By Dr. Benjamin Sutker
The joint at the base of the thumb, which allows for the swivel and pivoting motions of the thumb, is referred to as the basal joint or thumb CMC (carpometacarpal) joint. Because of its unique design, it tends to wear out and develop arthritis early in life. Basal joint arthritis is also common in people who have osteoarthritis. It is more common in women over the age of 40 and is felt to be part of the natural aging process.
Because of the forces across the thumb and wrist, even with normal pinch and grip activities, the joint is felt to be particularly prone to wear and tear from normal use. Many people appear to be predisposed to arthritis in this joint with or without arthritis in their other joints.
Ice for 5-15 minutes at a time on the area which is most swollen and tender can be helpful.
Over-the-counter nonsteroidal anti-inflammatory medications (NSAIDs) such as aspirin, ibuprofen, Naprosyn, or meloxicam may prove beneficial. It is important to check with your pharmacist or internist regarding possible side effects and drug interactions when taking these medications.
A splint or brace which supports both the wrist and thumb are helpful during the day. A wrist support splint which does not support the thumb is not as effective as one that does. On occasion, a hand therapist may provide a custom splint which supports the thumb and wrist. In addition, the therapist may be helpful in identifying aggravating activities and suggesting alternative postures. The therapist may also offer other modalities such as massage, heat, ice, and other treatments making the area more comfortable.
Your physician may prescribe stronger NSAID medication or cortisone-type medication. In addition, a cortisone injection into the joint may relieve pain and inflammation and allow you to function more comfortably with the additional conservative treatments. For patients who continue to have symptoms despite conservative treatment, then surgical reconstruction of the joint is an option.
Dr. Sutker performs a total joint reconstruction, also known as a “CMC arthroplasty” or “LRTI” (ligament reconstruction tendon interposition) procedure.
This procedure involves three main steps.
1. Excision or removal of the trapezium bone at the base of the thumb.
2. Suspending the thumb at the proper position by using a tendon graft from the wrist that is weaved through the base of the thumb to support it out at the level of the index finger. Dr. Sutker traditionally uses the flexor carpi radialis (FCR) tendon, which is an expendable donor tendon, and does not result in any functional weakness of the wrist.
3. Make a cushion to pad the space between the bones where the trapezium bone used to be. Dr. Sutker uses the remaining portion of the FCR tendon to form a tendon graft so that the base of the thumb rests on a pillow of your own body tissue, rather than on the rough surface of an arthritic bone.
On occasion, because of secondary changes at the metacarpophalangeal (MCP) joint, Dr. Sutker may recommend a procedure either to tighten this joint with a soft tissue tightening procedure known as a capsulodesis or in more severe cases of instability, he may recommend surgically fusing the MCP joint, known as an arthrodesis.
The postoperative regimen is extremely important to the success of the procedure. Recovery takes, on average, about three months. Initially, patients are in a postoperative splint for two weeks, at which point they are seen back in the office and the splint is changed to a cast incorporating the thumb, wrist, and forearm. This is continued until four weeks postoperatively.
At four weeks, the cast is removed and a hand therapist is seen. The hand therapist will make a custom removable splint that is used for another four to six weeks. This splint is removed for bathing and for progressive mobilization and strengthening exercises. The patient should anticipate no two-handed sports or heavy two-handed lifting for 10-12 weeks after surgery. Most strength recovery occurs in the first few months, but studies have shown that range of motion, strength, and dexterity will continue to improve for a year or more.
An important question that you may ask is what happens if I have no treatment? This truly depends on how much your thumb is bothering you. It really is a quality of life issue. This is not a problem which can spread to other parts of your body. Many people have thumb pain which subsides after a few years, when the arthritis and irritation in the joint “burns out.” There is, however, a limited period of time during which surgery can give the best result. After a period of years, the thumb weakness and loss of motion of the thumb may not be reversible, even with surgery.
The main reason to do surgery is to relieve pain and, when possible, prevent the progressive weakness and deformity which may occur. Some people have a mild problem which flares up from time to time and treat it themselves or ignore it, while others have a severe problem which prevents them from doing many things with their hand and feel that they have no choice but to have surgery.
A native of Charlotte, Dr. Benjamin Sutker specializes in elbow, hand and wrist at OrthoCarolina Rock Hill. He has a special interest in wrist and elbow trauma, arthritic reconstruction of the hand/wrist, nerve and tendon injuries, wrist/elbow arthroscopy, total elbow arthroplasty and needle aponeurotomy for Dupuytren's disease.
Outside of the office, Dr. Sutker enjoys spending time with his wife Lisa, their twin teenagers and their Goldendoodle, Finley, and likes to burn off steam fishing and road biking.