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Home / Surgical Options for Thumb Basal Joint Arthritis

Surgical Options for Thumb Basal Joint Arthritis

Posted on May 1, 2000 by Badia Hand to Shoulder Center

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Surgical Options for Thumb Basal Joint Arthritis

Author:  Alejandro Badia, M.D, F.A.C.S.

Section Heading SUB HEADING a report by
Alejandro Badia, MD, FACS
Hand & Upper Extremity Surgeon

Incidence

Osteoarthritis of the basal joint of the thumb is the second most common location for arthritis in the hand. However, it is by far the most functionally disabling. While distal interphalangeal joint arthritis is much more common, it is often minimally symptomatic, and the only good treatment option is fusion of this joint. This method of treatment is simple, and the results are reproducible with excellent return of function. Conversely, due to the many degrees of freedom involved in basal joint motion, the treatment is much more complex and the results less predictable. Not only is motion at this joint so functionally critical, but incredible stresses are transmitted across the basal joint even with simple, everyday activities. The forces seen at the tip during pinch, for example, are transmitted tenfold to the base of the thumb.1 It has been theorized that the basal joint of the thumb is what most separates us from other simians, and that its role in tool-making separates us from the remainder of the animal kingdom.

Conservative Management

The treatment of symptomatic basal joint arthritis is most often initially palliative. Anti-inflammatories, splinting, or even corticosteroid injections simply give pain relief—they do not alter the often inevitable course of progressive pain, and even deformity. Therapy plays little role in conservative treatment and may actually aggravate symptoms. For this reason, surgery has been generally the mainstay of treatment in symptomatic cases.The problem lies in the fact that so many different procedures are available, which either indicates that all of the procedures are effective or that perhaps no one procedure has really resolved the issue to a satisfactory degree. Regarding conservative treatment, it is often not effective because nothing is being done to change the joint itself. Since pinching activity is so ubiquitous in everyday life, the joint continues to experience stresses that propagate the symptomatic arthritis.A wide variety of splints are available that allow the joint to rest and may minimize the pain, but the fact that motion of this joint is important for hand function underscores the need for something other than splinting. Non-steroidal antiinflammatories have only a transient effect and are used simply for marginal symptomatic relief. Corticosteroid injections have a more sustained effect, but can have long-term detrimental effects on the articular cartilage or joint capsule. Persistent pain demands that something more definitive be instituted for treatment.

Surgical Options

One of the earliest surgical treatments described was complete excision of the trapezium. This was a simple operation, first described by Gervis in 1949.2 It is ironic that we have come full circle regarding surgical treatment, since Meals recently described a similar procedure in the literature nearly 50 years later.3 A more complex modification of this procedure has been described as the LRTI (ligament reconstruction tendon interposition). This has been, and remains, the most commonly used surgical procedure for treatment of painful basal joint osteoarthritis.4 This relatively complex operation combines several previously described procedures, encompassing the complete excision of the trapezium bone and stabilization of the metacarpal base, using a strip of the flexor carpi radialis wrist tendon in order to stabilize the newly formed joint. While reports in the literature are generally favorable in terms of the outcome, there are several problems that remain with this operation. One of them is that the recovery process is relatively long and can be painful. However, the main problem lies in the fact that there are few salvage options if painful symptoms persist. The reason lies in the simple fact that the trapezium has been completely excised. Once this bone, the pillar base of the thumb, is removed, there are few remedies available to reconstruct the thumb. Similar problems are faced after fusion, since the adjacent joints—which are frequently arthritic as well—can become more symptomatic. Reversing a fusion is a formidable task, and joint replacement may be the only option.

Total Joint Arthroplasty

For all of these reasons, a variety of different surgical approaches have been suggested to manage this common problem. As in so many other joints of the body, joint replacements are available. Unfortunately, some of the early designs were quite poor, and in cases of better implants, the selection criteria for patients were haphazard. The earliest implants were resurfacing implants that provided either little stability or tended to loosen. Silicone replacement became quite popular at the same time that Al Swanson was introducing a variety of other silicone joint implants in other joints of the hand.5 Frequent problems with instability, however, soon led to almost complete abandonment of this procedure, and the complications of silicone synovitis helped fuel this decline. In the hands of certain surgeons, the technique has been successful largely due to precise surgical technique that has often been difficult to reproduce.

