Joint Replacement for Base of Thumb Arthritis

Thumb Arthritis: The Game Changing Joint Replacement

Thumb arthritis is extremely common, and when pain at the base of the thumb makes it difficult to open a jar, turn a key, grip a golf club, or hold everyday objects, it can have a major impact on daily life.

In this episode of MedStar Health DocTalk, host Debra Schindler talks with Dr. Avi Giladi, hand and upper-extremity surgeon and research director at the Curtis National Hand Center, about the latest advances in treating thumb carpometacarpal (CMC) arthritis.

For decades, surgery has typically involved removing the trapezium bone, sometimes combined with tendon reconstruction or suspension. While these procedures can provide pain relief, recovery can be lengthy, and some patients experience lasting limitations in grip strength and function.

Dr. Giladi discusses a newer option: the Touch Prosthesis, a thumb joint replacement designed to preserve joint height and motion while providing stability. He explains how the implant works, who may be a candidate, how it compares with traditional surgery, and what patients can expect during recovery.

The conversation covers:
• Why thumb arthritis is so common
• Early symptoms and risk factors
• Non-surgical treatment options, including splints, therapy and injections
• Traditional thumb arthritis surgery and its recovery
• How the Touch prosthesis works
• Potential benefits, risks and limitations of thumb joint replacement
• Who may—and may not—be a candidate
• What recovery can look like after surgery
• What researchers and surgeons still need to learn about the implant long term

Dr. Giladi emphasizes that not everyone with thumb arthritis needs surgery, and that treatment should be individualized. But for appropriately selected patients whose symptoms persist despite non-surgical treatments, newer joint-replacement technology may offer another path toward restoring motion, strength and function.

Learn More or Schedule an Appointment: For more information about MedStar Health’s Curtis National Hand Center, visit MedStarHealth.org and search “Curtis.” To schedule an appointment with Dr. Avi Giladi or one of the center’s 14 hand surgeons, call 410-235-5405. If you’re closer to Washington, DC, call 202-444-3668 to schedule an appointment with hand surgeon Dr. Michael Kessler at MedStar Georgetown University Hospital.

Watch the full episode to learn what patients considering thumb arthritis surgery should know.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

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- Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health DocTalk. These are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. Do you ever experience pain at the base of your thumb that is so bad you struggle to open a jar or turn a key or hold something without dropping it? If so, you're far from alone. Thumb arthritis is the most common form of arthritis affecting the hand. And for millions of Americans, especially women over 50, it can make the simplest daily tasks incredibly painful. For years, treatment options have ranged from splints and injections to surgery that removes part of the joint. But today, new advances in thumb joint replacement are giving select patients another option that may help preserve motion, restore function, and get them back to doing the things they love with an astonishing recovery. I'm Deborah Schindler, your host, and this is MedStar Health Doc Talk. Today, we welcome Dr. Aviram or Avi Giladi, a hand and upper extremity surgeon and the research director for the Curtis National Hand Center and the scientific director for orthopedics at MedStar Union Memorial Hospital in Baltimore, Maryland. We're going to talk about a new joint replacement for the thumb called touch prosthesis. It's a new treatment option and very exciting. I can't wait to share this one. We'll find out who's a candidate for this new joint replacement and what patients should know before considering surgery. Dr. Giladi, thanks for being here today on DocTalk.- Yeah, thank you for having me. It's a great topic to be talking about and it's very exciting.- So in general, we call it thumb arthritis, but medically, this condition is known as carpometacarpal osteoarthritis or CMC joint arthritis. Did I say that right?- Yeah. Yeah. I mean, I think terminologies around arthritis really get complicated when you try to name the joints. So really what you're experiencing is trying to list the specific details of the joint. So carpometacarpal is between the wrist and the metacarpal bone, which is sort of the longer bones at the base of each of the fingers and the thumb. So all it is to say is it's arthritis at the base of the thumb in the joint that connects the thumb to the wrist, which anyone who's sitting there looking at your own hand can see has a lot of range of motion to it, which we think essentially predisposes it to having arthritis. It's a joint that was never designed to last as long as we do now. And so universally, once people get past age 40, 45, certainly by the age of 50, we see changes in the x-ray of arthritis in just about every single person that has this joint, which is pretty much everybody. So it's a joint that is predisposed to wear and tear over time. And for some people, that wear and tear becomes incredibly painful.