WEBVTT

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Welcome to the Deep Dive, the show where we really

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try to get to grips with complex medical topics,

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giving you the essential insights while the things

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you need to be truly well informed in your practice.

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Today, we're focusing on a joint that, despite

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its small size, is just absolutely fundamental

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to almost every single thing our patients do

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daily. You know, from intricate surgical tasks

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right down to simply holding a pen. We're talking,

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of course, about the thumb. And when its foundational

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joint, the one right at its very base, is compromised,

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the impact on daily life, and indeed professional

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function, can be profound. profoundly debilitating.

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So this deep dive is dedicated to basal thumb

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arthritis, also widely known, of course, as trapezium

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metacarpal, or sometimes carpal metacarpal joint

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arthritis of the thumb. It's a condition we encounter

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with, well, remarkable frequency in hand clinics

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all across the United Kingdom, presenting a unique

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set of diagnostic and treatment challenges for

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us as clinicians. Our mission today is to explore

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this condition comprehensively. We'll unpack

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its intricate anatomical and physiological mechanisms,

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delve into the various diagnostic approaches

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that guide our clinical decisions, examine the

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current evidence -based treatment paradigms,

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both conservative and surgical, and, crucially,

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shine a much -needed light on the often overlooked

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aspects of patient recovery and their holistic

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well -being. To guide us through this detailed

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discussion, we're incredibly fortunate to have

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an insightful authority in orthopedics and hand

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surgery joining us today. It's a real pleasure

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to be here. This is an incredibly important area

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within hand surgery, one that impacts a significant

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number of our patients quite directly, often

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limiting their ability to work and, you know,

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engage in daily life. So I'm keen to delve into

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the nuances of how we can best support them.

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Thank you for joining us. Let's begin right at

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the start then. When we refer to arthritis, particularly

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in the context of the thumb, how do we precisely

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define this condition and what are the key terms

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that, as medical professionals, we should be

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most familiar with? Right. Well, what's essential

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to understand from the outset is that arthritis,

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at its very core, signifies irritation or, more

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fundamentally, the progressive destruction of

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a joint. This process primarily involves the

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wearing out of the protective articular cartilage

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surface, that smooth layer that normally cushions

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the ends of bones, allowing them to glide smoothly

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against each other. Now in the thumb, the most

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frequent and clinically significant Cypher arthritis

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development is precisely at its base. what we

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refer to as the basal joint, or more technically,

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the thumb carpalmedic -coulmedic carpal joint,

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often abbreviated just to CMC joint. This joint

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is truly the workhorse of the thumb. The CMC

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joint, right. And when we diagnose arthritis

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predominantly affecting this basal joint, we're

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almost invariably referring to osteoarthritis.

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This is synonymous with what's commonly termed

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degenerative arthritis, or perhaps more colloquially,

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wear and tear arthritis. Okay, so degenerative,

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not inflammatory primarily. Exactly. That distinction

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is crucial because it immediately informs our

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understanding of the underlying pathological

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process. It's primarily a mechanical breakdown,

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not an inflammatory process like, say, rheumatoid

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arthritis. In clinical practice, you'll encounter

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several interchangeable terms for this condition,

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and it's helpful to be familiar with them all

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for clear communication. We might hear it called

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Basal or Thumb OA. Thumb carpel metacarpal joint

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OA or CMCJ OA, Thumb trapezium metacarpal joint

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OA or TMCJ OA, or even saddle joint OA, given

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the unique shape of the joint itself. Saddle

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joint, yes. The key insight here is that regardless

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of the specific term used, we're almost always

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dealing with the same fundamental degenerative

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process in this really critical joint. That distinction

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between degenerative and inflammatory arthritis

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is certainly a foundational point. Given it's

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essentially a wear and tear issue, let's explore

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the anatomy a bit more. The thumb -CMC joint

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is often described as a universal joint, what

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makes its architecture so special and perhaps

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paradoxically so vulnerable to these degenerative

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changes. It truly is a remarkable feat of natural

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engineering, actually. The thumb -CMC joint is

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classified as a unique biconcave saddle joint.

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You can sort of imagine two saddles perfectly

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fitted together, allowing movement in multiple

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planes. It's formed by the trapezium bone of

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the wrist and the first metacarpal bone of the

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thumb. This unique architecture is specifically

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designed to facilitate an incredibly wide range

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of movements, swiveling, pivoting, and crucially,

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opposition that unique human ability to bring

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your thumb across your palm to meet your other

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fingers. Which is vital for grip. Absolutely.

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These movements are indispensable for things

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like fine -gripping, grasping, and the precise

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manipulation of objects, which are fundamental

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to nearly every daily activity, from, you know,

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buttoning a shirt to performing intricate surgical

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maneuvers. Normally, the ends of these bones

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are covered by smooth, articular cartilage. This

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cartilage acts like a lubricated, low -friction

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surface, enabling effortless gliding and a wide,

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pain -free range of motion. However, and this

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is the crux of it, this extensive mobility comes

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at a significant biomechanical cost. The CMC

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joint endures substantial stresses. Consider

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this. The reactive force across the CMC joint

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can be up to 13 times the applied pitch force.

