Basal Joint Arthrosis of the Thumb - Stephen Powell, MD

Sechrest: Hello I'm Dr. Randale Sechrest, your host for eOrthopodTV. Today we are talking with Dr. Stephen Powell. Dr. Powell completed his medical training at Indiana University. He then went on to complete an orthopedic residence at the University Hospitals of Indiana. He did two fellowships. The first fellowship was an arthritis fellowship in Denver and then completed a hand surgery fellowship in Indianapolis, IN. Today we're going to be talking about a fairly complex problem in the hand balled basilar joint arthrosis. This is a wear and tear phenomenon that occurs at the base of the thumb. Good afternoon Dr. Powell.

Powell: Hello Randy.

Sechrest: Give us a little insight into basilar joint arthritis. This is also called, I think, carpal metacarpal arthrosis and that refers to the joint at the base of the thumb. So, tell us what this is about.

Powell: The base of the thumb is comprised if I can show you with my own hand, of the joint between the thumb metacarpal which is the first long bone of the thumb and a little bone you can't even see called trapezium which is a saddle shaped squarish type bone at the base of the metacarpal. The thumb metacarpal rolls over that bone and in many patients, the patients we are talking about today, that joint will become arthritic or have an arthrosis, roughness of the joint, bone spurs developing, narrowing of the joint and eventually sometimes subluxation of the joint where the joint actually comes out of the space that it's supposed to be in due to the bone deformation ligament disruption and a whole host of changes in the thumb and severe cases will draw into the palm. The other part of the thumb may go backwards and hyperextend so that it's a rather zig zag looking thumb in many people. Typically we see it in ladies. Ladies have it probably 9-1 10-1 compared to men. Typically it's something that happens in the 50, more commonly 60-year-old age group and up.

Sechrest: And, why? Why do we see it more in women and why do you get this one joint in the thumb that seems to wear out?

Powell: You know, that's a very good question. I don't have the answer for that. If you have the answer I would be happy to hear it.

Sechrest: Well, it's funny because I've been talking to patient's, it's easy to explain to them why their knees wear out and we're putting artificial knees in, it's relatively easy to think about the hip as a weight bearing joint. But, I think, I guess the way I've always thought about it is the fact that this is an incredibly used joint.

Powell: Especially when we consider the thumb half the hand. With the percentages of impairment when someone's lost their thumb, it's just about half the hand. It's very important, a lot of use out of their thumb. So, there is a lot of motion that's required. That thumb joint goes all the way from full straight all the way across the palm and in both directions. Toward the palm and away from the palm. The other fingers only move up and down. So, there's a lot of complexity to the motion arc in that joint.

Sechrest: Now, do you have any idea about non dominant versus dominant hand. I'm assuming this is a dominant hand more likely.

Powell: It is more often in the dominant side, yes.

Sechrest: But you do see it in the opposite hands.

Powell: That's correct.

Sechrest: I mean, sometimes you see it in both hands in people who really don't have any reason to have it.

Powell: That's right.

Sechrest: If I'm a 55-year-old female for example and I start having pain and I think I've got something going on in my hand, what is basal joint arthrosis cause? What kind of pain does it cause?

Powell: Patients will talk about pain in their thumb or their wrist because it really is in the junction of the thumb on the wrist. Some people will complain of pain going around the top of the wrist and down into their palm and/or shooting pain going out into their thumb. It's usually with a pinching motion that they feel, going to open the car door that has a knob or opening a cupboard that has a knob on it and pushing like that. Those types of things with the pinching and pushing of the thumb seem to cause the pain in that area.

Sechrest: You know it's interesting, I used to see patients who would come in and they thought they had carpal tunnel syndrome. That was their interpretation of what was going on and then when you really get down to them and start talking to them they come in and they tell you they've got carpal tunnel syndrome and some physician has perhaps has told them that. And really, when you really get down it it's the thumb that's really their problem.

Powell: That's right, I don't think it's as readily diagnosed by non orthopedic physicians.

Sechrest: I think that's true. So, how do you make the diagnosis? If the patient comes into the office, I guess first, what is the typical story you hear from these patients? What are they complaining of and then how do you go on to make that diagnosis?