In the past decade, total joint arthroplasty was revisited by using a semi-constrained, cemented implant that would allow freedom of motion in all axes while providing good stability at the interface.7 This option has not been popular amongst American surgeons, since early studies in the European literature show a relatively high complication rate, including loosening or dislocation.8 Careful scrutiny of these studies indicates that the implant surgery was applied to a wide range of patient ages and activity levels. Analysis of the literature does reveal that older patients had quite good outcomes with rapid recovery. There is little mention, however, of one of the main advantages of total joint arthroplasty—the fact that ‘no bridges have been burned.’ If the implant either fails or the patient is persistently symptomatic, the implant can be easily removed and the trapezium excised, allowing use of the standard LRTI procedure. Hence, total joint replacement remains a viable alternative in older patients where functional recovery is rapid, and there is a good salvage potential if necessary. While longterm studies are scarce, it is implicit that loosening of the implants can occur in scenarios where a great deal of stress is placed on the joint. For this reason, alternatives have been sought and a new concept has recently been developed.

Artelon® is a polyurethane urea material that allows for an interposition arthroplasty that would serve as a cushion for the joint to provide pain relief and also provide stability to the joint via its fixation method.A Swedish study documenting the early follow-up results indicates excellent pain relief with minimal complications.9 Again, one of the most compelling reasons to use it is simply that there are salvage options. If failure should occur, the implant can be excised and the remainder of the trapezium removed. As the procedure requires only several millimeters of trapezial excision, the underlying biomechanics of the thumb are maintained. Long-term studies are necessary, but this newer implant may solve the dilemma of allowing for a minimally invasive procedure with minimal bone resection, and provide adequate stability while allowing for biologic ingrowth at the new joint location. In certain scenarios, the implant may even be inserted arthroscopically and provide for a more minimally invasive procedure that accomplishes the same goals.

Role of Arthroscopy

The concept of arthroscopy may be most beneficial in the early stages of basal joint arthritis. The earliest presentation of this painful condition has few surgical options once conservative treatment has been exhausted. It is obvious that a 35-year-old active woman may not agree to a complete open excision of the trapezium, even when her symptoms are persistent. The other surgical options discussed are also relatively aggressive for the younger, active patient. Hence, failed conservative treatment of basal joint osteoarthritis in the younger, active patients remains a dilemma. However, there is now a viable alternative in arthroscopy.The patient who continues to have pain, despite several cortisone injections and prolonged splinting, may agree to an arthroscopic procedure. This is because a minimally invasive procedure at this small joint presents the same advantages that it does in larger, but more accepted, procedures, such as knee arthroscopy. An arthroscopic evaluation of this joint gives us the true stage of arthritis and minimizes the importance of radiographic staging. In fact, an arthroscopic classification has been suggested, and may well lead to the treatment options.10 For example, an arthroscopic stage one would comprise a joint with significant synovitis but no articular cartilage loss.This patient may gain considerable symptomatic relief by a simple synovectomy and, perhaps, radiofrequency shrinkage capsulorrhaphy. This roll of radiofrequency in small joints is only now being explored, but may present the same advantages that it has in larger joints.11 However, it can also lead to the same pitfalls as have been seen treating shoulder instability.12 Judicious use of this new technology is important, and further studies are necessary regarding its role in the treatment of small joint arthritis.

More advanced arthroscopic stages dictate more aggressive treatment. Stage two arthrosis, which indicates a focal articular cartilage loss, is a good indication to perform an osteotomy that alters the joint biomechanics. This is a previously described procedure that has only been recently revisited.13,14 Arthroscopic stage three implies nearly complete cartilage loss, and this would be an indication to either perform one of the open procedures, as previously described, or perhaps an arthroscopic interposition arthroplasty.This can be done with a free tendon graft as is done in the open LRTI procedure, or the Artelon® material can be used as mentioned. Therefore, arthroscopy allows us to treat much earlier stages of this condition in a minimally invasive manner, while giving us a true clinical picture of what is occurring.The same advantages that we have seen in other large joints are present in this joint, as well as others, such as the metacarpophalangeal joints. Further studies will determine the role of arthroscopy in the clinician’s treatment armamentarium.