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13 times! That's astonishing! It is. To put that

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into perspective, imagine the equivalent of pressing

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down with a small weight, maybe 10 -15 kilos,

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on a joint that's only a few square centimeters

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in size, every single time you pinch something

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forcefully. This astonishing repeatedly applied

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load over many years provides a very clear and

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compelling rationale for its inherent susceptibility

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to degenerative changes. It's hardly surprising

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it wears out, really. That 13 -time statistic

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certainly clarifies the immense stress on such

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a small area. It makes perfect sense, then, why

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it's so prone to wear. But beyond just the forces,

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what about the inherent stability of the joint?

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Are there specific structures designed to hold

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it all together, and how do their roles factor

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into this vulnerability and the progression of

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the disease? Yes. Joint stability is absolutely

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paramount for such a mobile joint, and it relies

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heavily on its sophisticated ligamentous support

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system. The most critical stabilizing ligaments

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are the anterior oblique, often referred to as

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the volar beak ligament, and the dorsal radial

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ligaments. The volar beak ligament is widely

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considered the primary static restraint against

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subluxation, meaning it's the main structure

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preventing the metacarpal from slipping forward,

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sort of volar words, and out of place from the

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trapezium. Okay, the volar beak ligament. And

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the dorsal radial ligament, on the other hand,

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is generally regarded as the strongest and thickest

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primary restraint against dorsal dislocation,

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preventing the thumb from dislocating backwards.

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We also have the inner metacarpal ligament, which

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plays a vital role in resisting radial translation,

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or the thumb moving sideways, radially. These

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ligaments are truly the unsung heroes of thumb

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stability, working constantly to keep that saddle

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joint congruent, nice and lined. However, with

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the high forces, the repetitive motion, and sometimes

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the natural laxity that develops with age, or

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perhaps genetic predisposition, these ligaments

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can stretch, weaken, or even, in some cases,

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rupture. Right. If we connect this to the bigger

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picture, any attenuation or injury to these crucial

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structures immediately compromises the joint's

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intrinsic stability, initiating that cascade

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of degeneration that we talked about. Once that

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crucial ligamentous belt, as it were, loosens,

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the bones are no longer held tightly in their

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optimal position, setting the stage for the cartilage

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damage. So the ligaments, despite their foundational

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role, can indeed be a vulnerable link over time.

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Let's really delve into that cascade, then. How

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does this degeneration actually progress step

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by step from a relatively stable joint to one

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that's causing significant pain and eventually

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visible deformity for the patient. Yes, the pathophysiology

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of basal thumb arthritis truly outlines a sort

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of vicious cycle of degeneration. It often starts

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quite subtly and progresses relentlessly if it's

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unchecked. The initial domino to fall is often

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the weakening or even rupture of the volar oblique

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ligament, that critical anterior oblique ligament

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we just discussed. As individuals age, or sometimes

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due to specific micro traumas from repetitive

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activities, this ligament, so vital for CMC joint

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stability, can lose its integrity. Okay, so ligament

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laxity is the starting point. It's often the

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crucial turning point, yes. This ligamentous

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compromise leads directly to a loss of joint

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congruency. Put simply, the bones no longer fit

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together perfectly like they once did. The first

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metacarpal bone then begins to misalign, or sublux,

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relative to the trapezium. You could perhaps

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imagine a tent pole that's no longer sitting

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squarely on its base. The load isn't distributed

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evenly anymore. This misalignment initiates a

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rapid and destructive cycle of cartilage degradation.

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The cartilage, no longer subjected to perfectly

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distributed loads, begins to thin and erode unevenly,

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much like a car tire wearing out faster on one

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side if the alignment is off. That makes sense.

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As this protective cartilage diminishes, you

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get direct bone -on -bone contact during movement.

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This contact is precisely what causes the deep

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aching pain and grinding friction that patients

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so often describe. Over time, this constant bone

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-on -bone rubbing stimulates the body to try

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and stabilize the joint, leading to the formation

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of osteophytes' bony projections along the joint

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margins. Those bony spurs. Exactly. These osteophytes

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are the body's sort of desperate attempt to add

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stability, but they often contribute to further

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stiffness, pain, and restricted motion, creating

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a painful feedback loop. And this leads to visible

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changes. Yes. Clinically, this degenerative process

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can manifest as visible and often distressing

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deformities. Early on, you might observe a characteristic

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flexed posture of the thumb with a noticeable

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fullness at its base due to the bony changes

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and the subluxation. In more advanced cases,

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this can progress to what's known as a zigzag

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or swan neck deformity. This involves a progressive

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adduction, or drawing inwards towards the palm

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of the first metacarpal bone, coupled with a

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compensatory hyperextension of the metacarpoflangeal,

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or MCP. Joint the middle joint of the thumb.

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Ah, the zigzag shape. That classic deformity

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is a clear, visible sign of significant disease

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progression and chronic instability, making everyday

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tasks even more challenging for the patient.

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That's a very clear step -by -step picture of

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how the joint deteriorates. Given that progression,

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who is most susceptible to developing basal thumb

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arthritis? Are there specific demographics, genetic

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predispositions, or lifestyle factors that, as

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clinicians, we should be particularly aware of

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when assessing our patients? This is a critical

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area for us to understand, both for patient counseling

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and for early identification. Basal thumb arthritis

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is an incredibly common hand arthritis. Indeed,

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second only to distal interphalangeal, or DIP,

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arthritis and prevalence. The pattern we typically

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observe in hand osteoarthritis is that the DIP

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joints are most frequently affected, followed

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by the thumb CMC joint, then the proximal interphalangeal

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PP joints, and finally the metacarpal phalangeal

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MCP joints. So thumb CMC is number two. DIP,

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then CMC, then PIP, then MCP. Yeah. Got it. Precisely.

