MedStar Health DocTalk

Thumb arthritis

March 23, 2022 Ryan Katz, MD Season 2 Episode 8
MedStar Health DocTalk
Thumb arthritis
Show Notes Transcript

Comprehensive, relevant and insightful conversations about health and medicine happen here… on MedStar Health Doc Talk.    …real conversations with physician experts from around the largest healthcare system in the Maryland-DC region.

Dr. Ryan Katz of the Curtis National Hand Center talks about one of the most commonly treated hand conditions: arthritis in the basal thumb joint. Patients with unrelenting  pain in the base of their thumb live compromised lives with loss of function and unrelenting pain. There are treatment options. When surgery is needed, so is an expert in hand surgery. 

For more information on Dr. Ryan Katz, the Curtis National Hand Center, or conditions of the hand, go to: MedStarHealth.org/locations/curtis-national-hand-center

For interviews with Dr. Ryan Katz, contact Debra Schindler, regional director of media and public relations for MedStar Health in Baltimore, 410-274-1260.

 

(upbeat music) - Comprehensive, relevant, and insightful conversations about health and medicine happen here, with MedStar Health DocTalk. (upbeat music) Nearly half of all functions of the hand require the ability to touch the thumb to each of the four fingers. Simple, right? Not if the cartilage in the basal joint of the thumb has disintegrated, and the patient suffers from arthritis. Today, we are joined by Dr. Ryan Katz, an attending hand surgeon at the Curtis National Hand Center at MedStar Union Memorial Hospital in Baltimore, to learn more about thumb arthritis. I'm Deborah Schindler, Director of Media and Public Relations for MedStar Health and your host. Dr. Katz, welcome to MedStar Health DocTalk. - Thank you. Wonderful to be here. - This may not surprise you, but it surprised me, that thumb arthritis was one of the most Googled search terms on the Hand Center's website. - Yeah, yeah, it's probably one of the most common things that are treated by hand surgeons, behind carpal tunnel and trigger finger. - So what's happening in their lives that brings them in to you? And do they need to see a hand specialist? - Yeah, almost always, they'll point to the base of the thumb, that's where the thumb takes off from the hand. and they'll say that they're having a lot of pain with everyday activities, specifically, twisting and turning type of activities, like twisting off the lid of a jar, opening things, twisting caps off bottles, doorknobs, that sort of thing, and they'll always point to the base of the thumb. Usually, this process starts off with some pain, some vague pain in or around the thumb, and it just progresses. It's an unremitting, slowly progressive pain that worsens over time, and then ultimately, it gets to a point where it affects their quality of life and activities of daily living, so things become harder and harder. - How do you diagnose it as thumb joint arthritis? - Usually, there's a classic picture of the location of pain, the duration of pain, the age of the patient. There's just a certain picture that the doctor expects to see. And then when the patient comes in and they kind of fall into that category, your radar's up. You're thinking, yeah, this is probably gonna be base of thumb arthritis. I mean, there are some other reasons for pain in and around the thumb, trigger finger, tendonitis, old- - You've mentioned trigger, what is a trigger finger? Is that a type of arthritis? - No, it's not a type of arthritis. A trigger finger is when a tendon gets swollen relative to a tunnel through which it has to pass. And the way I describe it to patients is I say, "Imagine that you have your belt passing through belt loops, you're trying to feed it through your belt loops. If that belt is swollen in a certain area, as you're trying to feed it through through the loops, it'll get hung up on the belt loops and it'll kinda click as it passes through." That's what a trigger finger is. So a swollen tendon passing through these tight loops will often get stuck and hung up, and the finger will get stuck. - So the person can't then move their finger. - Yeah, or they can move it, but it clicks when they do move it, or it'll get stuck in a down position. So oftentimes, patients will say, "Well, I went to bed, and then I woke up and my finger was stuck in a down position. I had to force it up, and when I did, I felt a click, and pain," and things like that. That's a trigger finger. That's one of the most common things we treat. - Okay, and thumb arthritis is next? I mean, why are so many people searching for it online? - Yeah. (both laugh) - Maybe there's just very little information out there, about it. - Well, you know, I was telling you that it's one of the most common things we treat, and the trifecta, the carpal tunnel, the trigger finger, and base of thumb arthritis, by far, that has to make up the majority of most elective hand surgeons' practices. These are age-related changes for the most part. So remember, I was telling you about the demographic and what you expect