Powell: As I said, the complaint of pain in the wrist and/or the thumb. Shooting out in the thumb, sometimes shooting up into the forearm area past the wrist. Pinching hand use are the things that cause it. They typically have a case of early arthrosis and when they start having it it's more of a mild ache with occasional thumb pain with use. As it becomes more severe, they'll starting having pain all the time and they'll talk about sharp and severe pain with pinching of the thumb. When we examine the patient, it really varies in what the thumb looks like. Sometimes patient's will have a hand that looks perfectly normal, they may have just a little bit of swelling in the base of the thumb down at the base of the thumb, metacarpal. Some patients on the other hand, even though they just started having symptoms may have pretty significant deformity with the base of the thumb sticking out quite a bit and perhaps the thumb drawn into the palm with inability to bring it back and get out of the palm to be able to grasp well. The patient's thumbs will be tender at that point. It's pretty typical pain at the base of the thumb. There are other things that can be arthritic in the thumb as well and you have sometimes concomitant or coexisting arthritis in other joints but the pain at the thumb base is the classic tenderness for this disease as well as crunching and popping, what we call crepitus when we roll the thumb metacarpal around on the trapezium.

Sechrest: Yeah, you can usually just grab it and put your fingers and pinch that joint and they'll tell you that that's right where the pain is.

Powell: That's correct.

Sechrest: Special test. What do we need to do after we suspect that this is basal thumb arthritis or arthrosis? What tests do you do at that point?

Powell: Well, for that disease, an x-ray is the diagnostic study.

Sechrest: So, get plain x-rays of the thumb, look at that joint and see how much descruction there is and what the anatomy of the area is.

Powell: That's right and there has to be some special view of the thumb that is looked at. Some plain x-rays of the thumb might not show that as well as the specific for that basilar joint. So, that's an important part of it.

Sechrest: So if I'm a primary care physician watching this video, there is a special x-ray then. You can't just get a hand and always see it.

Powell: That's right. If you don't have the patient roll their hand over for what we call AP view of that joint, then you're not going to see that joint in profile very well and not going to be able to see how much narrowing of the joint space they have as well as a good lateral.

Sechrest: Okay, so they should alert the radiologist that's going to look at the film or the radiological tech that's taking the film that you need a specific view for the basal joint.

Powell: Yes, what you're looking for is the basilar joint.

Sechrest: Okay, and any other tests that we need to do? I mean, is x-ray it?

Powell: Well, that makes the diagnosis. You know, there are people who have other things going on. They may have some carpal tunnel problems with some atrophy of the thenar muscles that are adjacent to that joint and you see some atrophy and you may be concerned about that so you may inquire or examine them or even study them with nerve studies. But, as far as the joint itself, the x-ray is the diagnostic test. In really early cases, the pain may be a little vague and the x-ray may be pretty normal looking. Sometimes and injection or just some numbing medicine, some Marcaine or Xylocaine, maybe put a little cortisone in there along with it as a treatment if you know that's what it is but the diagnostic study with some Xylocaine in the early cases won't tell you whether that takes the pain away or not.

Sechrest: So, put that right into the joint.

Powell: That's correct.

Sechrest: And that takes the pain away and they can move and then you sort of know that's where the pain is in that joint.

Powell: Right.

Sechrest: Is this associated with any other diseases? Is there anything when you see this disease you say I need to check for this disease as well.

Powell: No, you know, people with rheumatoid arthritis can get this, not as commonly as other joints that bother them. They have other joints that bother them more. There is an association with hip arthritis to a slight degree with the osteoarthritis of the hip, but no specific systemic diseases that otherwise cause carpal, metacarpal joint or basilar joint arthrosis.

Sechrest: So, that's interesting. I mean, so you think there is a genetic component to the women and some of the men that get this? That they're just more prone to osteoarthritis?

Powell: I think that the genetic part is certainly in the women's situation. I think men and some women may have some trauma that has played a role in it.

Sechrest: So they've injured that joint in the past?

Powell: That certainly can, yeah.

Sechrest: And then it's worn it's way out.

Powell: That's right.

Sechrest: So once you see this disease and you're pretty confident that this is the diagnosis and maybe you've done an injection to confirm it or done x-rays and you're convinced. What do you do at that point? How do you treat this?

Powell: Well, the first thing I do with patients who haven't had it for years, who come in and say I've had this for six months, twelve months, something like that, is I let them know that the natural course of the disease is not necessarily one that requires surgery. I have many patients who come in that have terrible pain and six months later the pain has gone away and in a year or two they'll have an occasional pain when their gardening or something. The joint looks terrible on x-ray. Their joint may look terrible in real life but it does not hurt anymore. And you'll see many 80-year-old, 70-year-old ladies who say oh yes it used to hurt back a while a go maybe in my 50s or my 60s, it doesn't look very good but it works fine. So, I let them know that more often than not the patient will get through the severe pain and not require any surgical treatment.

Sechrest: What do you think is going on there? I mean, why do you think that this joint goes through that process and then stops hurting?

