History: This is a 55-year-old, ambidextrous female who runs her own company. She has had 10 years of pain in her right thumb base. The pain has been getting worse over the past 1 year. She has intermittent symptoms, lasting about 2 or 3 weeks at a time. She has increased pain with grasping, such as opening jars. Her symptoms are also interfering with her work. She is a previous smoker, who quit in 1983. Previous treatments include:
- Thumb spica brace
- Steroid injections
Right thumb: Skin is intact. There is squaring at the thumb base, also called a “shoulder sign.” There is a bony prominence on the trapezium. She has an adduction contracture, but no significant metacarpophalangeal joint hyperextension. She has tenderness at the carpometacarpal joint with a positive grind test.
Lateral, oblique and Robert’s views of her right thumb are shown. She has marked narrowing of the carpometacarpal joint with bone-on-bone contact. The subchondral bone is sclerotic and there is a small subchondral cyst radially in the trapezium. She has large osteophytes, >2mm in size. There is minimal subluxation. The scaphotrapeziotrapezoid joint does not appear involved. She is Eaton stage 3 (osteophytes >2mm with no STT joint involvement).
Tests: Preoperative evaluation was normal.
Options: She has activity limiting symptoms and has already had a trial of injections and bracing. While hand therapy, anti-inflammatory medications, heat, ice, and creams and rubs can help with symptoms, she has poor symptom control with bracing and injections and is at a point where surgery can be helpful. Surgical possibilities include:
- Simple trapeziectomy—Most surgeons do not choose this option because of a concern that the thumb will settle, however, it can be just as effective as other procedures.
- Trapeziectomy and ligament reconstruction—This requires a small, but well-anchored tendon graft, typically using all or part of the flexor carpi radialis tendon.
- Trapeziectomy and tendon interposition arthroplasty—This may use any of a number of tendon grafts that is rolled and placed into the space where the bone was removed.
- Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)—This is arguably the most common procedure performed, repositioning and suspending the thumb.
- Implant arthroplasty—Most of these devices are experimental. Some implants, such as Orthosphere and Swanson silicone spacers, have had disastrous failures.
- Artelon spacer—This bioabsorbable material is designed to spare bone in lower grades of arthritis. Early experience suggests good results, but some have reported inflammatory reactions to the material.
- Arthroscopy with hemiresection and interposition—This is being done in lower grades of arthritis. Early results are promising. It is technically challenging to get an arthoscope in this small joint.
- Consideration can also be made for releasing the adduction contracture and correcting the metacarpophalangeal joint hyperextension, but she has minimal secondary deformity.
Treatment: She underwent a ligament reconstruction and tendon interposition (LRTI). She was in a splint until suture removal at about 10 days after surgery. She then wore a cast for an additional 4 weeks. She was transitioned to a brace and started hand therapy about 6 weeks after surgery.
Lateral, oblique and Robert’s views of her right thumb are shown. There are a few specks of trapezium visible in the soft tissues. There is a wide space between the scaphoid and thumb metacarpal, indicating a good soft tissue suspension of the thumb.
Outcome: 3 months after surgery, she was back to full duties at work and her pain was much improved compared to before surgery. She was quite pleased with her results.