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Radiographic evidence is quite widespread. Studies

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show it's present in approximately 25 % of women

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over 55 and a striking 40 % of women over 75.

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However, and this is a vital clinical point,

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many individuals with radiographic changes may

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accommodate these symptoms without ever seeking

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medical treatment. So the true symptomatic prevalence

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we see in clinic is often lower than what the

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x -rays might suggest. So radiographic findings

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don't always equal symptoms. Exactly. That disconnect

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is really important. Interestingly, it's also

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more common in Caucasian populations compared

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to other ethnic groups when we look at hand osteoarthritis

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generally. Demographically, there's a significantly

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higher incidence in women compared to men, often

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with a female to male ratio as high as 6 .1 being

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reported. 6 to 1, wow. Yes, it's quite striking.

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It typically emerges after 40 or 50 years of

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age, with a particular predisposition in post

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-menopausal women. This leads directly to the

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strong genetic and hormonal influences at play.

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There seems to be a clear genetic predisposition,

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indicating a familial tendency if your mother

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or grandmother had it, you might be at higher

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risk yourself. Furthermore, the decline in protective

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estrogen levels during menopause seems to play

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a significant role in increasing vulnerability.

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The oestrogen link again. Indeed. Oestrogen is

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thought to have a protective effect on cartilage

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and perhaps joint stability, and its reduction

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seems to remove this buffer, accounting for the

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notably higher incidence in postmenopausal women.

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Traumatic antecedents are also notable predisposing

00:12:20.860 --> 00:12:23.860
factors. Previous injuries or trauma to the thumb.

00:12:24.029 --> 00:12:26.970
such as Rolando or Bennett fractures. These are

00:12:26.970 --> 00:12:29.129
specific fractures involving the articular base

00:12:29.129 --> 00:12:31.450
of the metacarpal can significantly increase

00:12:31.450 --> 00:12:34.990
risk if they heal in a malunited position, disrupting

00:12:34.990 --> 00:12:37.389
the joint's delicate mechanics. So previous injury

00:12:37.389 --> 00:12:40.769
is a big one. It certainly can be. Joint hypermobility

00:12:40.769 --> 00:12:43.360
is another consideration. Excessive basal joint

00:12:43.360 --> 00:12:46.200
laxity or generalized joint hypermobility, often

00:12:46.200 --> 00:12:48.940
more prevalent in younger women, could theoretically

00:12:48.940 --> 00:12:51.700
predispose individuals to premature degenerative

00:12:51.700 --> 00:12:54.700
changes due to repeated loading of sublux joints.

00:12:55.399 --> 00:12:57.200
While this theory has been discussed, for instance

00:12:57.200 --> 00:12:59.340
in the context of conditions like Ehlers -Danlos

00:12:59.340 --> 00:13:02.159
syndrome, direct experimental evidence definitively

00:13:02.159 --> 00:13:04.419
linking generalized hypermobility directly to

00:13:04.419 --> 00:13:06.879
basal thumb osteoarthritis is still perhaps a

00:13:06.879 --> 00:13:09.120
subject of some debate in the literature. It's

00:13:09.120 --> 00:13:12.360
plausible, but not fully proven. Okay, so hypermobility

00:13:12.360 --> 00:13:15.500
is a maybe. What about work and lifestyle? Occupational

00:13:15.500 --> 00:13:17.500
and lifestyle contributions certainly shouldn't

00:13:17.500 --> 00:13:20.379
be overlooked. For patients engaged in manual

00:13:20.379 --> 00:13:22.740
labor, certain crafts, or even extensive use

00:13:22.740 --> 00:13:25.500
of hand tools, activities involving repetitive

00:13:25.500 --> 00:13:28.259
gripping and pinching motions place additional

00:13:28.259 --> 00:13:31.789
sustained stress on the joint. Obesity is another

00:13:31.789 --> 00:13:34.370
lifestyle factor that can exacerbate joint stress,

00:13:34.889 --> 00:13:37.029
potentially through systemic inflammation and

00:13:37.029 --> 00:13:38.809
certainly through increased mechanical load on

00:13:38.809 --> 00:13:40.970
weight -bearing joints, though its direct impact

00:13:40.970 --> 00:13:43.870
on hand joints is perhaps less clear, but still

00:13:43.870 --> 00:13:46.789
considered a factor. Lastly, we must consider

00:13:46.789 --> 00:13:49.679
associated systemic conditions. Inflammatory

00:13:49.679 --> 00:13:52.480
arthritides, such as rheumatoid arthritis, can

00:13:52.480 --> 00:13:55.039
involve the basal joint. Approximately one -third

00:13:55.039 --> 00:13:57.000
of affected rheumatoid arthritis patients may

00:13:57.000 --> 00:14:00.039
experience basal joint involvement. Despite all

00:14:00.039 --> 00:14:02.559
these identifiable risk factors, it's important

00:14:02.559 --> 00:14:04.360
for us to remember that the most common cause

00:14:04.360 --> 00:14:06.879
of symptomatic basal joint arthritis remains

00:14:06.879 --> 00:14:09.820
idiopathic, arising from a complex, often unseen

00:14:09.820 --> 00:14:12.100
interplay of these various elements. That's a

00:14:12.100 --> 00:14:14.299
truly comprehensive overview of the risk factors,

00:14:14.700 --> 00:14:17.139
highlighting the multifactorial nature of this

00:14:17.139 --> 00:14:20.370
condition. Now let's turn to how patients typically