- Why is the base of the thumb so commonly arthritic? And I think it's in my future. My mom has it and I already have base pain, so I'm really interested in knowing- More. Yeah. Arthritis as a condition is genetically related. So not just because your parents have arthritis doesn't mean you will have it, but it certainly substantially increases the risk. There is some thought about the way you use your hand or joint. So certain jobs and things like that people think can increase it. Certainly overuse over time and certain activities over time make it a little bit worse. Injuries for sure can do it. So if you've had a bad injury, especially fractures or dislocations of joints, those joints tend to develop arthritis, but the thumb is really susceptible to it because that special joint at the base of the thumb is inherently unstable in the sense that it has so many different ways that it moves. And to be able to get your thumb all the way touch the base of your pinky, to give a thumbs up, to make an okay sign, to heavy grip, it has to be very stable in a lot of positions. And over time, the ligaments and the joint structure that allow that to happen will just wear down. And so that is why this joint in particular is so susceptible to arthritis compared to the other joints of the hand and wrist.- Who's most likely to develop thumb arthritis? Who are your patients?- So everybody develops thumb arthritis. Every single human being will have arthritis by definition, meaning sort of changes on x-ray and certain changes in the way the joint appears and in some ways moves over by. The studies have showed over about the age of 50. So over age 50, we've gone out and different research studies have x-rayed hands of just people walking around, some having symptoms, some not. And they all have some changes of arthritis in this joint at the base of the thumb, the carpometacarpal joint. That can be a little bit of what we call subluxation where the joint slides a little, which sounds I think a lot worse sometimes than it actually is, but it's just the issue of the alignment of the two bones doesn't stay perfect anymore. That's the way we know the ligaments are starting to get a little looser. Anything from that to total wear of the cartilage, getting "bone on bone" as people like to talk about with arthritis a lot, and then everything in between. So it's not really even that much of a specific group, but really everybody gets this kind of arthritis. The harder part is figuring out who's going to be symptomatic from it because we're talking about a thumb surgery today, but the truth is most patients that have this arthritis don't need surgery for it because it's really a combination of use, compensation strategies, different things like as you mentioned in your introductions, splints, injections, things that we can do to find comfort that don't require a big surgery. Many people do really well with that. So the biggest thing to figure out is who's going to fail those things and then end up needing to go onto surgery. And that's really the hardest part for us, at least in the hand surgery world, to figure out ahead of time.- You mentioned the symptoms. What are some of the earlier symptoms that people should be aware of?- So I think the one that obviously brings most people to us is pain. As with most arthritis changes, pain is the way you know you have a problem. It probably does start to change the mechanics of the thumb before it hurts, but those are not things that people tend to notice very often. So the way you go to grip something, if you imagine putting your hand around like a cylinder shape, the changes in the way the joint works happen in that kind of movement earlier. And you start to compensate by just holding things differently or some of the other joints of the hand will begin to stretch a little in different ways to compensate. But those don't tend to be painful until at some point the arthritis tips over into a more painful problem after some probably number of years of wear and tear or abnormal use kind of stuff.- Are people already seeing a doctor at that point or is that when they usually start- Coming? Totally varies. We'll have people who come to the hand center having seen a rheumatologist, a primary care physician, gotten injections, all this kind of stuff, to people who come to us for their first visit to discuss this problem and everything in between. It's definitely a condition that can be helped by other specialties. And we work closely with rheumatologists, with people's primary care physicians, with physical medicine rehabilitation, hand therapy. All these different treatment modality teams can be helpful. So like I said, sometimes people will work with them first. Sometimes they'll come to us first, then we'll refer them out. Sometimes they'll come to us and we start working with them directly depending on kind of how severe it is when we first meet them.- If treatment is delayed, does that usually cause it to worsen? Or how long can you go without any treatment?