Treating CMC Arthritis with Dr. Todd Wurth

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The development of an opposable thumb in mankind is what has moved us beyond other animals, allowing us to make tools, eat more meat, and evolve a bigger brain. About seven million years ago, we grew a long thumb and shorter fingers allowing us to touch our thumbs to our other fingers. This is why our ancestors were able to throw a spear to kill wild game and hold a writing implement to record our history. However, because we use the thumb joint so much, thumb carpometacarpal (CMC) osteoarthritis is quite common. It affects up to 11% of men and 33% of women in their 50s and 60s. However, in the mid-1980s a successful surgical procedure was developed to return movement to the joint and relieve pain.

Todd Wurth, M.D. performs more than 100 of these surgeries every year, and has been recognized by the Nashville Business Journal many times as one of “Nashville’s Best Hand Surgeons.” He is a board-certified orthopaedic surgeon specializing in treatment of the shoulder, elbow, hand and wrist. He earned his medical degree in 1998 from the University of Louisville School of Medicine, completed his residency in orthopaedic surgery at the Indiana University Medical Center, then completed fellowship training at Allegheny General Hospital in Pittsburgh in the areas of hand, wrist, elbow, shoulder and microvascular surgery. He is a fellow in the American Academy of Orthopaedic Surgeons and a member of the American Society for Surgery of the Hand with a certificate of added qualifications in surgery of the hand.

Williamson Source: You do a lot of thumb carpometacarpal (CMC) arthroplasties every year. Tell us a little about the surgery?

Dr. Todd Wurth: CMC arthroplasty is a procedure that removes the damaged, arthritic trapezium bone at the base of the thumb and utilizes a tendon that is transferred from the forearm to stabilize the thumb in the absence of the trapezium. This is an exceptionally important joint, one that allows us to have an opposable thumb. The pain and dysfunction resulting from arthritis in the thumb CMC joint can have a huge impact on people’s lives.

There are many ways to complete this operation. A number of companies have developed implants to take the place of the damaged bone, but I prefer the use of my patient’s own tendon to stabilize the thumb and act as a soft tissue interposition rather than relying on manufactured implants that often only address one side of the arthritic joint and present a whole host of potential complications that are avoidable. I have seen the new technology in this area fail. The original description of this surgery was proposed in 1985 and has undergone some modifications since, but the original premise remains the same and is time tested. I value the idea of surgical procedures that use biologic rather than non-biologic materials to treat a condition when feasible. The biologic options typically outlast those of non-biologics and have lower rates of long-term complications.

After removing the damaged trapezium bone, I transfer a forearm tendon to create a sling that stabilizes the thumb in the absence of the removed trapezium. This transferred tendon actually reconstructs a ligament whose sole purpose is to stabilize the thumb. It is laxity within this original ligament that actually results in the arthritis to begin with. I then use the rest of the tendon to act as a soft tissue interposition to occupy the space of the removed trapezium.

The key to this surgery is stability of the thumb. Some surgeons simply remove the trapezium, which provides relief of the arthritic joint, but fails to stabilize the thumb. Studies have demonstrated similar outcomes to simple bone removal without tendon transfer to those of bone removal with tendon transfer at 1-3 years. Beyond three years, thumbs stabilized with tendon transfer outperformed and outlasted those without tendon transfer. My goal as a surgeon is to provide my patients with the best opportunity for long-lasting success.

WS: What is recovery time? What happens during recovery?

Dr. Wurth: Immediately after surgery the patient is put into a splint that immobilizes the thumb, wrist, and mid-forearm for five days. It is non-removable and must remain dry. After five days, the original splint is removed and replaced with a custom, removable splint that, like the original splint, goes up to the mid-forearm. This is worn day and night for about three weeks, removing it for bathing and wrist range of motion exercises. The fingers are not incorporated and we recommend aggressive finger range of motion from the start. We have patients refrain from heavy lifting and pinching activities, and because of this they may require assistance around the house for a period of time following surgery.

After three weeks in this splint, we cut the splint down to the hand only. This splint only immobilizes the thumb and leaves the wrist free when wearing. This splint is removed several times daily to work on the thumb range of motion including opposing to the other fingers. This splint is worn for approximately two weeks.

Finally, the splint is replaced with a neoprene sleeve. I encourage my patients to refrain from heavy gripping and pinching activities for a period of three months after surgery. At three months, I “cut them loose” to increase their activities as tolerated and return to all activities. Full return to certain activities can take up to six months.

WS: I know surgery is always a last resort, so what are non-surgical treatments?

Dr. Wurth: There are oral and topical anti-inflammatory medications that help relieve the pain. Over-the-counter versions would be things like Aleve, Motrin, Voltaren Gel or Icy Hot, but there are also prescription strength medications. Splinting is another option which works by adding additional stability to the thumb. Cortisone injections are also an option for temporary relief, but should be used judiciously. More than two a year may actually exacerbate the arthritic process.

WS: Is there any new technology being used to relieve the pain and damage of CMC arthritis?

Dr. Wurth: Work is being done on stem cell injections, but I would suggest holding off on this treatment until more research has been implemented. True stem cell lines are currently limited to research facilities. Facilities offering stem cell treatment in the community typically lack the quality and quantity of stem cell lineage to offer meaningful results. I have expectations that someday we may be able to use stem cell treatment to regenerate cartilage, but we are not there yet.

WS: As we age, we all get aches and pains? When will a patient know it is time to see you about the pain in their thumb?

Dr. Wurth: My recommendation to patients has always been that when their ailments, in this case basilar thumb pain, begin to affect what they need to do or what they want to do on a daily basis, then it’s time to come see me to discuss options for alleviating their symptoms.

If a patient has had a previous CMC surgery that is no longer relieving their pain, like those done with implants, they can be re-evaluated for revision surgery.

WS: Can anything be done to prevent thumb arthritis?

Dr. Wurth: Thumb arthritis is typically caused by a lack of stability in the CMC joint. Genetics plays a big role and women are more prone to it than men by a ratio of 7:1.

While some jobs are harder on the thumb joint than others, supporting the joint with a splint and changing thumb usage to minimize the strain that exacerbates laxity are ways to lessen the chance of developing arthritis or slowing its progress.

If you are suffering from arthritic pain and want more information, contact Dr. Wurth at Bone and Joint Institute of Tennessee.

To learn more about dealing with CMC arthritis joint pain, contact Dr. Wurth’s office at (615) 791-2630. Or schedule an appointment online.