00:14:20.370 --> 00:14:22.850
present in our clinics. What are the cardinal

00:14:22.850 --> 00:14:24.990
symptoms that should immediately raise our clinical

00:14:24.990 --> 00:14:26.990
suspicion and what kind of story does the patient

00:14:26.990 --> 00:14:29.669
usually tell us? The patient's story is often

00:14:29.669 --> 00:14:32.129
remarkably consistent and understanding it is,

00:14:32.129 --> 00:14:35.029
well, half the diagnosis, isn't it? The cardinal

00:14:35.029 --> 00:14:37.929
and most common presenting symptom is pain localized

00:14:37.929 --> 00:14:40.750
directly to the base of the thumb. This pain

00:14:40.750 --> 00:14:43.649
frequently radiates to the Theonar eminence,

00:14:43.870 --> 00:14:45.690
that fleshy part of the palm at the base of the

00:14:45.690 --> 00:14:48.529
thumb, and sometimes even up towards the metacarpoflangel

00:14:48.529 --> 00:14:52.169
or MCP joint, the large knuckle of the thumb.

00:14:52.389 --> 00:14:54.870
Okay, pain at the base, radiating outwards. Yes.

00:14:55.149 --> 00:14:57.990
It was particularly telling is how activity -related

00:14:57.990 --> 00:15:01.250
the pain typically is. It's almost always exacerbated

00:15:01.250 --> 00:15:03.690
by activities requiring fine or forceful grip

00:15:03.690 --> 00:15:06.370
and pinch. Think about the everyday tasks that

00:15:06.370 --> 00:15:08.590
patients often complain about. Turning a key,

00:15:08.730 --> 00:15:11.110
struggling to open jars, unscrewing bottle tops,

00:15:11.490 --> 00:15:13.450
writing for extended periods, or even trying

00:15:13.450 --> 00:15:16.090
to snap their fingers. These seemingly simple

00:15:16.090 --> 00:15:19.110
actions become incredibly painful. Those specific

00:15:19.110 --> 00:15:22.549
activities are key clues. Absolutely. And as

00:15:22.549 --> 00:15:25.590
the condition progresses, this intermittent activity

00:15:25.590 --> 00:15:28.370
-related pain can unfortunately become constant,

00:15:28.970 --> 00:15:30.750
significantly impacting their quality of life

00:15:30.750 --> 00:15:34.509
and independence. Beyond pain, other key manifestations

00:15:34.509 --> 00:15:37.570
include noticeable swelling and tenderness directly

00:15:37.570 --> 00:15:40.440
at the base of the thumb. Patients often report

00:15:40.440 --> 00:15:43.019
an aching discomfort after prolonged use of the

00:15:43.019 --> 00:15:45.980
thumb, a feeling of fatigue in the hand, and

00:15:45.980 --> 00:15:48.259
a marked reduction in grip strength becomes evident,

00:15:48.779 --> 00:15:50.740
directly impacting their functional capabilities.

00:15:51.019 --> 00:15:53.759
Weakness is a big complaint to them. Yes, weakness

00:15:53.759 --> 00:15:56.620
and pain often go hand in hand. In more advanced

00:15:56.620 --> 00:15:58.899
cases, we start to see more pronounced signs

00:15:58.899 --> 00:16:01.360
on inspection. There might be an enlarged, almost

00:16:01.360 --> 00:16:03.799
out of joint appearance, or a distinct dorsal

00:16:03.799 --> 00:16:06.340
radial prominence, a noticeable bump at the base

00:16:06.340 --> 00:16:09.210
of the thumb. A bony prominence or bump directly

00:16:09.210 --> 00:16:12.289
over the basal joint is also very common. Patients

00:16:12.289 --> 00:16:14.710
will also report limited thumb motion and, quite

00:16:14.710 --> 00:16:17.450
tellingly, crepitus, that gritty, crackling or

00:16:17.450 --> 00:16:20.210
grinding sound or sensation during joint movement.

00:16:20.269 --> 00:16:22.789
Crepitus, that crunching sound. That's the one.