- Yeah, so those are two very important but different questions. Arthritis is progressive, meaning it will get worse over time. And it is irreversible, meaning we do not know how to turn it around. That being said, we have no idea the timeline. Some people it goes quickly. Some people it takes years. Some people it takes decades. So the second question of like, can you wait too long and predict kind of when it's going to happen? You can't. It's also not a thing that if you let go too long means something bad has happened to you. So one of the reasons we do these non-surgical treatments first is because we're not causing harm by waiting. The joint is going to evolve and degenerate over time no matter what we do. The question is, can you stay comfortable or not? So the goal is much less about the arthritis and much more about the symptom and the patient who's navigating those symptoms. And that's why we kind of take a full patient approach. At least at our hand center, we take a very full patient approach in collaboration with our therapists and our surgical team to make sure we give patients the best opportunity for feeling better regardless of how we get there.- Is it preventable?- No. No. No. I mean, I think if you look at where a lot of research dollars, educational dollars are spent right now, it is understanding arthritis and how to prevent it, but we do not have successful ways of doing it now. There are a lot of things people will sell patients on. None of them have really been shown to work when it comes to turning arthritis back or reversing it or halting its progress. Absolutely there are things that help with symptoms, some of them more reliable than others. But as far as turning the condition around or stopping it, we have really no way to do that.- All right. Let's say that the injections have run their course, they're not working anymore, or they don't last very long, and now people are looking at surgeries. Explain what the standard approach has been to lead us to where we are today.- The traditional approaches to the problem of thumb CMC arthritis have been to remove the C part of the CMC joint. So the carpal part, the part of the wrist that connects to the thumb is called the trapezium. It's one of the small bones. If you've ever seen an x-ray of a wrist or if you want to just Google what an x-ray of a wrist looks like, there's eight little bones in the wrist. The one that's underneath the thumb is the one that tends to get worn down over time. That's the one that has all the ligaments that support it and those ligaments break down over time. And then the joint starts to take the wear and tear changes of arthritis. The general treatment has been to remove that bone, which sounds pretty gruesome. And I guess conceptually, probably the first person who ever did it, it probably felt pretty gruesome. But we've gotten so ingrained in our treatment algorithm that it's okay to do that and the thumb actually does quite well. But there are some known things that happen when you do that. So the length of the thumb will shorten a little bit. You lose a little bit of height. It's generally not meaningful, but it does change some of your grip parameters. By taking that bone out, you lose a little bit of stability underneath it, which makes sense because the platform changes. And then when you do that, you often will have grip strength that goes down. Now, a lot of people come in with low grip strength because it hurts so much. And we've accepted the fact that you already kind of have a weak grip. We're not making you much worse. Maybe we'll make it a little bit better by making it hurt less, but we accept loss of grip strength as part of the thumb arthritis treatment plan, or at least up until recently we accepted it that way because we didn't have a great way to fix that problem. A lot of things have been tried with what are called spacers, so things to fill the space between the bones. The- LRTI.- So LRTI is taking a tendon and weaving it and putting it in the space where the bone comes out. That's one of the things you can do. There are artificial things that have been put in that space. The tendons that we've taken to do that tend to be ones that we also think are relatively expendable. So they had functions back when we were younger, more aggressive, stronger athletes. As we age, some of these tendons become a little redundant to daily function. But they're still part of our body. They're not just sitting there waiting. They are doing things when we take them. They don't tend to result in a lot of loss of strength or function, but it is taking a tendon. So people have tried to avoid that with artificial things that have filled that space. None of those have worked. They've all had complications, so we've stopped using all those. And they've gone back to this, take the bone out and either leave it, just let that space fill with scar or put tendon, like you said, LRTI, or some people now are using suture in that space just to tighten up that space. Or metal, what it's called a tightrope, which is a metal support. But the idea is trying to keep support in the space because you're taking a whole bone out. And that's been the challenge is how do you support the thumb when the bone comes out?