Thumb Osteoarthritis Surgery Alternatives
I am going to open this article with an April 2018 study that appeared in the American Journal of Hand Surgery. The study from a team of Belgium doctors questions whether or not a thumb joint replacement surgery provides a good benefit for the patient. Here are the highlights of that study.
The study begins with four female patients who have stage III osteoarthritis at the Trapeziometacarpal (the base of the thumb). The four female patients had significant loss of range of motion in their thumbs. This lead to a recommendation for TMC (Trapeziometacarpal) joint replacement surgery.
So what happened after the surgery? How was the range of motion in the replaced thumbs?
To quote the research: “The study highlights that advanced Trapeziometacarpal osteoarthritis mainly restricts the MC1 (first metacarpal bone or the metacarpal bone of the thumb) mobility. We also showed that, whereas total joint arthroplasty (thumb replacement) is able to restore thumb function, it cannot fully replicate the kinematics of the healthy Trapeziometacarpal joint.”(1)
So after thumb replacement the thumb does not return to a more natural range of motion. This may not be an important factor for many people, especially people who have deformity from rheumatoid arthritis, but it is certainly an important factor for people who rely on their hands for work or if they are an artisan. Tell a pianist or a carpenter that his/her thumbs won’t move that well after surgery. See how fast they look for an alternative to their basal thumb arthritis.
Range of motion is found in the thumb ligaments. This is more evidence that osteoarthritis is not a cartilage disease
Thumb osteoarthritis is caused joint instability due to ligaments that are weakened or damaged by overuse or by a traumatic injury.(2) This according to researchers from Indiana University School of Medicine, Tufts University School of Medicine, University of Bristol, Bristol, and the Dutch university researchers who titled their paper: Yet more evidence that osteoarthritis is not a cartilage disease, published in the British Medical Journal.
Thumb arthritis often involves inflammation of the basal joint (the base of the the thumb), which is the joint that allows the thumb to swivel and pivot, it is also called the thumb carpometacarpal (CMC) joint or trapeziometacarpal (TMC) joint (as mentioned above), because the trapezium bone joins the metacarpal bone of the thumb.
The basal and metacarpophalangeal (MCP) (the knuckle joint of the thumb), are usually the first areas where pain is experienced.
- The thumb ligament that joins the wrist to the base of the thumb is called the radial collateral ligament, the same name as the ligament inside the elbow. The thumb ligament that joins the base of the thumb (the first metacarpal) to the succeeding joint (proximal phalanx) is the collateral ligament.
- If the ligaments in these joints are not strengthened, arthritis will eventually occur or worsen. Ligament damage and injury in the thumb can create 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, as well as a recommendation to surgery.
Surgery for osteoarthritis of the thumb often includes ligament reconstruction and bone removal
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.
In addition to the research above, research from the University of Massachusetts Medical School examined various surgical procedures for thumb osteoarthritis. 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.(3)
Thumb medicine can sometimes be very amazing in its desire to do the most complicated and invasive things.
Doctors at the Hand Surgery Unit, Department of Orthopedic Surgery, University Hospital, in Granada, Spain, wrote in the medical journal Orthopedics:
- Numerous surgical procedures have been described to treat trapeziometacarpal osteoarthritis, but no approach is currently considered superior.
- Good long-term outcomes have been reported with multiple procedures.
- No studies have been published comparing outcomes of the Arpe joint replacement with those of ligament reconstruction and tendon interposition (LRTI).
- Pain relief and functional improvement were similar between groups.
- Pinch strength and range of motion were superior in the joint replacement group.
- Metacarpophalangeal hyperextension appeared to be prevented in the joint replacement group but increased over the follow-up period in the ligament reconstruction group.
- However, the complication rate was higher in the joint replacement group.
- Conclusion: Joint replacement can be considered in selected patients who require greater strength and range of motion, although it has been associated with a higher complications rate.(4)
Despite this and other evidence. doctors from the University of Michigan write in the journal Plastic and Reconstructive Surgery: “With a consistent rise in health care spending, adherence to an evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option.”(5)
French doctors gave a thorough analysis of the challenges of surgical repair of Trapeziometacarpal osteoarthritis. Writing in the journal Hand Surgery and Rehabilitation, they write:
- The demand for surgical treatment for Trapeziometacarpal osteoarthritis is growing and the patients are becoming younger, adding to the challenge.
- Surgery can only be proposed after failure of well-conducted conservative treatment and requires a complete X-ray assessment.
- In the early stages, conservative surgery measures can be used to stabilize the joint or realign it in cases of dysplasia, but in most cases, patients are seen with more advanced arthritis and joint replacement must be considered.
- The ideal arthroplasty technique has yet to be defined. Although many studies have been published on this topic, they do not help define the treatment indications.
- Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications.(6)
Medicine can sometimes be very amazing in its desire to do the most complicated and invasive things.
Another team of French doctors gave a thorough analysis of the challenges of Total trapeziometacarpal joint replacement. Also writing in the journal Hand Surgery and Rehabilitation, they write:
- Total trapeziometacarpal 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.