00:16:23.289 --> 00:16:25.830
It strongly implies significant cartilage erosion

00:16:25.830 --> 00:16:29.629
and bone -on -bone friction. All of these symptoms,

00:16:29.629 --> 00:16:32.629
of course, converge to cause significant functional

00:16:32.629 --> 00:16:34.590
impairment, making it difficult for patients

00:16:34.590 --> 00:16:37.690
to perform daily tasks, impacting fine motor

00:16:37.690 --> 00:16:40.149
skills, and sometimes leading to an inability

00:16:40.149 --> 00:16:42.889
to effectively abduct the thumb, meaning they

00:16:42.889 --> 00:16:45.330
struggle to move it away from the palm, limiting

00:16:45.330 --> 00:16:48.529
their ability to grasp larger objects. That paints

00:16:48.529 --> 00:16:51.389
a very clear clinical picture for us. Once we

00:16:51.389 --> 00:16:53.840
have that crucial patient history, What are the

00:16:53.840 --> 00:16:55.799
next crucial steps in the clinical examination

00:16:55.799 --> 00:16:59.059
to confirm the diagnosis and uncover the underlying

00:16:59.059 --> 00:17:01.179
signs that will inform our management? Right.

00:17:01.279 --> 00:17:03.299
A comprehensive clinical examination is where

00:17:03.299 --> 00:17:06.019
we truly bring the history to life. It's vital

00:17:06.019 --> 00:17:08.359
to begin with a detailed history, specifically

00:17:08.359 --> 00:17:11.059
inquiring not just about symptom patterns, but

00:17:11.059 --> 00:17:13.880
any prior hand or thumb injuries and precisely

00:17:13.880 --> 00:17:16.470
which activities aggravate their condition. What's

00:17:16.470 --> 00:17:18.509
often overlooked, but incredibly important, is

00:17:18.509 --> 00:17:20.710
the high prevalence of concomitant conditions

00:17:20.710 --> 00:17:23.049
that frequently accompany basal thumb arthritis.

00:17:23.569 --> 00:17:25.849
We know that up to 50 % of patients with basal

00:17:25.849 --> 00:17:28.049
thumb arthritis can also have carpal tumble syndrome.

00:17:28.369 --> 00:17:31.769
50%, wow. Yes. So we must ask about tingling,

00:17:32.009 --> 00:17:35.230
numbness, or night pain. We also frequently encounter

00:17:35.230 --> 00:17:38.970
scaphotropiesial arthrosis, trigger digits, metacarpal

00:17:38.970 --> 00:17:42.410
phalangeal, MCP, hyperextension, and tenosynovitis

00:17:42.410 --> 00:17:45.609
of the wrist, like decervains. Therefore, it's

00:17:45.609 --> 00:17:48.410
crucial to proactively inquire about and assess

00:17:48.410 --> 00:17:50.269
for these conditions during our comprehensive

00:17:50.269 --> 00:17:53.210
examination to ensure we develop a truly holistic

00:17:53.210 --> 00:17:55.930
and tailored management plan. So check for carpal

00:17:55.930 --> 00:17:59.049
tunnel, decor vanes, trigger finger. Exactly.

00:17:59.339 --> 00:18:01.740
Missing these coexisting issues could lead to

00:18:01.740 --> 00:18:04.059
suboptimal outcomes for our patients. During

00:18:04.059 --> 00:18:06.220
inspection, especially in more advanced cases,

00:18:06.559 --> 00:18:08.880
you'll often observe visible signs such as bony

00:18:08.880 --> 00:18:11.519
swelling or that dorsaradial prominence of the

00:18:11.519 --> 00:18:14.400
thumb metacarpal base. Palpation is key. You'll

00:18:14.400 --> 00:18:16.400
find characteristic localized tenderness directly

00:18:16.400 --> 00:18:19.099
over the thumb carpometacarpal CMC joint. And

00:18:19.099 --> 00:18:20.799
as we discussed earlier, the presence of crepitus

00:18:20.799 --> 00:18:22.980
during the examination that gritty or crackling

00:18:22.980 --> 00:18:25.480
sensation strongly implies significant erosion

00:18:25.480 --> 00:18:27.420
of the articular cartilage. And the specific

00:18:27.420 --> 00:18:30.200
tests. We then move to provocative maneuvers,

00:18:30.460 --> 00:18:33.019
which are invaluable for eliciting specific responses.

00:18:33.720 --> 00:18:36.900
The CMC grind test is a classic and highly informative.

00:18:37.500 --> 00:18:39.480
This is performed by applying axial compression

00:18:39.480 --> 00:18:42.079
through the thumb and simultaneously rotating

00:18:42.079 --> 00:18:44.779
or circumducting the thumb metacarpal base. Grinding

00:18:44.779 --> 00:18:48.059
the joint, essentially. In effect, yes. A positive

00:18:48.059 --> 00:18:50.880
test indicated by the reproduction of pain or

00:18:50.880 --> 00:18:54.259
distinct crunching sensation is highly suggestive

00:18:54.259 --> 00:18:56.440
of underlying degenerative disease in cartilage

00:18:56.440 --> 00:18:59.299
wear. Another useful test is the distraction

00:18:59.299 --> 00:19:02.759
or torque test where you apply gentle axial traction

00:19:02.759 --> 00:19:06.200
while rotating the thumb at a carpal base. A

00:19:06.200 --> 00:19:08.380
positive result here often indicates synovitis

00:19:08.380 --> 00:19:10.920
which is inflammation of the joint lining and

00:19:10.920 --> 00:19:13.140
is more typically associated with milder disease

00:19:13.140 --> 00:19:15.819
stages where inflammation rather than just bone

00:19:15.819 --> 00:19:18.000
-on -bone rubbing might be a prominent feature.