Powell: Well, you have to understand that we're using the word arthrosis, but the word arthritis also applies and their arthritis means inflammation of the joint. And, whether the inflammation of the joint is the primary thing that happens in that joint, whether it's secondary to the changes that occur for whatever reason, stretching out the ligament between the two metacarpal bones and the bone slides this way perhaps, an injury to the joint, something that causes the joint to be inflamed will cause it to be painful and sometimes that arthritis may go away. The other thing is, if you look at a lot of those bones surgical, they don't look rough anymore, they look like two cue balls that are rubbing together and the bone doesn't have the grinding frictional change any more and that may be what it is.

Sechrest: So it sort of polishes itself into an artificial joint so to speak.

Powell: And, I think it's both of those things myself. I don't know that we have any good evidence as to exactly why that is, but it's certainly the majority of people that go through that very symptomatic phase to a pretty good phase.

Sechrest: So, during that phase where it's inflamed and you're not sure whether it's going to go through that phase and become painless, how do you treat it?

Powell: We'll do whatever we need to do to make the patient comfortable. I don't think treatment that I do changes what happens five years from now or next year. I may make them feel better but I think their arthritis or not progress regardless of what I do. If the patient is not doing too badly, you know, I'll let them know that they can rest their hand, avoid certain activities and that may be all they need. If it gets worse, we will do more, or if they're already having more symptoms, we might have our therapist make a splint that only incorporates their hand just below the wrist or above the wrist depending on how you look at it and leaving the thumb metacarpal phalangeal joint and the last joint free so they can still use their hand and their wrist and that rests the thumb. And, very many people who will wear it find that that's helpful. A lot of people leave them in the drawer and they just don't like wearing it because they don't like to put them on. So, I don't push those on people because of the issues of being inconvenient to wear. Cortisone injection as I mentioned, the steroid injection may be with the Xylocaine but specifically I know that's the diagnosis. I will very frequently offer then a cortisone injection into that joint which is a corticosteroid synthetic compound that cuts down on inflammation and very frequently an injection, not repetitive injections will help them and maybe get them on their way to that asymptomatic phase.

Sechrest: Okay, and how long to expect that injection to last?

Powell: Either zero or infinity months. It really varies.

Sechrest: Any, any medications, any pills or anything? Do you usually prescribe anti-inflammatories? Any pain pills?

Powell: I don't think that anti-inflammatory medication medications help that disease very much but some people get some benefit out of it and I certainly talk about that with them.

Sechrest: So, when do you decide on surgery? I mean, when do you finally say we're going to have to do something with this.

Powell: Well, clearly if it's somebody who has failed the period of time when I would expect them to be getting better in a period that their happy, that they're getting better. You know, it's a long enough period of time that they say, I'm tired of this and I want to get this fixed, or it's been going on in a progressively downhill way for two or three years and they are just finally at that point where they want to have surgery. In early cases I would certainly not recommend surgery.

Sechrest: So, how do you fix this? I mean, what surgery would you recommend and what are our options for surgery?

Powell: The operation that's most frequently done is called a soft tissue replacement arthroplasty. In that case the little bone that I mentioned that's a little square saddle shaped bone at the base of the thumb metacarpal is removed either through an incision on the top or the bottom of the thumb and in that case you have a space that is there. The ligament between the two metacarpal bones is not very stout in these people, it stretches out. So, you reconstruct that ligament and the way you do that, you take a tendon that goes up your forearm and attaches right to the base of the second metacarpal conveniently and you use that to make the new ligament by making a drill hole in the base of the bone. That holds the thumb metacarpal over where it's supposed to be better, suspending it in space and usually almost always the rest of the tendon will be rolled up into a little graft plug, some people call it an anchovy 'cause it looks like an anchovy on a pizza, and stick it inside that space and close all the layers over the top of that and then allow it to rest in a cast for about six weeks, putting it in a splint for the first couple of weeks 'cause of surgical swelling and then the patient takes it off and pretty much starts to use it as they are able to without having much in the way of physical therapy required usually. There are other operations which are coming and going sometimes. They gain favor and they lose favor. There are some artificial joints that you could put in there, there are silicone, rubber joints that you can put in there. Silicone has had some bad press and some complications so that's not used very typically but if you poll the hand surgeons across the country, I would suspect that 90% of the hand surgeons will use the operation that I described.

Sechrest: So this is not one that we've got a good useful artificial joint for yet that people prefer over the older technique of the soft tissue reconstruction.

Powell: That's correct.

Sechrest: Any pearls about that operation? Any loss of strength? Any loss of motion?