to see in a certain patient. I mean, you do not expect to see base of thumb arthritis in a 14-year-old. You just won't see it. These arthritic changes are wear and tear phenomena. - So who might typically get this? I mean, who's wearing and tearing their thumb down that bad? Carpenters? Piano players? (both laugh) - I'd say, mostly, it's people with a lot of birthdays, so it's an age-related phenomenon. You can definitely see it earlier in patients with either a genetic predisposition, which sometimes occurs, or yeah, there might be some job-related demand on the hand that could cause some extra wear and tear, which could lead you down the course of base of thumb arthritis. - Is there anything that we can do to avoid damaging that part of our hand or that cartilage in our thumb joint? - Yeah, that is a focus of ongoing investigation. There are some therapists who feel that if you can strengthen the muscles around the thumb, you could more balance the joint, and there might be a role for certain strengthening exercises of the muscles around the thumb. That might be helpful. But, you know, with a lot of these age-related issues, like vision changes, hair loss, decreased skin laxity, there's only so much you can do to prevent the changes over time. - I'm sorry to hear that, because, as you know, my mother has suffered with this in both thumbs, and she's been in pain. She's really been in pain. She couldn't wait to get surgery. And she loves to come and get shots. Which brings me to the next thing. One, how do you diagnose it, and how do you treat it? - Yeah, yeah. The diagnosis is the history, physical examination, and then a radiographic examination. And that's probably true for most things that the doctor will see and treat, right? You wanna hear from the patient, hey, what's going on? How long has it been going on? What's been your treatment to date, potential causes, things like that, and then you want to examine the patient. And our examination of the patient will include certain maneuvers around the thumb, to determine, is this coming from a trigger finger, is it coming from tendonitis, or is it coming from this osteoarthritis, this kind of wear and tear arthritis at the base of the thumb. And then after the clinical examination, you'd wanna review radiographs to see, what does the joint look like? Because base of thumb arthritis, it happens at a very particular joint, but sometimes there could be other joints involved nearby, and you should know that if you're going down the path of surgical treatment. - How would that change next steps for the patient? - Yeah, well, the first mode of treatment is usually conservative, and you- - Meaning medications? - Yeah, oral anti-inflammatories could be helpful, splinting could be helpful, physical therapy can be helpful, like we talked about, maybe a strengthening program about the thumb, maybe some intermittent bracing, and things like that, topical anti-inflammatories, perhaps. And then if that fails, you would consider kinda stepping it up a notch, and that would be steroid injections, and for someone who hasn't ever had a steroid injection in that location, that can provide significant long-lasting relief on the order of months, and you could do steroid injections until such time as they're not working anymore, and then like you point out, the patient will often come in, saying, "I just feel like something needs to be done here." - Something more dramatic. - Yeah, something more dramatic. And then that takes you to surgery, and if you're gonna do surgery, you need to know specifically what are the joints involved. Is this truly just the classic thumb CMC joint? CMC stands for carpometacarpal joint, so it's the thumb metacarpal and the carpal bone that lives right under the metacarpal. The classic treatment there is to take one of those bones out, but if you have other bones that are involved, you would wanna know about that, because you would want to address them at the time of surgery as well. - Right, how many bones can you take out before the thumb's no longer functioning? (both laugh) - Yeah, that's a good question. So typically, we take one bone out. That's the offending bone, and that's called the trapezium. And then right next to it is its little buddy called the trapezoid, and sometimes the trapezoid is involved, and you would shave off a little bit of the trapezoid. - And that does not alter the way the thumb bends or the joint moves, or the hand functions? - Surprisingly, surprisingly, it will often restore function in a way that's a little bit challenging to understand, but the patients who ultimately progress to surgery are having such a tough time with hand use that they say, "I can't twist off a bottle cap." "I cannot open this jar." "Opening a door is impossible." "Driving is very painful." - So their lives are very compromised? - Yeah, right, so when you treat them surgically and eliminate the pain, and they still have motion, if you measure their preoperative motion and strength and their postoperative motion and strength, you will find that despite having taken