Is Thumb Joint Replacement Surgery Right for You?
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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 technological 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.”
Osteoarthritis is a disease of aging, and it’s very common. The Centers for Disease Control and Prevention reports that osteoarthritis is the most common form of arthritis, affecting more than 30 million adults in America. OA features inflammation of the joint that can impact its mobility and function.
“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 75 years.”
Most cases of OA can be well managed “with conservative options including nonsteroidal anti-inflammatory medications,” Hays says. These NSAID medications are available over the counter and include products such as ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). “Joint immobilization, activity modification, corticosteroid injections and hand therapy” are also often used to control OA, and “many people consider over-the-counter supplements such as glucosamine chondroitin sulfate and turmeric,” which are heralded for their anti-inflammatory properties, he says.
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 placement.”
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 procedure.”
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,” Hays says.
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.”