Powell: Well, you're not starting out with a normal thumb. To make that thumb that has some deformity normal, again is a tall order and you're not making it by reestablishing the normal anatomy. You're changing the anatomy totally. So, typically what people will notice is that they may not have as much motion in planes that they really don't notice. The one that they typically lose the most is the ability to bring the thumb up flat with the rest of the hand. They tend to be down a little bit. Fortunately they tend to have good function this way, back and forth. They may not come back quite as far because of the stretching out of the structures here and many people will tighten up these tendons on that side to try to make it tighter. As far as strength goes, it probably isn't as strong as an uninjured, unarthritic joint but it's stronger than it was before the patient had surgery. The other procedures have not shown that they're any better as far as causing good strength in the hand after the surgery.

Sechrest: You've covered most of this, but what is the post operative rehabilitation? You're in a cast for around six weeks or a brace for six weeks?

Powell: Yes, I put the patients, myself I put them in a brace type of a thing, a splint or plaster over a bulky dressing to control bleeding and swelling. And then when the swelling is gone down after surgery, I put them in a cast for an additional four weeks after the first two weeks of the plaster splints.

Sechrest: And then do you send them to a physical therapist at that point? Is this something that they tend to do the rehab on their own? The nice thing about the thumb is that once you start to use your hand you can't stop using your thumb. So, people pretty much rehab their thumb with the exercises that I describe without therapy. If I am seeing a problem gaining motion or gaining strength back, I may have a therapist see the patient. But, probably the most common cause for sending somebody to therapy is if they're having some soreness in the area of the scar and I think they need to have some inflammation work done by the therapist.

Sechrest: And how long do you think it is for people to completely recover from this operation to where they can pretty much forget this has occurred to them and go about their business?

Powell: I think by three months they're pretty happy with it. By six months if they have done as the vast majority of people do, which is well, they're pretty much on their own without thinking about their thumb very much.

Sechrest: Now, is this an outpatient procedure? Is this something you have to stay in the hospital for?

Powell: Outpatient, either in the hospital or a surgery center?

Sechrest: And type of anesthesia? Is this something you can do under a block? Is it a general anesthesia or does it matter?

Powell: As long as the patient is not having pain, you can do it either way.

Sechrest: Okay. People are always interested in complications and always interested in what you as a surgeon worry about and what you tell patients. With this operation, what are you worried about?

Powell: Well, any surgical procedure has a risk of injection. That's very unusual, very uncommon in this procedure. There are some patients who don't get as good of pain relief as you would like. I'm not sure that's a complication, it's just the outcome isn't as good for them. There are nerves that run on both sides of the wrist going down to the thumb that can be irritated by the incision and the retraction and perhaps injuring very tiny nerves and some people have more sensitivity in the area of the surgery than you'd like to have and so a painful scar is probably one of them. We tell patients that they may have some stiffness as far as not being able to bend the thumb back or down as far as they'd like. One of the things we didn't talk about is that the real severe cases of this disease as the thumb draws in, preoperatively the patient can't get the thumb back, they'll start to back bend at the joint at the metacarpal phalangeal joint and that may require treatment to stabilize that joint as well and if you don't do that, and sometimes you don't think it's bad enough, sometimes they'll back bend more than you'd like and their thumb may be a little weaker than you'd like.

Sechrest: Now, when you say stabilization, are you fusing that joint?

Powell: You can either fuse it or tighten up the ligament.

Sechrest: Anything else that we haven't covered on this disease process? Anything that you can think of that patient's need to know before they choose to have surgery for basal joint arthrosis?

Powell: No, I think the real take home on that disease is that it's typically a disease that will get better with time. If you've had a pretty significant period of time that it's not getting better but it's gradually getting worse, months and years, it's probably something that's going to need surgery when it's bad enough. The good news is that without trying to sound like a salesman, it's one of our more predictable operations with a small percentage of people who don't get benefit from it.

Sechrest: Well, corollary to that discussion is, is that this is a more complex hand operation than some of the hand operations that general orthopedists do. Is this an operation you think should be done by a hand surgeon? If I'm a patient looking to have this done, should I choose to have it done by a hand surgeon or is this something that most orthopedic surgeons would feel comfortable doing.

Powell: I think the vast majority of these operations are done by hand surgeons for the reason that you just mentioned. I think that a well trained orthopedic surgeon in hand surgery who is not a hand surgeon but has had experience and can do this well but typically that training is found in specialization of hand surgery.

Sechrest: So if I went to an orthopedic group that had six or eight orthopedists and I say the first orthopedist that was available, they would probably refer me to the hand surgeon in the group to have this done.

Powell: That's correct.

Sechrest: Anything else that you think we ought to let patients know about this problem.

Powell: I can't think of anything, I think we covered it pretty well.

Sechrest: Well, thank you.

Powell: Thank you Randy.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.