00:19:18.519 --> 00:19:20.740
So grind test for where? Distraction test for

00:19:20.740 --> 00:19:23.690
synovitis. Broadly speaking, yes, though for

00:19:23.690 --> 00:19:25.410
our medical audience, it's worth noting that

00:19:25.410 --> 00:19:27.930
while valuable, these provocative tests are perhaps

00:19:27.930 --> 00:19:30.210
more commonly utilized and refined in specialist

00:19:30.210 --> 00:19:32.849
hand surgery settings, where a precise diagnosis

00:19:32.849 --> 00:19:35.059
is paramount for surgical planning. Okay, that

00:19:35.059 --> 00:19:37.500
makes sense. So we've gathered the patient history,

00:19:37.779 --> 00:19:39.640
performed a thorough clinical exam, including

00:19:39.640 --> 00:19:41.940
looking for those associated conditions, and

00:19:41.940 --> 00:19:43.980
now we need to see what's happening beneath the

00:19:43.980 --> 00:19:46.400
surface to confirm our suspicions and precisely

00:19:46.400 --> 00:19:49.660
stage the disease. What role do imaging studies

00:19:49.660 --> 00:19:52.339
play and how do we use them to categorize the

00:19:52.339 --> 00:19:55.339
severity of the condition? Right. Imaging, particularly

00:19:55.339 --> 00:19:58.029
radiographs, are absolutely fundamental. They

00:19:58.029 --> 00:20:00.069
are essential not just for confirming our clinical

00:20:00.069 --> 00:20:02.769
diagnosis, but crucially for assessing the severity

00:20:02.769 --> 00:20:06.109
of the disease and ruling out other osseous abnormalities

00:20:06.109 --> 00:20:08.730
that might mimic the condition. For standard

00:20:08.730 --> 00:20:11.710
views, we always obtain AP and lateral projections

00:20:11.710 --> 00:20:14.829
of the hand. However, the Roberts view is particularly

00:20:14.829 --> 00:20:17.630
important and really a cornerstone for diagnosing

00:20:17.630 --> 00:20:19.930
basal thumb arthritis. The Roberts view? Okay,

00:20:20.210 --> 00:20:23.019
how is that done? It's a postural anterior view

00:20:23.019 --> 00:20:26.119
of both thumb trapezium metacarpal joints taken

00:20:26.119 --> 00:20:28.880
with the thumb flat on the cassette and hyperpronated.

00:20:29.660 --> 00:20:32.380
This specific positioning provides the best visualization

00:20:32.380 --> 00:20:35.559
of the joint surfaces and any abnormal changes.

00:20:36.559 --> 00:20:38.920
A lateral wrist view can also be immensely useful

00:20:38.920 --> 00:20:42.079
to assess overall alignment and any coexisting

00:20:42.079 --> 00:20:44.259
ligament attenuation in the wider wrist complex.

00:20:45.079 --> 00:20:46.720
And what are we looking for on these x -rays?

00:20:47.079 --> 00:20:49.220
We look for key findings that signify degenerative

00:20:49.220 --> 00:20:52.049
changes. Firstly, Joint space narrowing, which

00:20:52.049 --> 00:20:54.250
directly indicates cartilage loss. Secondly,

00:20:54.470 --> 00:20:56.509
subchondral sclerosis, which is a hardening and

00:20:56.509 --> 00:20:58.430
increased density of the bone directly beneath

00:20:58.430 --> 00:21:01.150
the cartilage, indicating increased stress. And

00:21:01.150 --> 00:21:03.730
thirdly, the formation of osteophytes, those

00:21:03.730 --> 00:21:05.809
extra bony projections along the joint margins,

00:21:06.230 --> 00:21:08.250
which are the body's attempt at stabilization.

00:21:08.670 --> 00:21:11.690
Narrowing sclerosis osteophytes, the classic

00:21:11.690 --> 00:21:15.500
OA signs. Precisely. To systematically assess

00:21:15.500 --> 00:21:17.579
the disease severity and guide our treatment

00:21:17.579 --> 00:21:20.480
decisions, we commonly use the Eaton and Glickle

00:21:20.480 --> 00:21:23.779
classification system. This widely accepted system

00:21:23.779 --> 00:21:26.220
stages pathological changes in the basal joint

00:21:26.220 --> 00:21:28.619
based purely on radiographic appearance, and

00:21:28.619 --> 00:21:31.019
it's crucial for both preoperative planning and

00:21:31.019 --> 00:21:32.740
for effectively educating our patients about

00:21:32.740 --> 00:21:34.859
their condition. Can you briefly outline those

00:21:34.859 --> 00:21:38.460
stages for us? Certainly. Stage 1. Characterized

00:21:38.460 --> 00:21:40.900
by normal trapezium metacarpal joint contours,

00:21:41.059 --> 00:21:42.990
but... perhaps some widening, maybe with less

00:21:42.990 --> 00:21:45.390
than one -third joint subluxation seen on stress

00:21:45.390 --> 00:21:48.009
views. This is considered a pre -arthritis state,

00:21:48.349 --> 00:21:50.529
often with instability but minimal actual cartilage

00:21:50.529 --> 00:21:53.849
damage yet. Stage two, here we see slight TM

00:21:53.849 --> 00:21:56.269
joint narrowing with chlorosis and osteophytes,

00:21:56.549 --> 00:21:58.430
or maybe loose bodies less than two millimeters.

