Thumb Arthritis: Treatment Options

Thumb Arthritis: Treatment Options

This video will provide an overview of the treatment options for thumb carpometacarpal joint arthritis, both conservatively without surgery and options with surgery. To review the pertinent anatomy, the carpometacarpal joint, or CMC joint of the thumb, lies between the trapezium and metacarpal bone at the base of the thumb, and is a common location to develop arthritis in the hand.

Nonsurgical treatment for thumb CMC osteoarthritis, also called OA, is based on resting or unloading the joint by wearing a thumb-based splint or brace, oral anti-inflammatory medications known as NSAIDs, corticosteroid injections into the joint space, and potential biologic options such as platelet-rich plasma known as PRP. Despite options for nonoperative treatment, a significant number of patients end up requiring some form of surgical treatment.

There are many iterations of techniques, though the concept remains the same. Bone-on-bone contact between the thumb's metacarpal and the trapezium joint surfaces is the primary pain source in this condition. This is primarily addressed by removing the trapezium bone, either partially or entirely. When the small trapezium is removed, the body forms scar tissue in its void, which continues to help cushion and support the thumb.

Surgical procedures have evolved over time to provide additional support to this area. Let us look at the evolution of these surgical solutions. In 1949, Gervis and Wells described the simple removal of the trapezium bone called the trapeziectomy. This is where the trapezium and a portion of the metacarpal are removed only, allowing scar to form in this gap.

Another viable solution is a fusion of the thumb CMC joint. This is especially useful for those who use their hands for heavy labor. Noting that motion will be limited in the joint after this procedure, fusion is the joining of the 2 bones to stop the painful motion in between them.

Later, Burton and Pellegrini popularized ligament reconstruction with tendon interposition. This is called the LRTI technique. This technique requires that another tendon in the hand is cut and relocated to fill the trapezium's void. In 2009, the LRTI was improved further by stabilizing the thumb's motion through a procedure called tenodesis interference fixation.

These surgical procedures have failed the test of time due to loosening, or they have required prolonged cast immobilization and the use of metal wires with consequent stiffness. Since 2009, newer procedures have been developed utilizing suture and implant technology. With the most advanced suture and implant technology, hand surgeons can offer these minimally invasive procedures with less surgical trauma.

They spare previously harvested tendons and provide a durable, reliable, and stable sling fixation that can shorten the time in a cast, making patients feel more comfortable during the recovery process and potentially improving functional results and return to previous activities.