This study examined the results of 12 cases of failed TMC joint replacement that were treated by trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty. The study found the Trapeziectomy with LRTI after TMC joint replacement appears to be an attractive salvage procedure.(7)
Simply doctors had to go back to a surgery that could have been the first choice procedure, to repair the damage of an alternative choice surgery. Two surgeries when one would have offered similar results with less trauma to the patient.
Non-surgical options for thumb arthritis
In an August 2017 study, doctors in Germany writing in the journal Plastic and reconstructive surgery say that “Most operations for carpometacarpal joint osteoarthritis of the thumb irreversibly alter or destroy the anatomy.” That is why there is a high demand among doctors anj patients for minimally invasive alternatives. In this study, the German team report on the results of autologous fat transfer for treatment of thumb carpometacarpal joint osteoarthritis (Adipose derived stem cell treatment).
In following 50 patients, the researchers were able to record significant pain reduction, especially in stage two osteoarthritis. They were able to conclude:
“Autologous fat transplantation is an appealing alternative, especially in early-stage basal joint osteoarthritis of the thumb. The low invasiveness of the procedure and early recovery of patients compared with classical procedures such as trapeziectomy, and the superior long-term results compared with classical injection therapy, make this approach feasible as a first-line therapy in early-stage basal joint osteoarthritis of the thumb.”7
In 2014, Christopher J. Centeno, MD of the Centeno Schultz Clinic published research in the Wiener Medizinische Wochenschrift (Vienna Medical Weekly) describing six patients who received autologous mesenchymal stem cell therapy for symptomatic carpometacarpal joint and hand osteoarthritis.
- Six patients who received injections of adult autologous culture expanded MSCs in their thumb CMC joints were followed for 1 year posttreatment, and matched with four procedure candidates who remained untreated.
- Positive outcomes were observed in the treatment group for both symptoms and function related to the osteoarthritis, compared with a reported worsening among the untreated controls.
The conclusion: “While these results should be interpreted with caution because of the small number of treated subjects and lack of placebo control and randomization, we find sufficient evidence for further investigation of MSC therapy as an alternative to more invasive surgery in patients with osteoarthritis of the hand.”(8)
In our research published by Caring Medical 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. Here are our highlights:
- Considered a conservative treatment in comparison to surgery, Prolotherapy is a simple procedure, in which solutions of dextrose are injected into the afflicted area.
- Sessions occur over a period of time. The number of injections administered depends on the individual’s progress or failure to progress. A series of injections 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.
- Patients typically need three to six treatments to achieve the best outcome, scheduled approximately four weeks apart.
- The procedure takes a few minutes.
- A patient could expect to receive 10-15 injections per session for basal thumb arthritis.
- Patients usually report a mild discomfort in the injected area that may last 24-48 hours after treatment.
- Normal activities can be resumed as soon as 24 hours.
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.(9)
Prolotherapy has also successfully decreased pain and the degree of deformity in a thumb with subluxation and deformity caused by rheumatoid arthritis.(10)
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.(11)
If you have question about Thumb Osteoarthritis Surgery Alternatives, get help and information from our Caring Medical staff
1 D’Agostino P, Dourthe B, Kerkhof F, Vereecke EE, Stockmans F. Impact of Osteoarthritis and Total Joint Arthroplasty on the Kinematics of the Trapeziometacarpal Joint: A Pilot Study. The Journal of hand surgery. 2018 Apr 1;43(4):382-e1. [Google Scholar]
2 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. [Google Scholar]
3 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. [Google Scholar]
4. Robles-Molina MJ, López-Caba F, Gómez-Sánchez RC, Cárdenas-Grande E, Pajares-López M, Hernández-Cortés P. Trapeziectomy With Ligament Reconstruction and Tendon Interposition Versus a Trapeziometacarpal Prosthesis for the Treatment of Thumb Basal Joint Osteoarthritis. Orthopedics. 2017 May 8. [Google Scholar]
5 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. [Google Scholar]
6 Gay AM, Cerlier A, Iniesta A, Legré R. Surgery for trapeziometacarpal osteoarthritis. Hand Surgery and Rehabilitation. 2016 Sep 30;35(4):238-49. [Google Scholar]
7 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.
8 Herold C, Rennekampff HO, Groddeck R, Allert S. Autologous fat transfer for thumb carpometacarpal joint osteoarthritis: A prospective study. Plastic and Reconstructive Surgery. 2017 Aug 1;140(2):327-35. [Google Scholar]
8. Centeno CJ, Freeman MD. Percutaneous injection of autologous, culture-expanded mesenchymal stem cells into carpometacarpal hand joints: a case series with an untreated comparison group. Wiener Medizinische Wochenschrift. 2014 Mar 1;164(5-6):83-7.[Google Scholar]
9 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. [Google Scholar]
10 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.
11. Loibl M, Lang S, Dendl LM, Nerlich M, Angele P, Gehmert S, Huber M. Leukocyte-reduced platelet-rich plasma treatment of basal thumb arthritis: a pilot study. BioMed research international. 2016 Jul 5;2016.[Google Scholar]