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Facebook Live: Dr. Todd Wurth and Laura Davis on CMC Arthritis

Dr. Wurth, Tell Us A Little Bit About Yourself And What Specialties You See Here At Bone And Joint Institute

Dr. Todd Wurth: My subspecialty is predominately shoulder, elbow, wrist and hand. At Bone and Joint, by and large we all do – to some degree – general orthopaedics but the majority of us are subspecialty trained so we have areas of clinical interests that we’ve had additional training in and mine is predominately upper extremity surgery.

Originally I was born in Tennessee, grew up in Kentucky and did my residency at Indiana University. I went to medical school at the University of Louisville in Kentucky, did my orthopaedic residency at Indiana, and a year of fellowship in Pittsburgh before coming to this, my one and only job.

Laura, Tell Us A Little Bit About Yourself and What You Do Here At Bone And Joint Institute

Laura Davis: I was born and raised in Middle Tennessee. I began occupational therapy in 2002 and then in 2004, started in upper extremity occupational therapy focusing on orthopaedic treatment of shoulders down to the hand. I’ve actually worked with Dr. Wurth here for almost 18 years.

We’re Talking About CMC Arthritis. Can You Explain What Is It, Where Is It?

Dr. Wurth: CMC Arthritis is also known as Basal Joint Arthritis or Basalar Thumb Joint Arthritis. There’s a joint at the base of the thumb that’s involved with this condition that’s very common, it’s the second-most common joint involved with arthritis in the hand next to the finger tips. This is one that can be very debilitating. Patients will usually notice first pain when trying to open jars and it progresses and effects grip strength. As you can imagine, there’s not much in life you don’t do without using your thumbs so Basalar Joint Arthritis is common. There’s, to a degree, a genetic predisposition to it but you can have post-traumatic findings with that. It’s a bit more common in women then men but we see it in both. It causes significant morbidity for people in their lives. 

What Are Some Treatments? Conservative? Surgical? A Combination Of Both?

Dr. Wurth: Conservative management of CMC Arthritis is predominately anti-inflamatories – either oral like Advil or Aleve or something prescription or topical modalities you can use. We do splint them, and we consider occasional cortisone injections. They’ve looked at other things, other types of injections which have not yet proven to be really successful. There’s a lot you hear about stem cell and whatnot. The stem cell realm has not gotten to the point where we’re re-growing cartilage with that. True stem cells are government sanctioned and you can’t get ahold of them unless you’re a research facility. A lot of stem cells that are being used in the public today are maybe a combination of some stem cells and then other cells that are also involved with that. There can be some improvement with some of the symptoms but it’s just symptom improvement – they’re not re-growing the cartilage. I always caution people about that. I do think, though, it does hold promise. Research will get there, and we’ll be able to treat a lot of orthopaedic modalities with that in the future but we’re just not there yet.

Can You Explain What You Do In Surgery To Assist?

Dr. Wurth: There’s different ways you can address arthritis surgically. The biggest question I get asked is “When should I do this?” It’s a joint replacement so it’s like any other joint replacement if you’re replacing a shoulder or hip or knee, you can do it at any point. My guidance to my patients is “When it gets to the point where your arthritis is keeping you from doing the things you want to do or need to do in your life, then I’d think about getting it done.”

The way I personally take care of CMC Arthritis and my surgical technique is, there’s a bone at the base of the thumb that is involved with an arthritic process called the trapezium. I remove that bone completely and then I also transfer a tendon, so I release a tendon from the forearm. A tendon is a structure that attaches muscle to bone. So I release that tendon from its muscle attachment, maintain its bone attachment, but use that tendon to stabilize the thumb in the absence of that bone that I removed. That’s the key, you can remove the bone and that provides pain relief but if you don’t have stability to the thumb then that can lead to long-term problems several years down the road. I want the procedure that will provide a life-long lasting effect for my patients. This is a procedure that was first described back in 1985, it’s been around for over 30 years, it has changed a little bit throughout the years – predominantly in the 90’s – but the principle has stayed the same. It’s a reproducible surgery, a common one we perform here and patients typically have really good outcomes with that.

After Surgery, Take Us Through Recovery And Your Role As An Occupational Therapist In Recovery

Davis: Typically after surgery, we see patients between five and seven days postoperatively. They come in in a bulky dressing after their surgery, we remove that. It’s then a lot of education in the beginning. In the beginning, we make a custom splint or orthosis to protect that joint because again, the success of this is all about stability so it’s not therapy that pushes range of motion or pushes strength, it’s very much letting it heal, letting the thumb get stable.

For the first four weeks, we’re keeping that thumb pretty still but making sure people get their fingers moving, their wrists moving, not getting stiff and controlling swelling and pain. Then at about four weeks post-op, we start moving that thumb. That’s all about gentle motion, it’s all about getting a functional thumb, a functional range of motion. Oftentimes I tell people “Your thumb might not look like it bends as far as the other thumb, but if you have good function and good stability, that’s the ultimate goal.”

We kind of guide these patients along, we’re more like a coach. We see them every couple of weeks, and then at eight weeks typically we do very light strengthening, we go over joint protection and how to make that thumb last as they get back to activities and daily living. 

It All Ties Into The Comprehensive Care We Offer Here At Bone And Joint Institute, Can You Talk A Little Bit About What A Comprehensive Hand Therapist Is?

Davis: We are, in our department, occupational therapists. Physical therapists can also be certified hand therapists as well. We’ve all been to occupational therapy school which is typically four years of undergraduate and then a graduate program. Then, we have to work for three years in upper extremity. You have to get so many thousands of hours of just upper extremity experience, and then you take a specialty examination and that is where you get your certified hand therapy certification.

Then you have to maintain that by doing a certain number of continuing education hours and by recertifying every five years. It’s very specialized. We focus on treatment from the shoulder to the hand and we work very, very closely with our hand surgeons. We’re definitely a team. I can’t function without [Dr. Wurth] knowing exactly what he did and that’s the benefit of being right down the hall. If I have a question, I can just go ask and it keeps us all on the same page which helps the patient.

How Does Having Hand Therapists and Occupational Therapy in The Building Positively Affect Your Practice?

Dr. Wurth: I echo what Laura said. With surgery and anything, things can arise. You may have a little wound issue or something like that, and it’s always good to have multiple eyes. Having multiple eyes on a patient is good but if you don’t have the communication then it doesn’t do anything. So that’s what we’re really blessed with here is we have all of this in-house, we have a good team approach to take care of our patients. We communicate and if anything arises, we’re addressing anything immediately and that’s what allows you to have good, reliable long-term outcomes.

To watch the full segment with Dr. Wurth and Laura Davis from Facebook Live, click here.