Treatment Options

Arthroscopy

The concept of arthroscopy may be most beneficial in the early stages of basal joint arthritis. During an arthroscopy, a small tube connected to a high-definition camera is inserted into the joint through a tiny incision. An arthroscopic evaluation of this joint gives a surgeon the true stage of arthritis. During arthroscopy, your surgeon may also remove bone spurs, perform an osteotomy to realign the joint or be able to make recommendations for another form of surgical correction.

Advantages

The procedure is low-risk and performed in a minimally invasive fashion. It allows the surgeon to assess the joint better than routine x-rays which may allow a quicker diagnosis of your condition.

Disadvantages

The procedure is mainly indicated in the early stages of arthritis and may not be beneficial if it has progressed to the late stages.

Trapeziectomy (Traditional Procedure)

It is reported that 90% of all surgeries to treat basal thumb arthritis involve the removal of the trapezium bone, which is called a trapeziectomy². After removing the bone, most surgeries involve suspending the first metacarpal bone to the second metacarpal with either a suture or a tendon harvested from the forearm.  This is done to help reduce the risk of the metacarpal bone moving into the space where the trapezium was and shortening the length of the thumb.

Trapeziectomy with LRTI (Ligament Reconstruction with Tendon Interposition)

The most common procedure performed is referred to as an LRTI, also called the anchovy procedure. During this procedure, a surgical incision is made in the forearm and the FCR (flexor carpi radialis) tendon is split. An incision is then made over the carpometacarpal (CMC) joint and the trapezium bone is removed. A hole is then drilled into the base of the metacarpal where the FCR is passed through, and the remaining tendon is rolled up into a coil and inserted into the empty space created by the removal of the trapezium bone.

After the procedure, you will be placed in a cast. The amount of time in a cast will vary depending on the surgeon and patient, however, it is often required for 8-12 weeks and replaced with a removable thumb spica splint. After 12 weeks, grip strengthening, and pinching exercises are begun.

Advantages

The LRTI has been the gold standard procedure that newer procedures are often compared to. The majority of studies find that it provides predictable pain relief since it removes bone-on-bone contact. Finally, due to its popularity, there are many surgeons experienced in the procedure allowing most patients the ability to be treated locally.

Disadvantages

The LRTI has several disadvantages such as lengthy recovery, thumb shortening (subsidence), and limited to no revision options. While pain relief is often expected, complication rates can be seen in up to one-third of cases.^3,4  These complications can include symptomatic subsidence, pain, swelling, and wound healing. The biggest disadvantage is that there are few revision options, and studies show that revision LRTI patients reported significantly worse outcomes compared with primary patients.⁵

Trapeziectomy with Suspensionplasty

Another common procedure is called Suspensionplasty. This again involves removing the trapezium bone but instead of inserting a tendon into the joint, it is only suspended by either a suture or another tendon, typically the abductor pollicis longus (APL) tendon.

After the procedure, you will be placed in a cast. The amount of time in a cast will vary depending on the surgeon and patient, however, it is often required for 8-12 weeks and replaced with a removable thumb spica splint. After 12 weeks, grip strengthening, and pinching exercises are begun.

Advantages

The majority of studies find that it provides predictable pain relief since it removes bone-on-bone contact. If using a suture material to suspend the metacarpal, a tendon won’t need to be harvested. Finally, due to its popularity, there are many surgeons experienced in the procedure allowing most patients the ability to be treated locally.

Disadvantages

Suspensionplasty has the same disadvantages as an LRTI such as lengthy recovery, thumb shortening (subsidence), and limited to no revision options.

Joint Replacement (Implant Arthroplasty)

A joint replacement procedure involves removing the damaged cartilage and placing an artificial implant, similar to a hip replacement, in the joint to prevent bone-on-bone contact. There are two types of joint replacement, total joint replacement, and hemi joint replacement. A total joint replacement replaces both sides of the joint and requires a cup to be fixated into the trapezium bone and a stem into the metacarpal. A hemi joint replacement only replaces one side of the joint and will instead form a socket into the trapezium for the head to articulate into.

After the procedure, your hand is then placed in a cast for 2-4 weeks while your healing begins. After the cast is removed, grip strengthening and pinching exercises are begun. Most patients have unrestricted activity after 12 weeks.

Advantages

Joint replacement has many advantages including maintaining motion and a firm foundation for pinch and grip strength. Another significant advantage is that if joint replacement fails, a revision to a traditional procedure such as the LRTI is still available.^6-7

Disadvantages

There are a variety of joint replacements available and not all have the same success rates. It is important to choose an implant with clinical data showing successful outcomes. There are not as many surgeons that perform joint replacement so receiving local treatment may be difficult.