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After Surgery Instructions for Thumb Replacement Arthroplasty »

Symptoms
Pain is usually the most prominent symptom. The pain may be sharp (with activity) or aching in nature. It is located at the base of the thumb, but can radiate in several directions. It is often noticed with grasping activities or simple turning tasks such as opening a lid or buttoning clothing. Patients often relate that they drop objects that they are holding or picking up. Limited motion of the thumb can occur, and may affect the ability to open the palm as well as limit the movement in other thumb joints. Swelling and bony deformity of the joint may be visible. Catching and clicking may be felt and even heard. Weakness of pinch and grasp is usually present.

Diagnosis
The diagnosis is made by the history and physical examination, with confirmation by x-rays. X-rays allow the arthritis to be staged as early or mild, moderate, or severe.

Non-Surgical Treatment

1. Splints, which immobilize the wrist and thumb, are often useful. These splints should be worn on a part-time basis. Times to wear the splint would generally be during heavy activities, which bring on or flare the thumb pain, or during periods when the thumb pain is already flared. The splint is meant to immobilize the thumb and enforce rest for the inflamed joint.
   
   
2. Anti-inflammatory medications These should also be used on an as-needed basis, in conjunction with increased activities or periods of increased pain. There are many different medications available, and all are generally felt to be equally effective. Medicines like advil, motrin, and ibuprofen are simple and usually well tolerated. They should be taken with food, and preferably only when needed. A common starting dose is two 200 mg tablets 3 times a day. The most common side effect is stomach irritation, even leading to ulcers. Patients on blood thinners, patients with asthma, and patients with stomach ulcers or similar stomach problems should not use these medications. Some prescription anti-inflammatory medications are more expensive, but may be better tolerated by the stomach, and may need to be taken only once or twice a day.
   
   
3. Ice Application of ice may reduce inflammation and pain. Ice is generally most effective when applied right after work or activity that may flare the pain.
   
   
4. Moist Heat This modality may take the form of hot water bottles, heated moist towels, warm soaks, or even hot tubs. It is generally most effective when applied hours after work or activity, or even before exercise.
   
   
5. Cortisone Injections Cortisone will not cure or change the arthritis, but may help reduce painful flare-ups not being controlled by the above measures. It provides temporary relief. Up to three injections can be given.
   
   
6. Isometric Thumb Exercises Strengthening of the thumb muscles may take stress off the arthritic joint surface.
   
   
7. Supervised Therapy Therapists may be able to provide techniques and aids to allow activities so that less stress is applied to the thumb. Instructions in muscle strengthening can be given. They can also apply cortisone through ultrasound, which is less painful than a cortisone injection.
   
   
8. Nutritional Supplements Many patients are trying non-prescription supplements such as glucosamine and chondroiten sulfate, which theoretically help maintain and repair cartilage. Studies reviewing this medication are conflicting, but the majority of patients report that it helps.

Surgical Treatment
When symptoms and limitations become persistently frustrating, and are not adequately reduced by non-surgical measures, surgery may be necessary.

In early stages of this condition, before cartilage wear is significant, surgery may be available to prevent or significantly slow the onset of further arthritis. This includes either ligament reconstruction or a bone straightening procedure called metacarpal osteotomy. These two surgeries are most likely to preserve a near-normal thumb in terms of strength, motion and appearance, but again can only be done in early stages.

In later stages of this arthritis, when the cartilage cushion is significantly worn, there are two surgical alternatives:

1. The most common form of surgery is to remove one of the bones that form the thumb CMC joint, and replace it with soft tissue from an adjacent tendon. The bone that is removed is called the trapezium. A wrist tendon is used to rebuild a ligament for the joint, and then fill the joint space with soft tissue. A temporary pin is used to hold the joint in place for 4 weeks while the tissue heals. This removes the arthritis, and is usually very effective in eliminating the pain. This surgery is very common, and has proven to be excellent at relieving pain. Therapy is required, and recovery of strength is experienced for at least one year, with some studies showing strength continuing to improve over several years. This surgery should be long lasting, and subsequent surgeries are extremely rare.
   
   
   

   If this surgery is selected, you are admitted to the hospital on the day of surgery, and stay one night in the hospital after the surgery. A bulky dressing with splint is applied and worn for one week. After the first week, the bulky dressing is removed and a fiberglass cast is applied. The cast and pin are removed after 4 weeks and therapy is started at this point. A plastic splint is worn except for exercises and showering for the next 3 weeks. The splint is then worn gradually less over the next two months.
   
   

2. Another surgical option is to fuse the arthritic joint. This replaces the joint with bone, so that motion is lost. It does provide a strong thumb, with elimination of the arthritic pain. Surgery is done as above, with a bulky dressing for one week, cast for the next 3 weeks, and a splint for the subsequent 4 weeks. A bone graft may be needed. This surgery is more commonly performed in manual workers who are more interested in strength than motion. Because of potential arthritis in adjacent joints, this surgery may not be available for some patients.