- But not just that. I mean, am I wrong to say that that is a difficult recovery for that surgery?- Oh, yeah. So the recovery has really for years been the biggest challenge because it takes anywhere from six weeks at the absolute fastest person to get back to their sort of regular things. Almost impossible to do it that fast. I've had one or two patients who get there. I think some of them just are sucking it up more than others. It always still hurts at six weeks. It's not till close to six months till you'll get a good portion of patients who feel good. I'd say a year is what I tell my patients that until a year goes by, they will not forget that they had the surgery. And there are still in this data that we've published out of this institution and have looked at national databases, about 20% of people still need treatment for their thumb pain after having had surgery for their thumb arthritis using what's called the trapeziectomy, taking the bone out, or trapeziectomy with LRTI or suspension where you put the tendon in. Any of those surgery varieties, you still have about 20% of people getting treatment at a year after- Surgery.- Like shots or- Taking- Medication? Shots, therapy, pain medication, splinting. Yeah, all that stuff. So 80% is a pretty good success rate, but that means 20% even after a year are still pretty unhappy, which is a long time.- I told you my mom had the surgery in another state and she kept complaining. Five months later, I was asking you guys, "Is this normal? Is something wrong?" And they're going,"No, that's about right."- Yeah. Unfortunately, that has become the normal for many people that have these traditional surgeries. And I think the surgeries over time have worked well. I certainly think that they have a really successful track record for people of mostly making pain go away, mostly getting you back to using your hand. I'm definitely not here to say those surgeries don't work because they do. And the surgeons out there doing them are providing an incredibly good service to the patients that need them. That being said, I think all of us have felt that many of our patients slightly younger, people trying to do more even as they age, people staying in the gym now into their 70s and 80s, which maybe wasn't as common 20 years ago. Those are people who are pushing the limits of this surgery and I think are probably more and more likely to be unhappy over time because it doesn't have as much of that restoration of grip. It doesn't get all that sort of that faster recovery. It's a really long recovery. Those are things that we really haven't felt good about, but it's kind of been the best we've had for a long time.- And the patients need something- Because- They're in such agony. It's an agonizing condition when it gets to its worst point.- Yeah. And we often - By the time you're- Talking about surgery.- Right. And we often joke, or at least I often joke with my patients, most people don't know anything about hand surgeons until you need one. And then once you need one, it's kind of a daily problem. I mean, we use our hands for everything all the time, every day. And the thumb is somewhere between 50, 60, 70% of the function of the hand, depending on what you read and what you believe. But ultimately, it does a huge thing. It's a huge part of almost everything we do. It's what sets us apart as human from other animals. I mean, it's a totally different structure. And when it's bothering you, you know it, and you know it all the time. And once it gets into that spot, getting out of that place is really difficult.- I did another podcast on thumb arthritis at a time that we did not have this new touch prosthesis. And I asked about implants, a joint replacement for the thumb at that time, thinking like any hip or a knee replacement or a shoulder replacement, it's a great option. But at that time, I was told the burden on the thumb joint, the joint replacements had not been effective.- Yeah, that's true. What's- Changed?- Yeah, that's true. And I mentioned it a little bit before that they have tried a lot of prosthetic things, whether it's the replacing the bone, filling the space, joint replacements of older styles that have just not held up. And they've had too many complications. They don't really work for enough patients, and most of us have stopped using them. The touch prosthesis is new and I am totally, just to be clear, unconflicted, meaning I have no ownership. They don't pay me anything. I'm totally unbiased. I have trained on it with the company, which is one of their current requirements for implanting it.- Sure. - But I totally took a very zoomed out view of it, looked at all the data that have been published and reported on it. It's been only around for about 10 years, which is a shorter time horizon than many of the other surgeries we've talked about so far today.- Here or in Europe?