00:21:59.230 --> 00:22:01.450
Instability may also be apparent on stress views,

00:22:01.869 --> 00:22:03.890
with equal to or greater than one -third joint

00:22:03.890 --> 00:22:06.970
subluxation. This indicates early but definite

00:22:06.970 --> 00:22:09.839
degenerative changes. Stage three. shows marked

00:22:09.839 --> 00:22:12.799
TM joint narrowing, prominent subchondral sclerosis,

00:22:13.380 --> 00:22:15.240
and osteophytes or loose bodies greater than

00:22:15.240 --> 00:22:17.900
two millimeters. Significant subluxation equal

00:22:17.900 --> 00:22:20.220
to or greater than one -third typically persists.

00:22:20.490 --> 00:22:22.930
This is clear advanced arthritis of the CMC joint

00:22:22.930 --> 00:22:25.769
itself. Stage 4 represents the most advanced

00:22:25.769 --> 00:22:27.650
disease affecting not only the TM joint, but

00:22:27.650 --> 00:22:30.150
also the scaphedrapezoid STT joint, the joint

00:22:30.150 --> 00:22:32.509
between the scaphoid and trapezium bones. This

00:22:32.509 --> 00:22:34.930
is termed pantrapezoid arthritis involving the

00:22:34.930 --> 00:22:37.410
entire trapezoid complex. Pantrapezoid. So stage

00:22:37.410 --> 00:22:39.789
4 involves the neighboring joint too. Exactly.

00:22:40.190 --> 00:22:42.450
While x -rays are generally the primary imaging

00:22:42.450 --> 00:22:45.369
modality, CT scans may occasionally be used for

00:22:45.369 --> 00:22:48.150
a more detailed view of bone structures, especially

00:22:48.150 --> 00:22:50.559
for complex surgical planning. where precise

00:22:50.559 --> 00:22:54.019
bone anatomy is required. However, it's important

00:22:54.019 --> 00:22:56.140
to remember that magnetic resonance imaging,

00:22:56.700 --> 00:22:59.839
MRI, tomography, or ultrasonography, are generally

00:22:59.839 --> 00:23:02.420
not indicated for routine evaluation of basal

00:23:02.420 --> 00:23:05.339
joint disease. X -rays usually provide sufficient

00:23:05.339 --> 00:23:08.299
information for diagnosis and staging. Good to

00:23:08.299 --> 00:23:11.549
know MRI isn't typically needed here. Yes, and

00:23:11.549 --> 00:23:13.470
a crucial clinical point to reiterate, one that

00:23:13.470 --> 00:23:15.589
often surprises patients, is that there is frequently

00:23:15.589 --> 00:23:18.390
a poor correlation between the radiographic severity

00:23:18.390 --> 00:23:21.210
of degenerative disease and the patient's clinical

00:23:21.210 --> 00:23:23.470
symptomatology. Yes, you mentioned this disconnect.

00:23:23.769 --> 00:23:25.849
Indeed. You might find patients with minimal

00:23:25.849 --> 00:23:28.390
joint space narrowing and experiencing disabling

00:23:28.390 --> 00:23:31.690
pain, while conversely, some asymptomatic patients

00:23:31.690 --> 00:23:33.950
may incidentally present with stage 5 -E disease

00:23:33.950 --> 00:23:36.730
on radiographs. It really underscores that we

00:23:36.730 --> 00:23:38.890
treat the patient, not just the picture. That's

00:23:38.890 --> 00:23:40.910
a vital reminder that the imaging doesn't always

00:23:40.910 --> 00:23:42.670
tell the whole story when it comes to patient

00:23:42.670 --> 00:23:45.390
experience, and our clinical assessment remains

00:23:45.390 --> 00:23:48.569
paramount. Before we delve into treatment strategies,

00:23:49.029 --> 00:23:51.190
what other conditions might present similarly

00:23:51.190 --> 00:23:54.250
to basal thumb arthritis, potentially confusing

00:23:54.250 --> 00:23:57.369
the diagnosis, and how do we accurately differentiate

00:23:57.369 --> 00:24:00.190
them? Distinguishing basal thumb arthritis from

00:24:00.190 --> 00:24:02.990
conditions that mimic its symptoms is absolutely

00:24:02.990 --> 00:24:06.269
essential for accurate diagnosis and, critically,

00:24:06.769 --> 00:24:08.950
for ensuring we provide the appropriate and effective

00:24:08.950 --> 00:24:11.569
management. It really prompts the question, what

00:24:11.569 --> 00:24:13.589
else could this be that presents with similar

00:24:13.589 --> 00:24:16.190
thumb and wrist pain? The differential diagnosis.

00:24:16.390 --> 00:24:19.509
Precisely. One condition to consider is C6 radiculopathy.

00:24:19.970 --> 00:24:22.049
This is characterized by pain radiating from

00:24:22.049 --> 00:24:25.250
the neck with peristhesias or numbness and tingling

00:24:25.250 --> 00:24:27.349
primarily affecting the thumb and index finger.