Summary

As the population ages and continues to be more active, it will be necessary to provide different options for the painful osteoarthritic basal joint of the hand. Newer technologies, such as small joint arthroscopy, or advances in biomaterials will lead to greater treatment options at this small but critical joint. Resection arthroplasty, or fusion, will likely continue to have a role in treatment, but I suspect that over time it will not be the primary option as is currently the gold standard.

References:

1. Cooney W P, Chao E Y S,“Biomechanical analysis of static forces in the thumb during hand function”, J Bone Joint Surg Am (1977);59: p. 27.
2. Gervis H W,“Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint”, J Bone Joint Surg Br (1949);31:pp. 537–539.
3. Kuhns C A, Meals R A,“Hematoma and distraction arthroplasty for basal thumb osteoarthritis”, Tech Hand Up Extrem Surg (2004);Mar: 8: pp. 2–6.
4. Burton R I, Pellegrini V D,“Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty”, J Hand Surg Am (1986):11: pp. 324–332.
5. Swanson A B, de Groot Swanson G,Watermeier J J, “Trapezium implant arthroplasty. Long-term evaluation of 150 cases”, J Hand Surg Am (1991);16(3): pp. 510–519.
6. Sollerman J, Herrlin K,Abrahamsson S O, Lindholm A,“Silastic replacement of the trapezium for arthrosis–a twelve year followup study” J Hand Surg Br (1988);Nov; 13(4): pp. 426–429.
7. Braun R M,“Total joint arthroplasty at the carpometacarpal joint of the thumb”, Clin Orthop (1985);195; pp. 161–167.
8. van Cappelle H G, Eizenga P,Van Horn J R, “Long-term results and loosening analysis of de la Caffiniere replacements of the trapeziometacarpal joint”, J Bone and Joint Surg Br (1998);80 (1): pp. 121–125.
9. Nilsson A, Liljensten E, Bergstrom C, Sollerman C, “Results from a degradable TMC joint Spacer (Artelon) compared with tendon arthroplasty”, J Hand Surg Am (2005);30: pp. 380–389.
10. Badia A, “Trapeziometacarpal arthroscopy: a classification and treatment algorithm”, Hand Clin (2006);22(2): pp.153–163.
11. Fanton G S, Khan A M, “Thermal energy in arthroscopic surgery of the wrist”, Clin Sports Med (2002);Oct 1;21(4): pp.727–735.
12. Wong K L,Williams G R, “Complications of thermal capsulorrhaphy of the shoulder”, J Bone Joint Surg Am (2001);83-A Suppl 2 Pt 2: pp. 151–155.
13. Wilson J N, “Basal osteotomy of the first metacarpal in the treatment of arthritis of the carpo-metacarpal joint of the thumb”, Br J Surg (1973);60: pp. 854–858.

Tomaino M M, “Treatment of Eaton stage I trapeziometacarpal disease with thumb metacarpal extension osteotomy”, J Hand Surg Am (2000) Nov; 25(6): pp. 1,100–1,106.

 