- Oh, only in Europe up until about six months ago. Okay. So it is on the newer side, but what's different to your question is that they've taken the hip prosthetic approach, which is called dual mobility, which kind of just gives for lack of, to avoid too much clinical detail, but it allows for movement in different planes and remaining stable in multiple different planes and also tolerating load. And so ultimately they took that approach that has worked so well for many of the different hip arthritis problems and implemented in the thumb. This is a company that's out of Europe that is dedicated to hand and wrist surgery, which is really unique. Most companies focus on the bigger joints. Quite frankly, that is where the money is and that's business. And so they've focused on hips and knees, which is such a common problem. I'm sure many of the people thinking about hand arthritis, most of my patients with hand arthritis have already had a knee replacement or hip replacement by time I see them because arthritis is genetic and it's generally not only in the hands, it's usually in other joints, but people are more familiar with these big joints. So they took the hip approach and applied it to the thumb. And it has resulted in a nice mobility restoration, which is unique, and stability restoration. And that combination has people recovering faster, regaining motion faster, with durability, with grip strength that is getting to 80 or 90% of their non-operated side, with pinch strength that is allowing people to turn a key, which is such a hard thing to do when you have thumb arthritis, that just that pinch of the thumb against the index finger, all those things are coming back much faster because of the design of this implant and its stability while also providing that mobility.- I'm not trying to sell it, but I do want to say that the patients who I've spoken to talked about the recovery. So not only are you describing a stronger joint and the stability of it, the strength and function that's restored, but the recovery has been so quick for these patients.- Yeah. And I think that's been - Tell me about that. Yeah, that's really been the selling point. Like I said, these traditional surgeries at a year, the trapeziectomy, the old style that we used to do, or then that many people are still doing, because there's a lot of people for whom that is still a good option. Those surgeries work. We know they work. We know they work relatively well and they work at about a year. Most people are pretty happy. So what had to occur for us to go to this new implant model is something that really changed at least something in a major way. And that recovery has been the most notable difference. We already talked about the grip strength, which I do think is important, and the mobility, which I think is important. But that's not hugely different from some of the other techniques. I think the strength part is maybe a bit of a standout, but what really is different is how fast they've recovered. I have had my first number of patients come back and are almost in no pain at one week. I've had one of my patients who, even against my better suggestion, was golfing at two and a half weeks, which I would say is unheard of in thumb arthritis surgery. That's- Amazing. Wearing a bandaid.- Yeah. We made them a splint. They didn't even want to wear it. One of my patients, we gave her a splint. She had it and only wore it because she felt like she had to, but she said it didn't feel any different or any better. It just couldn't believe how comfortable she was early. And so I think that has been the very distinct difference in this surgery compared to others is the moving early, but moving without substantial pain within weeks, within days sometimes, which is a total game changer, I think, when you talk about how much of your life you can have downtime from this original sort of traditional approach. I agree. Six months to a year of not feeling great. Certainly six to eight weeks of almost doing nothing with your hand is gone. And now we're doing stuff within a week and we're moving early.- It's exciting.- Yeah.- So how long is the surgery? How long does it take?- An hour or less. One of the things that gets difficult is if you have minimal versus substantial changes of arthritis, it just takes a little bit longer to make sure it's really prepared properly for the implant. You have to get the joint ready. That just is a stepwise process. But it's about an hour of surgery or less. I think of many of the cases it can be less, but for some people it's taking close to that hour, somewhere in that range.- Is it challenging for you as a surgeon to put this implant in?- I think as the surgery goes, most of it is pretty straightforward. I think the surgical approach is one we are incredibly familiar with. The technique is very reminiscent of other implant techniques. So the steps you have to know, but the specific technical exercise is not super challenging. It's one that we do a lot of hand surgery here. We deal with a lot of trauma, a lot of arthritis, a lot of complex and simple, and it sort of falls in that middle zone of nuance. And so that's the thing that has to be really trained and be ready for before you start doing it.- Who would be an ideal candidate and who wouldn't be an ideal candidate?