease
– Radiographic HOA: 81% of elderly white
– Heberden’s in 58%, Bouchard’s in 30% of American adults> 60
years
– Heberden’s 13%, Bouchard’s 4.3% in 869 Filipino patients with
OA (Racaza, Salido, Penserga. International Journal of Rheumatic Diseases
2012; 15: 399–406)
• Risk factors
– Age, female, family history
– Accelerated course after menopause
– Obesity
– Mechanical forces appied to the joints ( Hunter D, et al Chopstick
arthropathy: The Beijing Osteoarthritis A&R 6 May 2004 pp. 1495-1500Full publication
history DOI: 10.1002/art.20145

9. What is known of generalized OA
including HOA
• High prevalence in obesity, metabolic syndrome
• Thelier-Deloison et al. Prevalence of clinical digital
OA (Heberden and Bouchard) in a selected
population of patients with severe obesity: A
prospective study. Osteo & Cart ((20)S1 April 2012
ISSN 1063-4584
• Orellanan C. High prevalence of metabolic
syndrome in patients with hand OA in a primary
care setting. Osteo & Cart 20 S1 April 2012 ISSN
1063-4584
• Association with atherosclerosis in knee, DIP and
MCP joints in women
• Hoeven TA et al. Association of atherosclerosis with
presence and progression of OA of the jnee and
hand: The Rotterdam study. Osteo & Cart (20)S1
April2012 ISSN 1063-4584 Rotterdam Study

10. Racaza, Salido, Penserga. International Journal of Rheumatic
Diseases 2012; 15: 399–406)
BMI Men (n =
185)
Frequency
(%)
Women (n =
348)
Total %
Normal (BMI
<23)
17 (9.2) 80 (23.0) 18.2
Overweight
(BMI 23.0-
24.9)
17 (3.2) 159 (45.8) 33.0
Obese
(>25.0)
151 (81.6) 109 (31.3) 48.8
BMI profile of 533 Filipinos with OA

11. What is known of HOA
• Burden of illness
– Frequent consultation (Spanish data)
– Decreased grip affecting writing and carrying >4.5kg load
(Framingham data)
– Cause of pain and minor disability
– Indicator of systemic tendency to OA, esp. of the hips and
knees (Annals of the Rheumatic Diseases 1994; 53: 220-223 )
• Erosive OA (EOA) is related to development of more
nodes
• More nodes, worse functional outcome
• Non-erosive conversion to EOA in 25%

12. What is known of OA
• Burden of illness
– Erosive OA: pain, ankylosing deformities and disability
more than non-erosive OA
• Pain: adjusted OR 3.1 (2.0,4.8)
• Hand disability: adjusted OR 2.5n(1.1,5.8)
– 2011 Rotterdam Study
– EOA in DIPJs and PIPJs 37.6% vs. 6.3% more likely to
have pain, aching or stiffness
– Framingham study
– More pain, functional limitation, less satisfaction with
aesthetics

13. Site-specific pathogenic classification of osteoarthritis (OA)
Type of OA Recognized causes
Chondrogenic Traumatic cartilage injury
Hereditary genetic disorder
chondrodysplasias
Ligamentogenic (enthesogenic) Trauma, e.g. ACL rupture
Generalized nodal OA – hand OA
Cervical spondylosis
Lumbar spondylosis
DISH
Meniscogenic Primary meniscal degeneration
Meniscal extrusion
Root horn tears
Synoviogenic Inflammatory, e.g. CPPD-, MSU,-BCP-
Secondary to inflammatory arthritis
Osteogenic Neuropathic joint disease
Avascular necrosis
Bony dysplasia
Joint fracture
Paget's disease
Mixed pattern –‘multifocal’ Proportion of age-related disease with serial
insults to different joint structures
Anat March 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829386/#

14. Although OA is a heterogeneous disease process,
occasionally multifactorial in origin,
disease initiation at specific
anatomical locations in different groups offers a
new way
for disease classification that is of
direct translational relevance.
This is especially relevant for the
targeted development
of regenerative medicine
strategies for joint failure or for strategies
to prevent joint failure.

15. Sagittal section of the knee joint showing the
tissues on which the proposed classification of
osteoarthritis is based: articular cartilage (AC),
subchondral bone (SB), meniscus (M),
synovium (S) and (inset) ligament (L). C,
capsule; CB, cancellous bone; F, femur; H,
Hoffa's fat pad; P, patella; PL, patellar ligament;
QT, quadriceps tendon; T, tibia. Anatomical
specimen kindly provided by Dr Stefan Milz.

16. Tan AL1, Grainger AJ, Tanner SF, Shelley DM,
Pease C, Emery P, McGonagle D. High-resolution
magnetic resonance imaging for the assessment
of hand osteoarthritis.Arthritis Rheum.
2005 Aug;52(8):2355-65.

17. • Key to the development
of the erosive OA
phenotype and joint
erosion in general
(Grainger et al.
2007; McGonagle et al.
2009).
• Primary changes in
ligaments and their
insertions can profoundly
affect the adjacent bone
and synovial tissues.

18. Tan AL, Grainger AJ, Tanner SF, Shelley DM, PeaseC, EmeryP, McGonagle D.
High-resolution magnetic resonance imaging for the assessment of
hand osteoarthritis. A & R 52 (8) pp 2355–2365, August 2005

19. Translational implications
• Understanding the initiator/ initiating
anatomic site
– Prevent end stage joint disease
• Several different tissues implicated
– Treatment approach modification

20. Hand OA starts with disease of soft tissues – ligaments and enthesis,
----Association with inflammatory events and erosive disease
--- nodal lesions
Hand OA treatment may invite targeted, regenerative medicine
Hand OA burden of illness extends systemically,
Includes metabolic diseases
In Summary

21. McGonagle D, Tan AL, Carey J, Benjamin M. The anatomical
basis for a novel classification of osteoarthritis and allied disorders. J Anat. Mar 2010; ]
216(3): 279–291. Published online Jan 7, 2010. doi: 10.1111/j.1469-7580.2009.01186.x
PMCID: PMC2829386
Kloppenburg M, Kwok WY. Hand Osteoarthritis- a heterogenous disorder. Nature Reviews Rheumatology 8, 23-31
(January 2012) doi:10.1038/nrrheum.2011.170
References:
McGonagle D, Tan AL, Grainger AJ, Benjamin M. Heberdend’s nodes and Heberden could not see.
Rheumatology (Oxford). 2008 Sep;47(9):1278-85. doi: 10.1093/rheumatology/ken093.
Epub 2008 Apr 4.
Tan AL, Grainger AJ, Tanner SF, Shelley DM, PeaseC, EmeryP, McGonagle D.
High-resolution magnetic resonance imaging for the assessment of
hand osteoarthritis. A & R 52 (8) pp 2355–2365, August 2005
Thelier-Deloison et al. Prevalence of clinical digital OA (Heberden and Bouchard in selected
Population of patients with sever obesityL A prospective study. Osteo and Cart (20) S1.
April 2012 ISSN 1063-4584
Orellana C.et al. High prevalence of metabolic syndrome in patinets wiith hand OA in a primary
Care setting. Osteo 5Cart (20) S1 April 2012 1063-4584
Hoeven TA et al. Association of artherosclerosis with presence and progression of OA of Knee and hand:
The Rotterdam Study. Osteo & Cart. (20) S1 April 2012 ISSN 1063-4584