IT’S LONG BEEN SAID that in addition to a large brain, another critical
characteristic that separates us from most other animals is our opposable
thumbs. The thumb joint has a wide range of motion that makes pinching
and grasping motions possible, and most other animals, save for fellow
primates, lack this ability. Thumb joints have been credited with enabling
us to make a variety of technologic advancements, but over the course
of a life, they sustain a lot of wear and tear. “Dexterity comes
at a price,” the Arthritis Foundation reports. That price is “an
increased risk of osteoarthritis in the first carpometacarpal joint, where
the thumb meets the trapezium bone in the wrist.”
If you live long enough, you’ll eventually develop osteoarthritis
in at least one joint. “Some people call it degenerative joint disease
or ‘wear and tear’ arthritis,” the CDC reports. Over
time, the cartilage and fluid that cushions the bones in joints wears
out, and eventually the bones begin rubbing together. OA often develops
slowly over many years. It causes pain, stiffness and swelling. Many people
lose function of the affected joint. When that joint is the thumb, it
can make many activities of daily living, such as writing, getting dressed,
turning a key in a lock and opening containers, difficult or downright
“Joint pain, tenderness and instability occur at the base of the
thumb where the thumb meets the
wrist,” says Dr. Peyton L. Hays, an orthopedic hand and upper extremity
surgeon with ProHEALTH Care Associates in New York. “Many people
also experience weakness or discomfort with pinch and grip activities,”
such as pulling a zipper shut on a bag.
The older you are, the more likely you are to develop OA in the basilar
(or thumb) joint. He notes that the presence of OA can be confirmed with
X-rays, and that “evidence of basilar joint arthritis is present
on X-rays of approximately 40% of women and 25% of men over the age of
But when these conservative interventions stop helping or the joint becomes
completely disabled, surgery might be recommended for certain patients.
In the right person, surgery can “provide excellent relief of arthritis
pain,” he says.
LRTI Joint Reconstruction Arthroplasty
There are a few different types of thumb joint surgery available, but
the Arthritis Foundation reports that a procedure called ligament reconstruction
and tendon interposition arthroplasty has been around for more than 40
years and “is the most commonly performed surgery for thumb arthritis.”
Dr. Ying Chi, a hand and wrist surgeon with
Hoag Orthopedic Institute in Irvine, California, which is the largest-volume joint replacement hospital
on the West Coast, says thumb LRTI joint reconstruction may be considered
for patients with arthritis of the thumb joint who have “debilitating
pain that affects the patient’s hand function. It is an excellent,
pain-relieving surgery that doesn’t require fusion of the thumb
joint, and therefore preserves the thumb motion.”
Hays says that during thumb joint surgery, “the
surgeon makes an incision over the region of the thumb basilar joint. The arthritic
joint is identified, and a small bone called the trapezium is removed.”
From there, the surgeon, who’s typically an
orthopedic surgeon, has options. In LRTI surgery, after the surgeon removes the trapezium
bone, he or she typically uses “the patient’s own tissue (flexor
carpi radialis tendon) to reconstruct the joint and create the new joint
cushion,” Chi explains. The FCR tendon runs down the inside of the
forearm, from a point near the inner elbow to the wrist near the thumb.
The replacement tendon is often folded into what’s sometimes called
an “anchovy.” This anchovy sits in the space that the trapezium
used to occupy and creates a cushion for the remaining bones. In some
instances, an artificial anchovy implant may be used instead of the patient’s
own tissue, the Arthritis Foundation notes.
Dr. C. Liam Dwyer, a hand and upper extremity surgeon at
Geisinger in Danville, Pennsylvania, notes that “Although there are many variations
of this procedure, including using an implant or performing the procedure
arthroscopically, the most common approach to restore stability involves
removing the arthritis followed by soft tissue reconstruction or hardware
What to Expect From Thumb Surgery
LRTI surgery is usually conducted either under
general anesthesia or a regional axillary block, a type of anesthetic that affects only a
specific region of the body, rather than putting you completely to sleep.
“Thumb joint replacement is typically a same-day, in-and-out surgical
procedure,” Dwyer says. “Patients typically go home the same
day, wearing a splint that immobilizes the wrist and thumb for two weeks.