- I think ideal is a tricky word. I think certainly someone who has been dealing with arthritis for a long time, who really has tried therapy and splints, cognitive behavioral therapy, which can be very helpful for arthritis. Injections like we talked about, have gone through the motions of really working with it and understanding their limitations, understanding how to cope with discomfort and really have worked through it and are still at kind of the breaking point. And when they aren't having success with therapy, which is time and money intensive and doesn't always work for people and exhausting for patients and really wear them down. So people who have been dealing with it feel ready for the big commitment of surgery. I think that that's a good place to start the conversation. I don't like to drag it out too long, but I do think it's good prehabilitation, if nothing else, building some of that strength even before we're going to have surgery. So I do think that's an important thing to do to set you up.- Is there ever a time where you would say, "Yeah, I don't think this implant is a good option for you. We should do the trapeziectomy."- Oh, so that to me is a very other side of it. That's somebody whose arthritis has gotten so advanced that the bone has collapsed to a place like trapezium is the bone that we take out. If that bone has collapsed to a place that can't accommodate the implant, that is someone who by x-ray measures is just not eligible. When you see somebody who has a lot of osteophytes, which is one of the things that happens with arthritis, you get a lot of bone change. This is sort of a technical issue, but if there's too much of that going on, you can get to a place where the implant just won't have space to move if there's too much bone change around it. But that's usually something we can deal with surgically, but it's something that we look at as kind of a concern. And then if they have arthritis in other parts of the wrist, that sometimes makes us pause and say, "We can make the thumb better, but you may still have wrist discomfort because the other bones are also seeing some of this arthritis change." So the two major things we're looking for is that I just talked about is arthritis and the other bones around the trapezium because that bone connects to the rest of the wrist. So if those areas have arthritis, that's a reason to pause. And then if the trapezium itself has gotten collapsed to a point it can't accommodate the implant. And those are the two red flags, but nobody would know that walking around at home. So it's not something that if someone's sitting at home, they would know. I think anyone dealing with arthritis should at least be looked at for this if they're heading towards surgery, because I think it is an incredibly good option. But those are things we look at. And- How miserable are patients to come in and want to get a surgery for their thumb- Arthritis? Again, it's across the whole spectrum. Like we were just talking about, there are some patients who have done the therapy for years and injections for years. And by the time they come to me, they're like at the end of the rope, really just totally burnt out and frustrated. And there's some who they deal with one injection, it works for six months, it wears off, which they almost always do. And they try the splints and they're doing it, but it's in the way and they can't do their job because the splint is bulky. And so they're not miserable, but they're coming to try to get ahead of that problem, which I also think makes sense. So you've tried the things to get you comfortable. You've tried things to slow this process down. It's just not working. I think people who come in before they get to the end of the rope is also very appropriate and also a lot of what we see. So it's kind of a split group. Some people kind of ahead of it and some people have tried to do everything they can to avoid surgery and just have not succeeded.- And when do you introduce the idea of this? How do you suggest it?- Well, it varies. Some people come in asking about it. We're doing a podcast. I'm sure now there are patients who are going to call and say, "Hey, I heard about this. Am I eligible?" So I think, again, it's about starting and sticking with the flow that has worked. Trying non-surgical things, trying to get people comfortable without jumping to a surgery. But the introduction of the conversation, even in our first visit, a lot of times I will talk about surgery because I think it's important people know that it's out there.- It's outpatient.- Yeah, it's outpatient surgery. It is a downtime. So no matter what you do, you're out of work for probably two or three weeks, even with this touch implant, because I want to make sure that you get comfortable enough to get back to a job. Now, I've had people say, "Hey, look, I'm ready to go back earlier. Totally fine. But I still want people to prepare for a few weeks out of work, a few weeks of some help at home because you're going to have one hand sort of out of commission." And we start that conversation relatively early. But like I said, I don't move people to surgery right out of the gate. So it depends a little bit on the person.- How big is the incision?