Houston Methodist. Leading Medicine

Hand FAQ

Question:

I know this may not sound like much, but I have terrible thumb pain from arthritis from playing competitive ping pong. I really hate to give it up, but I'm not a candidate (yet) for a joint replacement. Are there any options for people like me?

Answer:

The first step in treating carpometacarpal (CMC) (thumb) joint pain is usually conservative care. Nonsteroidal antiinflammatory drugs (NSAIDs) are often the first line of defense. Over-the-counter products can be tried but most doctors prefer to prescribe something a little stronger for patients who have disabling pain. The second recommendation is to see a hand therapist. This is usually an occupational or physical therapist. The therapist can show you ways to protect your thumb and reduce the shear and compressive forces transmitted through the joint. Splinting or bracing may be appropriate to also help reduce the load. Techniques such as manual therapy and joint mobilization can be used to reduce the pain, restore more normal alignment, and improve function. Strengthening the muscles around the joint can also help reduce the physical stress that leads to degenerative changes and the resulting pain. The therapist may also use modalities such as deep heat or electrical stimulation to help reduce the pain. If a series of treatments over a period of three to six months does not alter your symptoms or function, then surgery is often the next step. So, if you've arrived at surgical options without completing this first phase, take a step back and give nonoperative care a good try. However, if you've already been through therapy and surgery is the next step, then there are a couple of approaches that can help restore painfree motion and function. For example, there is the extension osteotomy, an extra-articular (outside the joint) procedure. It is done by removing a wedge- or pie-shaped piece of bone from the metacarpal above the CMC joint. A wire is used to pull the opening (made by removing the bone) closed. This procedure changes the angle of the metacarpal bone where it connects with the wrist and brings it more into a neutral position (normal alignment). Younger patients and anyone with less advanced disease can qualify for an extension osteotomy. The main advantage of this procedure is that it doesn't mess with the joint itself. That means patients can still have joint reconstruction or joint replacement sometime in the future should they need it. Another possibility is the traditional operation for treating CMC joint arthritis. This is resection (excision) arthroplasty. This method has been used for many years and has withstood the test of time. Patients with severe symptoms in later stages of CMC arthritis who have failed nonsurgical treatment are good candidates for resection arthroplasty. The purpose of resection arthroplasty is to remove the arthritic joint surfaces of the CMC joint and replace them with a cushion of material that will keep the bones separated. The trapezium bone in the wrist next to the thumb is removed in a procedure called a trapeziectomy. A rolled up piece of tendon is placed into the space created by removing the bone. This procedure is called a resection arthroplasty with ligament reconstruction and tendon interposition (LRTI). During the healing phase after surgery, this tendon turns into tough scar tissue that forms a flexible connection between the bones, similar to a joint. Sometimes the surgeon uses a silicone-based or metal implant or disc made of costochondral tissue instead of a rolled up tendon for the interpositional material. Costochondral allografts are plugs of tissue taken from the material between the breastbone and the ribs. Resection arthroplasty with or without LRTI can be combined with a ligament reconstruction of the joint. Tendons in the area are used to create a ligament sling between the metacarpal bone of the thumb and the carpal bone of the index finger. This helps hold the thumb in place and keeps the space between the bones from collapsing. Fusion of the bones or joint replacement are final options to consider. But because these two operations have permanent effects, younger patients are usually steered to some of the other choices first. Talk with your surgeon about what would work best for you. There are many younger patients who benefit greatly from some of these other more conservative approaches before considering something joint replacement. Wendy L. Parker, MD, PhD, et al. Long-Term Outcomes of First Metacarpal Extension Osteotomy in the Treatment of Carpal-Metacarpal Osteoarthritis. In The Journal of Hand Surgery. December 2008. Vol. 33A. No. 10. Pp. 1737-1743.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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