Thumb osteoarthritis caused by joint instability is due to ligaments that are weakened or damaged by overuse or by a traumatic injury.1 In this article we will discuss the treatment options in treating basal joint instability of the thumb.
Thumb arthritis often involves inflammation of the basal joint, which is the joint that allows the thumb to swivel and pivot. It is also called the thumb carpometacarpal (CMC) joint or the trapeziometacarpal (TMC) joint, because the trapezium bone joins the metacarpal bone of the thumb. Basal thumb arthritis or trapeziometacarpal arthritis is often the result of ligament laxity or injury to the thumb, which then creates a cascade of arthritic effects. For example, the cartilage that cushions the joint begins to deteriorate, and then swelling and pain develop as the bones rub against each other. The ligaments eventually weaken further as they try to overcompensate for the lack of cartilage. The synovial tissue that lines the joint capsules may also become inflamed, leading to fluid accumulation in the joint. Pain, swelling and decreased mobility are the results.
Surgery for osteoarthritis of the thumb
Much of the research and attention of surgery for thumb osteoarthritis centers around the removal of the trapezium bone at the base of the thumb. The surgery is called a trapeziectomy.
The trapeziectomy can be performed with variations to the technique. First is the removal of the bone. Some procedures will include a ligament reconstruction to strengthen the compromised anatomy and filling the void left with a forearm tendon. For patients with thumb arthritis being recommended to surgery the term interpositional arthroplasty or commonly referred to as trapeziectomy with LRTI would likely be recommended as surgical choice.
Questions about surgery for thumb arthritis
New research from the University of Massachusetts Medical School examined these surgical procedures, here are their findings:
In the treatment of basal joint arthritis of the thumb, recent studies suggest equal outcomes with regard to long-term pain, mobility, and strength, in patients undergoing either trapeziectomy alone or trapeziectomy with ligament reconstruction and tendon interposition (LRTI).
A retrospective chart review of 5 surgeons at a single institution performing CMC (wrist joint) arthroplasties from November 2006 to November 2012. A total of 200 thumbs in 179 patients underwent simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization (wires instead of tendons to stabilize the void) , or ligament reconstruction.
Seventy hands had a postoperative complication. Ten of these complications were considered major, defined as requiring antibiotics, reoperation, or other aggressive interventions.
Risk of total complications was significantly greater in patients undergoing either trapeziectomy with LRTI or ligament reconstruction in comparison with trapeziectomy with K-wire stabilization.
These results suggest an advantage of simple trapeziectomy.2 Despite this and other evidence “Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option.”3
Another study suggests that total trapeziometacarpal (TMC) joint replacement is increasingly being performed for the treatment of basal joint arthritis. However, complications such as instability or loosening are also frequent with TMC ball-and-socket joint replacement.
Management of these complications lacks consensus. In fact French doctors in September 2016 wrote: “Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications.”4
The best salvage operation for this failed joint replacement? Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty.5
Medicine can sometimes be very amazing in its desire to do the most complicated and invasive things.
Non-surgical options for thumb arthritis
In our research published in the Journal of Prolotherapy, we were able to document the beneficial use of Prolotherapy Injections. Prolotherapy was administered to 13 patients suffering from basal thumb arthritis in 17 thumbs. For more information on Prolotherapy for Hand Pain.
A series of injections of dextrose, along with intra-articular Human Growth Hormone, over three to six months was shown to reduce pain, improve function, and, thereby, improve the quality of life for the patients in this study.
Prolotherapy enables TMC joint arthritis sufferers to avoid surgery and its possible adverse effects. The substantial advantages and minimal drawbacks (e.g., aversion to needles) as well as the reduced risks and increased rewards of Prolotherapy over conventional treatments suggest that this option for the second most common joint arthritis—that of the thumb—should be considered by doctors and patients.6
Prolotherapy has also successfully decreased pain and the degree of deformity in a thumb with subluxation and deformity caused by rheumatoid arthritis.7
New research from German and Swiss investigators say Platelet Rich Plasma Therapy (PRP) injections for patients with thumb osteoarthritis “is a reasonable therapeutic option in early stages of trapeziometacarpal osteoarthritis” and that their research supports PRP as another option in the conservative management of trapeziometacarpal osteoarthritis.8
1 Brandt KD, Radin P, Dieppe P, Putte L. Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis. 2006;65(10):1261-1264. [British Medical Journal]
2 Naram A, Lyons K, Rothkopf DM, Calkins ER, Breen T, Jones M, Shufflebarger JV. Increased Complications in Trapeziectomy With Ligament Reconstruction and Tendon Interposition Compared With Trapeziectomy Alone. Hand (N Y). 2016 Mar;11(1):78-82. doi: 10.1177/1558944715617215. [Citation]
3 Mahmoudi E, Yuan F, Lark ME, Aliu O, Chung KC. Medicare Spending and Evidence-Based Approach in Surgical Treatment of Thumb Carpometacarpal Joint Arthritis: 2001 to 2010. Plast Reconstr Surg. 2016 Jun;137(6):980e-9e. [Pubmed]
4 Gay AM, Cerlier A, Iniesta A, Legré R. Surgery for trapeziometacarpal osteoarthritis. Hand Surg Rehabil. 2016 Sep;35(4):238-249. doi: 10.1016/j.hansur.2016.06.002. Epub 2016 Jul 21.
5 Lenoir H, Erbland A, Lumens D, Coulet B, Chammas M. Trapeziectomy and ligament reconstruction tendon interposition after failed trapeziometacarpal joint replacement. Hand Surg Rehabil. 2016 Feb;35(1):21-6. doi: 10.1016/j.hansur.2015.09.002.
6 Hauser R, Feister W. Treatment of Basal Thumb Osteoarthritis: A Retrospective Study of Dextrose Prolotherapy Injections as an Alternative Treatment Journal of Prolotherapy. 2013;5:e913-e921.
7 Hauser R, Ostergaard S,Santilli S. Stabilization of Rheumatoid Thumb Interphalangeal Joint Boutonniere Deformity and Severe Subluxation with Splinting and Prolotherapy: A Case Report. Journal of Prolotherapy. 2012;4:e849-e854.
8. Loibl M, Lang S, Dendl L-M, et al. Leukocyte-Reduced Platelet-Rich Plasma Treatment of Basal Thumb Arthritis: A Pilot Study. BioMed Research International. 2016;2016:9262909. doi:10.1155/2016/9262909.