- It is, let's say, I mean, if you're getting a measurement out, two to three inches, two inches, a few centimeters. Depends a little bit on the size of the hand. But it is not a big incision. Once it heals, it's very cosmetically comfortable for people. It doesn't really sit in a very visually obvious area. It's on a part of the hand that isn't often seen because it's kind of on the border of the thumb that faces inward, not the back of the hand, not the palm side. It's kind of on the side of the hand. It's not a very big incision, and it's an area that tends to heal pretty well. So we don't worry too much about- It. And do patients then have to come in and get the stitches removed?- So no, the stitches are all dissolvable. Essentially, you do the surgery and then everything dissolves. The implant, of course, is designed to stay in. The stitches are designed to dissolve. So you have a little, for me, I put little what are called Steri-Strips, little sticky tapes on it, and those are just on until they fall off. And then after that, by then, the wound is usually healed.- So what is the follow-up after surgery? They go home same day?- So everyone does it a little differently. For me, I still put people in a splint at the time of surgery. You probably don't even have to, but I just think it's helpful tissue, just rest, just kind of just let it chill out for a few days. I have them come back six days later. So it's pretty quick. Come out of the splint at that point. And then I ask our therapy team to make them a custom removable splint. But that's to their own preference. If they don't want to use it, they don't have to at that point. So already at six days, most of the approach allows for you to be totally out of a splint, moving to your comfort. We offer therapy at that point. I've had patients that do it. I've had patients that say, "I actually feel like I'm already moving pretty well. I don't even want to do it." So all of that is variable, but the general flow is come back at six days, come back two weeks after that, so then come back at six weeks. Those are sort of the three time points that are set. And then because it's an implant, I like to follow it at least to make sure the patients are doing well at three months, six months, a year. And then beyond that, I like to see my patients, but it's not really a critical thing. Most of the time we're not doing anything beyond that.- What about pain medication? Do they go home with pain- Medication? They go home with pain medication. I actually am not even sure whether the patients have used it. Certainly by six days when I've seen them, they have not needed more. At least no one has yet.- And a sling?- Only if you get a block, which puts the arm to sleep at the time of surgery. But within a day, you should not be in a sling, meaning the shoulder and the elbow are free to move almost immediately after surgery. It's really just the thumb and wrist that we cool off for a few days with that splint after surgery.- Thus, the splint, so- They- Can't really move it around. But after the stitches heal, the joint is good to- Lift- Something heavy maybe?- Yeah. So generally, the instruction manual has like a 15, 20 pound weight restriction. That's sort of the discussion on a lot of implants is they have a lot of load restrictions that people have comfortably gone past, but it's just sort of a guideline of where to start and where to kind of aim to be. So I wouldn't say that someone who's driving a jackhammer every day, this is not a great idea for them. Someone who's doing a ton of heavy hammering of metals and things like that, this might not hold up. I mean, that's a lot of force.- Sure,- Sure. But like I said - That's- Extreme.- Yeah. Turning a key, gripping a golf club, holding some weights in a gym, all that stuff within a few weeks is okay.- What are the advantages and potential limitations of thumb joint replacement compared with a trapeziectomy? And what's been your experience with patients who've received the implant?- Yeah. So I mean, assuming the surgery goes well, which generally it does and has, the benefits of the implant are better grip strength, earlier recovery, and more durable use early. There have actually not been great studies comparing long-term differences. Sure. Although there's a number of patients who've had a trapeziectomy on one side and a touch implant on the other. And to all the ones I've spoken to, which I'm sure it's not everybody, but to all the The ones I've spoken to have preferred the touch because it feels more normal to them because the thumb height is back to normal as well. That's really hard to quantify in a study, but generally they just feel more normal with it. It feels like it's at the right place for their grip. It feels like they're pinching more naturally because it's replacing the movement and the height of the joint as opposed to the trapeziectomy, which allows for movement, but it's a new movement pattern and it's lost some height. Even if we do the LRTI or the suture suspension or the tightrope, all of those still lose some height or they're a little tight or both. And so those things are differences.- If something would go wrong, what could go wrong?