this bone, their postoperative measurements are usually better. Now, that's not to say that if you measured their 14-year-old self and their postoperative self, their postoperative self is gonna be better. It's just they're better than their preoperative state. - I understand. So yes, it does, it restores function and preserves motion, so it's a real winner of a surgery. - Right. When do you tell the patient, "I think that we've exhausted the shots and the other options. Now you should consider this"? - Yeah, I have two answers. - Do you introduce that or do they come to... Do you wait for them to ask for it? - You know, the guidance and counseling starts at the very first visit, because the patient needs to know what's going on, so we'll explain the pathology, the mechanics, the reasons for the problem, introduce the possibility of surgery, but talk about conservative treatment first, which I think is a very reasonable way of managing most elective hand issues. Try a conservative treatment first, see if it works. If it doesn't work, only then should you consider surgery. I would say, if steroid injections are giving you less than three months' relief, that's not really working for you. - Okay, that sounds like a good rule of thumb. (both laugh) - Did you plan that? That's a good- - Not at all. - Yeah, yeah, that is a good rule of thumb there, less than three months. But there are other reasons to consider surgery as well, and that is, you know, sometimes when that steroid wears off the pain is just, it's just really tough for the patient to bear, and the patient says, "Look, I don't wanna keep kicking the can down the road. I've tried the conservative stuff, and it's just not working for me." I think if the patient has radiographic findings and a clinical exam consistent with base of thumb arthritis, then you can consider surgery. - A question about the shots, because I've heard this in orthopedics in other areas, that you can only get three shots. Like, you're only allowed three shots. - That's a great question. So- - Is that true? - We don't know the answer to that question. And I could tell you that the shots are different in different hands. There's different amounts of steroid going in, there's different concentrations of steroids, there's shots for tendonitis, like for trigger fingers, and then there's shots for arthritis, like for base of thumb, and those are not, they're not the same. So you don't wanna keep putting steroids in a tendon. We don't know how much you can get, but steroids can weaken surrounding soft tissues, and they can be associated with tendon pathologies. So I think that rule of three, that typically applies to tendonitis, like trigger fingers, and stuff like that. But, you know, we all know people with chronic back pain, chronic shoulder pain, and they go to the doctor not infrequently for a steroid shot in the back or shoulder. - Knees, knees. - Knees, yeah. - A lot of people get them. - That's a good example, yeah. And, you know, these folks have more than three for sure. And that's a good example of steroids in joints. So it's different than steroids in and around tendons, soft tissues. - What is LRTI? - That stands for ligament reconstruction and tendon interposition, and that's the gold standard treatment of base of thumb arthritis. That's the classic surgical treatment. - So, but it's not used every time, - Right, that's- - Correct? - Explain what happens with LRTI. - So the classic treatment for base of thumb arthritis is to get rid of the arthritic bone, essentially. There's two bones rubbing together. We're gonna take one of them out, that's the trapezium, so that's the smaller of the two. It's easier to take that out than to address the thumb metacarpal. So you take a bone out, and you say, okay, we've solved the problem, we've gotten rid of these two bones rubbing together, so that's it, we've done it. - Which is what causes the arthritis. - Well, yes, the arthritis is the two bones rubbing together, and what happens there, we think, is that just over time, just like everything gets more lax, the ligaments around the thumb joint get lax. And that thumb sees a lot of action, like you said, it's about 50% of the use of the hand. Because the thumb sees so much action, as the ligaments become lax, the thumb metacarpal starts to shift relative to the trapezium. It's almost like having a tire on your car that's misaligned, and then your car will still run, but the tread on the tire is gonna wear out a lot faster. And the same here for the cartilage of the thumb. - Great analogy. - Oh, thanks. (both laugh) Yeah, so the cartilage wears out, and then you get bone on bone, and that, in most people, causes pain. Interestingly, it doesn't cause pain in everybody. So you can see some x-rays with terrible-looking arthrosis, where the joint looks bad, and the patient doesn't have any pain. We don't really know why that is. But for most people, this is a predictable pathway to pain. Cartilage wears out, you get bone on bone, that translates to pain, decreased hand use, decreased strength, pain with activities