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I had a really severe thumb break into 3 PCs. My Finger was in the shape of a Z. I remembered OthroNow and went to Dr... Badia. Was best decision I could make, had surgery next day and was successful. My thumb looks great and doing great. Their staff is amazing from full service of urgent care, to his doctor office staff, surgery center, and their therapy staff is amazing. I would highly recommend them especially for full service from beginning to end.read more
Lia L
Lia L
18:00 25 Jan 21
Not good for pediatric patients . Long wait time, so had a lot of ppl waiting. Would not let me wait on chaira... outside of xray room but rather in the outside waiting room even though my child was only 10. Don’t take pediatric patients if you can’t properly accommodate one guardian.read more
Maria Santos
Maria Santos
01:45 06 Nov 20
I am really satisfy with my hand surgery that was done by Dr. Alejandro Badia, and I want to thanks all the... professional personal and staff that always are very kind. I highly recommended!read more
Najlaa Bayram
Najlaa Bayram
03:45 02 Nov 20
Dr. Badia is an outstanding Dr and surgeon. I first sought his expertise, in late 2013, after a misdiagnosis and a... botched surgery by another Dr that left me with unbearable pain and unable to move my right hand for months.After doing some research online, looking for some excellent hand surgeons, a lot of articles came up praising Dr. Badia's expertise and competence. I sent him an email explaining what happened, how the pain started and asked for his opinion. To my surprise,I received a thorough response the same day with detailed information.I right then decided to drive 4hours to go see him; I must say it was the best decision I made. From the 1st visit, Dr. Badia performed surgery to fix the initial issue and later did another surgery to correct the botched one; I couldn't be happier with the results.Earlier this year, I slipped and injured my left wrist. I made another trip to Miami and once again Dr. Badia came to the rescue. He did surgery on my left wrist after the conservative treatment didn't fully help and at the same time did a cubital nerve release on my right elbow that instantly stopped the pain I've been having.I HIGHLY recommend Dr. Badia; he's a true expert and an outstanding surgeon. His staff is very kind, professional, friendly and truly cares.read more
danadenni
danadenni
21:18 17 Oct 20
My husband and I contacted Dr Badia for my hand issues. I had researched approximately five hand specialists in... Florida and one in New York city before I found Dr Badia about an hour away from us.My husband and I went to Doral, Florida and the minute I met Dr Badia I knew he was going to do my surgery.He has personality plus !!! and loves what he does. He is kind, patient and listens to his patients. He respects your hands !Dr Badia was highly recommended and I am so glad that we found him. He did the surgery on my hand and with a bit of rehab it healed better than I expected and my pain was gone !Dr Badias office personnel are wonderful ! It is quite obvious that they love working there with him and that they love their jobs. My husband and I have never experienced an office with so many helpful and caring people.We both recommend Dr Badia. We still drive to his office for anything to do with hand issues and he takes care of whatever it is. We both trust our hands ONLY to him ! He is a gem.read more
Yohann Dessureault
Yohann Dessureault
02:25 01 Oct 20
I first contacted Dr. Badia's clinic after I injured my hamate bone. I needed a surgery and someone in my family that... knew Dr. Badia convinced me that he was one of the best if not the best hand surgeon in the world. I am a high level Baseball player so I needed treatments in order to get back on the field as soon as possible. I have been able to book an appointment the next week which was great. I'm Canadian which made it tougher with my insurance company, but Dr. Badia's team has been really helpful with that, they sent numerous emails and even made some calls with the company to make sure I would not have any fees related to the consultation and surgery. The surgery went really well, without any complication and I don't think it would have been as quick and easy with anyone else than Dr. Badia and his team. I would definitively recomand Badia Hand to Shoulder Center to anyone in the need of treatments.read more
David Carvallo
David Carvallo
15:29 31 Aug 20
I injured my shoulder right as we entered into a lockdown due to a pandemic. It was next to impossible to get anyone to... see me and assess my injury. Dr. Badia and his team, following carefully laid out safety protocols, were able to bring me in, have x-rays, MRI and thorough review of the findings all in ONE visit!!! I was given an interim treatment plan to bridge the gap as surgeries were restricted due to COVID-19. As soon as surgeries resumed, I was scheduled for my procedure. To say that both Dr. Badia and his team are amazing is an understatement.They helped me handle a difficult insurance approval process to ensure I had the best surgeon treating me and my procedure at The Surgery Center at Doral and communication with my PCP and Cardiologist was excellent.Everyone made me feel very safe and confident that I was in the best possible setting where I wouldn’t be exposed to needless risk in a traditional hospital. The results of my surgery so far have been amazing. I’ve had next to no pain post-op and my recovery is coming along at lightning speed thanks Dr. B’s amazing talent and the dream team he has at OrthoNow where I have been undergoing physical therapy. I couldn’t say enough good things about him and the team. His expertise and dedication to providing the best possible care using cutting edge technology make for patient centered care and well being vs. insurance driven red tape so often seen today. Highly recommend Dr. Badia!read more