- Well, anytime you have surgery, you can have an infection. Infections, especially around implants, can be a really big problem. Now, we're very fortunate that most hand and wrist surgery has a very low infection rate at baseline, but that's always a thing to worry about. Okay. Longer term, the implant. I mean, shorter term, meaning in the surgery itself or shortly after, you can certainly have a bone break. So we're putting this piece of metal in a bone. If the bone breaks, that changes the game a little bit. Sometimes it just means you got to wait longer before you move it to allow the bone to heal. Sometimes it means we can't do the implant. If that kind of a thing happens and the trapezium totally breaks, it may not be able to do the implant anymore. So that's something that every patient, when we consent them or have a conversation about the surgery, understands is that if I cannot safely do it, then they're getting a trapeziectomy. We're going back to the old version. Those are rare things. The other thing you worry about is just the implant failing. It can dislocate, meaning the two components can pop apart. That's very unusual with this implant. It has been reported. You can have continued pain. Sometimes it's because you have arthritis in other joints. Sometimes it's just maybe this wasn't good enough solution for the patient. Again, that's very uncommon overall, but certainly has been reported. But for the most part, if you get through the surgery without an infection, you're moving relatively well early, this is a surgery that's had somewhere between 85, 95% success rate.- Is that good?- That's really good.- Okay.- The old, like I said, the old ones longer term are more 75 to 80%. And success is measured differently for different people. But ultimately, I think this one does a little bit better and has it more reliably getting there. Definitely not perfect. Nothing we do is perfect, but this one has had pretty good success in the first 10 years.- I know your patients are very happy.- Yeah. Yeah.- What do you think about this surgery for the future?- I think I am an inherently skeptical person, right? I mean, you read at the beginning of my research titles come from a place of me doing a lot of academic work. So studying deeply the details of surgery, not focusing on all the positives, but in fact, understanding what the negatives are. And that's sort of part of my job. That's what researchers inherently want to do is find the gaps, find the shortcomings so we can understand them and then hopefully make them better. So like I said, I was pretty skeptical about this one, but really dug into the available data, went out and saw patients, saw people who've had this now implanted for eight or nine years and saw the longer term. That's never as good as studying every patient that's had it, which we're working to do a better job of. But for the ones that we've seen and for the ones that we've been able to track, for the ones that we've got follow up on, it has done incredibly well. The short turnaround after surgery is a total game changer. And that's what I think motivated me to really start doing this surgery is how happy the patients were early. It's hard to say we know long-term how this holds up compared to the tried and true surgeries because we've been doing those for 50, 60, 70 years. We've only been doing this anywhere in the world for eight or nine, maybe 10. And it's only been very popular for five or less, even in Europe. And in the United States, it's only been happening for about a year. But the early differences have been so, so magnificently better that it's hard to kind of ignore this as an option for patients.- Well, I was going to ask as a final question, what are the key takeaways? But that sounds like the key takeaway.- Yeah. I think the hardest thing for people out there is to understand that not everyone is ready for surgery. Not everyone's a candidate for this, although a lot of people are. And arthritis is a lifelong challenge. When we replace a joint with an implant, it isn't the same as having the joint. And so I think we get really excited about options like this because by the time we see people, they're so unhappy and they're so limited. And we're able to really restore that is we do a lot of things before surgery and I don't want to get rid of those. But when surgery is kind of the option you're being presented, this touch prosthesis has been a total game changer in how thumb arthritis surgery is delivered, how the recovery has been shortened, how strength can be restored. It is totally different. And if it holds up the way we've seen it hold up so far, I think it will in many places become the standard of care because of just how much different and how much better it is.- Thank you, Dr. Giladi. I've been talking with Dr. Avi Gilari, a hand surgeon at the Curtis National Hand Center in Baltimore, Maryland. Thank you for sharing your expertise with us here on Dove Talk.- Deb, thanks for having me. It's a great topic and I look forward to helping a lot more people with it.- For more information about MedStar Health's Curtis National Hand Center, go to medstarhealth.org and search Curtis. To schedule an appointment with Dr. Gilati or any of the center's 14 hand surgeons, call 410-235-5405. If you're closer to Washington DC, call for an appointment with hand surgeon Dr. Michael Kessler at MedStar Georgetown University Hospital, 202-444-3668.