At their follow-up visit, patients are placed into a cast for approximately
four weeks, then transitioned into a brace. The length of immobilization
time is determined on a case-by-case basis depending on the patient and
Chi says keeping the joint immobile for roughly six weeks after surgery
is an important component of the healing process that “protects
the reconstruction.” After that period, most patients can begin
“gentle use” and you’ll likely start physical or occupational
therapy to restore range of motion and strength to the joint. Chi says
PT typically runs for about five weeks, and most people have normal function
of the joint restored within three months of the surgery.
Once motion is restored and the patient feels better, PT can be tapered
off. Nevertheless, it’s still a good idea to take it easy for a
while after this surgery to make sure your joint and tendons heal properly.
“I recommend avoiding strenuous activity, sports and heavy lifting
for approximately three months or until symptoms have resolved,”
Any type of surgery carries potential risks, and for LRTI, Chi says the
risks include “tendon injury, vascular injury and possible infection.
These are very rare, but the LRTI procedure is quite technically demanding
and should only be performed by a board-certified and fellowship-trained
hand surgeon.” Hays adds that bleeding, delayed healing, damage
to surrounding tissues or structures, post-operative pain and stiffness
can all result from this type of surgery, but “overall, patients
demonstrate significant improvement following surgery.”
Studies have found that LRTI surgery offers significant pain relief and improved
mobility for some 95% of patients, and most patients typically gain back
more than 60% of their original grip strength. Though the recovery from this procedure
can be long, most patients get more than a decade of relief from it. If
symptoms return, your surgeon will help you evaluate other options or
additional surgical procedures.
Other Types of Thumb Surgery
Chi says the ideal patient for the LRTI procedure is “someone with
painful arthritis at the thumb basal joint who wants to preserve thumb
motion and decrease pain.” However, he adds, “we do not recommend
this for patients younger than 45 who have heavy, manual jobs. Those patients
are better off with fusion surgery.”
If LRTI is not a good option for your situation, there are a few other
surgical procedures that may be recommended. Here are other surgery options
for thumb arthritis:
Fusion surgery. Some patients can get significant symptom relief from a fusion procedure,
in which the surgeon fuses two of the bones together to prevent movement.
Younger patients, those with physical jobs and those with
rheumatoid arthritis – a form of inflammatory arthritis caused by an autoimmune disorder
– are most likely to benefit from this approach, the Arthritis Foundation
reports. The downside to fusion is that it reduces mobility in the thumb
joint that can impact functionality of the hand.
Ligament reconstruction. This procedure features the removal of a portion of the damaged ligament
and replacement with a piece of the flexor tendon (from the inner arm,
as with LRTI surgery). This procedure does not include removal or repair
of the arthritic bone. Patients whose symptoms are caused by lax tendon
rather than a loss of cartilage may find this procedure helpful.
Hematoma and distraction arthroplasty. This procedure is considered somewhat controversial, the Arthritis Foundation
reports, and features the removal of the trapezium bone. Then a wire is
inserted to temporarily immobilize the thumb. The wire is removed after
six weeks. The idea is that immobilizing the thumb after removing the
source of friction allows the body to heal itself. It may be a good option
for older patients who want a less invasive procedure and for those who’ve
had failed reconstructions in the past. The Arthritis Foundation reports
that while most patients who undergo this procedure experience pain relief,
increased grip strength and improve function, "removal of the trapezium
has been known to come with significant complications, including loss
of pinch strength and thumb shortening. Proponents of the procedure claim
immobilizing the joint for a few weeks prevents these complications."
Total joint replacement (arthroplasty). For some patients, the best option is to simply replace the whole joint
with a prosthetic, as would be done for hip or knee replacement procedures.
Although this procedure generally involves less recovery time than an
LRTI because there’s no transplantation of the patient’s own
tissue, these replacements are typically made of metal and aren’t
recommend for people who use their hands a lot for manual labor.
If you’re seeking treatment for arthritis of the thumb joint or considering
surgery, Dwyer recommends that you “understand your diagnosis and
symptoms as well as alternative treatment options, both surgical and nonsurgical,”
which requires a “thorough discussion between patient and surgeon.”
This should include a review of your X-ray images to determine the best
treatment plan, he says.
The bottom line, Hays adds, is that people suffering from severe arthritis
in the thumb have some surgical options that can provide significant relief.
But you shouldn’t rush into them. “In general, I recommend
that patients exhaust conservative treatment options before considering
surgery. However, when these options fail to provide adequate relief,
a number of successful surgical arthroplasty options are available to
address thumb basilar joint arthritis, reduce pain and restore function.”