Ruth Rheaume
Ruth Rheaume
22:34 11 Aug 20
I went to Dr. Badia with a bad infection in my nail. He is so good at what he does and took care of me with such... concern. Gigi is the sweetest, cutest thing ever, who also made sure that I was comfortable and helped so I would not be nervous. The whole staff makes you feel like family. Thank you everyone from the bottom of my heart and I would recommend Dr. Badia's expertise and his office to anyone. So, if you have an injury or a problem, please go see him.read more
Mark Ferry
Mark Ferry
20:51 05 Aug 20
Tele-med conference with Dr. Badia and staff regarding "golfer's elbow"
Richard Chung
Richard Chung
11:49 23 Jul 20
Staff was very welcoming and accommodating.. Dr. B. was very professional and caring.He seems to be a driving... innovator and in improving the lives of patients in the South Florida area.read more
julio hernandez
julio hernandez
17:05 15 Jul 20
Dr Badia is the best orthopedic surgeon in Miami hands down. I need surgery because of a multiple fracture in my left... forearm. Went to other doctors (UM, mount Sinai) and they didn’t promise me I would recover 100% of my injuries and told me I would not be able to do sports again.Dr Badia did tell me I would heal 100% and it’s true. I did a much simpler surgery and fixed me in no time.Would recommend to anyone. Two thumbs upread more
Deb Duro
Deb Duro
17:19 07 Jul 20
Wonderful practice very welcoming staff and amazing service with top notch technology. I was a patient and I am a... colleague of Dr Badia and had the best treatment for my hand injury got diagnosed in the spot with a 3D Ultrason super modern technology and treated at the same moment. Really superb experience being a physician I absolutely recommended Dr Badia Hand and Shoulder Center at OrthoNOW!read more
Leonard Wolfson
Leonard Wolfson
19:42 04 Nov 19
Excellent visit. I injured my finger yesterday and was seen today by Dr. Badia. The staff was friendly and very... efficient and the doctor spent more than enough time explaining what was going on and explaining my options. Truly a great experience.read more
Luisa Alfonso
Luisa Alfonso
16:25 06 Sep 19
The Dr and staff are professional and friendly. I’m happy I came here and I received the attention and answers I... needed. I had injured my hand and I left the office feeling better. Thank you all for everything!!!read more
Robledo Aybar
Robledo Aybar
16:30 09 Aug 19
Due to a fall, I fractured my wrist in late Nov. 2018. Dr Badia and his team helped me overcome this issue and today... I’m working, and back on my bike and running. The best service and experience!read more
Ellen Westbrook
Ellen Westbrook
23:08 29 Jul 19
Staff displayed professionalism and caring. Dr. Badia was as enthusiastic as I was about this surgery to improve the... function of my hand. The surgical day process was smooth; I was kept informed every step of the way. I felt comfortable and safe.read more
victor mendelsohn
victor mendelsohn
02:37 30 May 19
From the first call I made to Dr. Badia‘s office I was impressed by the professionalism of the person who answered the... phone. When I arrived at the office for my appointment I was once again greeted in a professional manner. This professionalism radiated through all of the team. I hadn’t seen Dr. Badia for over 10 years and he greeted me as if we’ve been in contact with each other for years.read more
Alexander Aguiar
Alexander Aguiar
18:19 24 Apr 19
From my first visit the staff as well as the Dr. Badia have been exceptionally professional and caring. I had an injury... to my pinky finger, the required a placement of a rod in order to align. The surgery went well and was scheduled right away. The office staff has been amazing with scheduling and confirming appointments. Overall I am very happy with the care i received as well as the results. My finger healed and my range of motion has also gotten much better. Thank you Dr. Badiaread more
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305 227-HAND (4263)

3650 NW 82nd Ave. Suite 103
Doral, Florida 33166
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Badia Hand to Shoulder Center
Complete Care of the Hand, Wrist, Elbow and Shoulder in one Medical Facility Dr. Alejandro Badia, M.D, F.A.C.S. Past President ISSPORTH (2011-2013)
Our Office Hours:
3650 NW 82nd Ave, Doral, FL 33166, USA - Badia Hand to Shoulder Center
Monday 8:30 AM – 5:00 PM
Tuesday 8:30 AM – 5:00 PM
Wednesday 8:30 AM – 5:00 PM
Thursday 8:30 AM – 5:00 PM
Friday 8:30 AM – 5:00 PM
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305 227-HAND (4263)

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