of daily living, et cetera. And so the treatment is to get rid of the arthritic bone, the trapezium, classically. - Leaving a void in the- - Right, so that's the question, is well, wait a minute, didn't I need that bone? What is gonna happen to the thumb metacarpal when I take the trapezium out? And is the thumb gonna collapse? And the answer is yes, to some extent, and that's called subsidence, and that's a risk of the surgery. It's expected to happen, to some degree. What would be a real problem is if the thumb collapses so much that it starts rubbing on another bone, and that's a rare complication, but it has been described. So knowing that the thumb could subside, the thumb could collapse and rub against another bone, we say, well, let's keep it out for a period of time after we excise the trapezium. There's many ways to do that, but the classic way of doing that is to take a tendon from the forearm, that tendon inserts on the index finger at the level of the hand, and use that tendon as a tether. If we can tie that tendon to the thumb in some way, it holds the thumb up towards the index finger, and it prevents the thumb metacarpal from collapsing backwards, from falling towards the arm. - A collapsed thumb joint sounds worse than thumb arthritis, actually. So what is that surgery like? It's a two-part surgery then, essentially. - Right, so what I've described there is the ligament resuspension, the LR of the LRTI, so what we're doing is we're using a tendon to reconstruct the ligaments of the joint. Remember, those ligaments of the thumb, they used to keep the thumb in line, and as those ligaments fail, we think that's what caused the arthritis, and so we're gonna excise the arthritic bone, and then we're gonna reconstruct the ligaments to hold the thumb metacarpal and prevent it from subsiding. So that's the LR. - So how do you get that out, and how does it stay in the joint? - So you make a separate incision, a small incision in the forearm, and then you have access to the tendon in the wound created by removal of the trapezium. You can see the tendon at the base of that wound, and that's why it's the one that's often used. And so you cut the tendon in the forearm, and you can pull it out through the wound of the thumb. - So it never really completely detaches? - It doesn't disinsert. And what I mean by that is, that thumb, that tendon that you've pulled out, that has a very strong attachment to the index finger, and if you were to pull on it, you would find that you're pulling on the whole hand, essentially. So you have this very stout tendon with a native insertion, and if you can somehow affix that to the thumb metacarpal, the thumb metacarpal should stay out to length for a period of time. - And does it? - Well, you almost always see some subsidence, no matter how tight you do your ligament resuspension. - So the collapse is still a subsidence, being partial collapse. - Partial collapse, yeah, right. The question is, does it help you in some way? Does it prevent subsidence to the point of developing arthritis in a new location? And there are some studies, some very good studies, that say you don't really need that tendon. Now, most hand surgeons train, the way that most hand surgeon trains is they learn what is essentially the gold standard treatment, which is the LRTI. And that appeals to our sense of mechanics. If you're going to take out this bone of the thumb, it would be nice to support the thumb out to length for a period of time. Now, we all know that you will get some subsidence of the thumb, but the thinking is that well, if you hold the thumb out to length for six weeks or so, that's when the body forms a fair amount of scar where you took this bone out, and even though you'll get some subsidence, you've protected it from getting the really bad subsidence, where the thumb metacarpal starts bumping against another bone in the wrist. - Are they in pain if you have subsidence? - No, if you have a small amount of subsidence, which is expected, no, I wouldn't expect that to cause a problem at all. But if you have the rare pathologic collapse, that would be an issue, that would be an issue, and the way that we would treat that would be to resuspend the thumb metacarpal, and there are various ways of doing it. And you don't need the tendon from the forearm to do it. You can do it with suture alone, you can do it with other tendons around the thumb. There's various ways of bringing that thumb back out to length. - Is therapy a part of the recovery? - Yeah, yeah. Every doc has their own algorithm. If I were treating the patient, it would be six weeks of splinting and really trying to give soft tissue rest to prevent subsidence to a significant degree, so six weeks of splinting followed by six weeks of therapy. So it's a 12-week course. - I just learned about rheumatoid arthritis and thumb or joint replacement, which was new to me. Would it be easier to replace the thumb joint than- - That's been tried, and- - It's not a good option? - Not at this point. I just don't think the technology is there to give a reliable