Osteoarthritis of the thumb, most typically basal joint arthritis, is the second most common location for arthritis in the hand, but the most functionally disabling.
The function of thumb opposition and subsequent pinch are crucial for such daily activities as turning a key, opening a jar, or picking a small object off the table. No wonder pain and weakness from the base of the thumb is so functionally disabling!
The initial treatment of symptomatic basal joint arthritis is most often for pain relief. Anti-inflammatories, splinting, or even corticosteroid injections simply diminish symptoms, but do not provide a long-term solution. They do not alter the often inevitable course of progressive pain and even deformity. Although therapy may help in certain circumstances, in many cases it can actually aggravate symptoms. Because of this, we rarely recommend therapy for this condition. A wide variety of splints are available that allow the joint to rest and may minimize the pain, but the very fact that motion in this joint is important for hand function underscores the need for something other than splinting. Nonsteroidal anti-inflammatories (ibuprofen / naproxen / celebrex) have only temporary effect and are used simply for marginal symptomatic relief. The gastric complications of using these drugs should not be overlooked and patients should not use them long-term when seeking relief from simply one joint in the hand. Corticosteroid injections have a more prolonged effect but can have long-term deleterious effects on the joint cartilage or capsule.
Persistent pain demands that something more definitive be instituted for treatment. For this reason, surgery has generally been the most effective treatment in symptomatic cases. The problem is that until recently, there have been few surgical options, and those were often quite painful and required a prolonged recovery.
One of the earliest surgical treatments was complete excision of the trapezium, a small bone at the base of the thumb within the wrist. This simple operation was first described over 50 years ago. A more complex version of this procedure is termed the LRTI (ligament reconstruction tendon interposition) and has become the most commonly used surgical procedure for treatment of painful basal joint arthritis.
This relatively complex operation includes removing the trapezium bone, then stabilizing the area using a strip of wrist tendon. While the outcome for this is usually favorable, several problems remain with this operation. One problem is that the recovery process is relatively long and can be painful. The main problem, however, is that there are few salvage options if painful symptoms persist, because the trapezium has been removed, so few remedies are available to reconstruct the thumb, should the need arise. For this reason, other surgical approaches have been suggested to manage this common problem.
Just as in so many other joints, joint replacements are available and offer good alternative in older patients where demands are less and functional recovery is rapid. For higher demand patients, two newer arthroscopic options exist, depending on how advanced the osteoarthritis is.
The first open involves inserting an arthroscope into the joint and cleaning out any “spurs” that have formed. Then a small cut is made in the metacarpal, and the alignment of the bone is modified to bring it back to an anatomical position. This is maintained with a pin for several weeks, and then the pin is removed. The second option also involves inserting an arthroscope, but then a few millimeters of the trapezium is burred down, to eliminate the bone-on-bone area that causes pain. A pin is inserted in this case as well, to allow the body to create a fibrous cushion, so that the bone-on-bone area does not recur. This pin would also be removed several weeks later. Both of these procedures involve a short period of casting post-operatively (while the pin is in place), followed by hand therapy.