and predictable result for this problem. And the reason for it is because the thumb does so much for the hand, it just does so much. You know, it flexes, it extends, it comes away from the fingers, it goes towards the fingers, it can move in a cone, it's called circumduction, and your joint replacement would have to live up to the demands of the thumb without breaking, without getting loose. - It's asking a lot. - It's asking a lot of a small implant. I think we will have that technology at some point, but we just don't have it yet, - What is a Bouchard node? - So Heberden's and Bouchard's nodes are arthritic changes of the small joints of the fingers. Heberden's nodes are by the joint by the nails, that's called the DIP joint, and Bouchard's nodes are by the knuckle that you see between the knuckles of the hand and the knuckle by the nail, that's called the PIP joint. And these are signs of osteoarthritis, which is a wear and tear type of arthritis. They're classic findings where the joint starts to deteriorate, and you'll get these reactive changes of the bone, and it'll look like little areas of swelling. So if you look at your grandparents' hands, or elderly parents' hands, you will see swelling of the small joints, and that's usually, I mean, just about everybody gets it. that's usually the result of wear and tear arthritis, and those are called Heberden's nodes and Bouchard's nodes. - Is that something that you just live with, or are they treatable? - I think for most osteoarthritis, most wear and tear arthritis, the best mode of treatment is to leave it alone unless it's causing a problem, and the problem could either be loss of motion, severe angulation, or some deformity where the finger's getting in the way of other digits, or pain with motion. Those would be the reasons to consider some sort of intervention. But if you have a painless joint that looks swollen, but your motion is pretty good and your quality of life is high, I would leave it alone. - That's always the priority, right, is not so much the aesthetics, but the function of the hand. - Yeah. - Any final thoughts on thumb arthritis, basal joint, metacarpal, all of that? (laughs) - Yeah. - Yeah, I think it's a very common problem, like we talked about in the very beginning. I think we have great treatments for it. Surgery is the gold standard, and that usually involves taking the trapezium out. Whether or not your surgeon likes to do a ligament reconstruction, it's dealer's choice. The patient should know that you don't need to have that ligament reconstruction. There are some other potential treatments out there which would be considered novel, new on the scene, not well studied. One that stands out is called a joint denervation, where you actually are disrupting the nerves that go to the joint, the thinking being, well, you have arthritis and you should have pain, but if we can disrupt the nerves that go to the joint, not the nerves that go to the skin, it does nothing for the feeling of your hand or fingertips, it's just nerves that go to the joint, then you could give the patient pain relief while preserving the trapezium. You are disrupting the pathway by which the joint communicates to the brain. So that's called a joint denervation. It's kind of new on the scene. It is not what I offer my patients, because it's untested. There's not enough long-term data to say, yeah, it's better or worse in some way. But it's very tempting, so... I think a good analogy would be someone who has chronic back pain, chronic back pain, or there are some patients who have chronic face pain, and the treatment is to disrupt the nerves that are causing pain, so they go in for a nerve ablation. And I think a lot of people out there probably have heard of a nerve ablation, and that says, okay, well, here you have a nerve that's acting up, it's giving you pain, so we are going to destroy that nerve. And sometimes that can provide patients with significant pain relief, significant pain relief, but we just don't know enough about that to say that should be the standard treatment. We do know a lot about base of thumb arthritis and trapeziectomy. We know a lot lot about that, we've been doing that surgery forever, and that works. Now, there are some people out there who think that it might be working because to get the trapezium out, you're doing a denervation. It's hard to get a bone out without disrupting the nerves that go to the joint. - True. - Yeah. That's just a little food for thought. - Well, through the course of this conversation, I think I answered one of my questions, which was, should patients see a hand specialist? - Go, without a doubt! - We've been talking with Dr. Ryan Katz, attending hand surgeon at the Curtis National Hand Center here at MedStar Union Memorial Hospital in Baltimore. Thank you for sharing your expertise with us on DocTalk. - Thanks for having me. - If you need to see an expert about thumb arthritis or any issue related to the hand or upper extremity, you can see an expert at the Curtis National Hand Center by calling (410) 235-5405. (music chimes)