00:24:27.470 --> 00:24:30.130
This suggests a nerve root issue in the cervical

00:24:30.130 --> 00:24:32.630
spine rather than a primary joint problem in

00:24:32.630 --> 00:24:35.029
the hand. We differentiate this through neck

00:24:35.029 --> 00:24:38.190
examination, specific neurological tests, and

00:24:38.190 --> 00:24:40.349
potentially imaging of the cervical spine. So

00:24:40.349 --> 00:24:43.579
always consider the neck. Always. Decurvain's

00:24:43.579 --> 00:24:46.240
tenosynovitis is another common mimic. This is

00:24:46.240 --> 00:24:48.640
an inflammation of the tendons in the first dorsal

00:24:48.640 --> 00:24:51.599
compartment on the thumb side of the wrist. It's

00:24:51.599 --> 00:24:53.859
distinguished by a positive Finkelstein's test,

00:24:54.299 --> 00:24:56.519
where pain is reproduced when the thumb is flexed

00:24:56.519 --> 00:24:58.980
into the palm, the fingers are wrapped over it,

00:24:59.140 --> 00:25:01.140
and the wrist is then sharply deviated towards

00:25:01.140 --> 00:25:04.279
the ulna. This specifically irritates the affected

00:25:04.279 --> 00:25:07.119
tendons, differentiating it from CMC joint pain.

00:25:07.839 --> 00:25:11.960
Finkelstein's for Decurvain's. Spot on. Scaphotropiesial

00:25:11.960 --> 00:25:14.900
STT arthritis causes pain and tenderness typically

00:25:14.900 --> 00:25:17.720
localized just proximal or closer to the wrist

00:25:17.720 --> 00:25:20.819
compared to the TMC joint itself. Because of

00:25:20.819 --> 00:25:23.339
the close anatomical relationship it can be easily

00:25:23.339 --> 00:25:26.240
confused. Diagnostic injections precisely into

00:25:26.240 --> 00:25:28.799
the STT joint or specific radiographic views

00:25:28.799 --> 00:25:31.539
focusing on this area may be needed to differentiate

00:25:31.539 --> 00:25:33.980
it. So location of tenderness is key there? It

00:25:33.980 --> 00:25:37.460
helps, yes. We also must actively look for conditions

00:25:37.460 --> 00:25:40.299
like scaphoid non -union advanced collapse, as

00:25:40.299 --> 00:25:43.039
in a Steve's wrist, and radioscaphoid arthritis.

00:25:43.779 --> 00:25:46.079
These are chronic conditions stemming from previous

00:25:46.079 --> 00:25:48.420
scaphoid fractures or long -term degenerative

00:25:48.420 --> 00:25:51.019
changes in the wrist. Both are usually evident

00:25:51.019 --> 00:25:53.920
on standard wrist radiographs and their distinct

00:25:53.920 --> 00:25:56.420
radiographic patterns help us differentiate them

00:25:56.420 --> 00:25:58.819
as they require very different management strategies

00:25:58.819 --> 00:26:01.750
than basal thumb arthritis. Okay. Check the wrist

00:26:01.750 --> 00:26:04.329
x -rays carefully, too. And finally, given its

00:26:04.329 --> 00:26:06.269
high co -occurrence with basal thumb arthritis,

00:26:06.349 --> 00:26:09.470
as we mentioned, up to 50 % of patients, it's

00:26:09.470 --> 00:26:11.990
absolutely crucial to assess for signs of carpal

00:26:11.990 --> 00:26:14.789
tunnel syndrome. This is compression to the median

00:26:14.789 --> 00:26:17.890
nerve at the wrist. Patients might report numbness,

00:26:18.150 --> 00:26:20.829
tingling, or pain in the thumb, index middle,

00:26:21.109 --> 00:26:23.190
and half of the ring finger, particularly symptoms

00:26:23.190 --> 00:26:25.960
that wake them at night. If suspected, nerve

00:26:25.960 --> 00:26:28.099
conduction studies may be required to confirm

00:26:28.099 --> 00:26:30.720
this diagnosis. Right. Never forget the carpal

00:26:30.720 --> 00:26:33.420
tunnel. The careful differentiation of all these

00:26:33.420 --> 00:26:35.240
conditions ensures we're treating the correct

00:26:35.240 --> 00:26:38.579
pathology or, as is often the case, multiple

00:26:38.579 --> 00:26:41.319
pathologies simultaneously, leading to much more

00:26:41.319 --> 00:26:43.880
effective patient care. With a confirmed diagnosis

00:26:43.880 --> 00:26:46.200
and a clear understanding of potential mimics,

00:26:46.599 --> 00:26:48.980
let's explore the treatment landscape. What's

00:26:48.980 --> 00:26:50.759
the initial approach we should always consider?

00:26:50.920 --> 00:26:54.140
And how far can conservative management realistically

00:26:54.140 --> 00:26:57.319
take a patient before we consider surgical options?

00:26:57.599 --> 00:27:00.859
Conservative management truly forms the indispensable

00:27:00.859 --> 00:27:03.079
foundation of care for basal thumb arthritis.

00:27:03.519 --> 00:27:06.140
It's the absolute mainstay of initial treatment,

00:27:06.220 --> 00:27:08.460
even sometimes in later stages of the disease,

00:27:08.799 --> 00:27:11.160
particularly for patients presenting with mild

00:27:11.160 --> 00:27:13.920
to moderate symptoms. It's important to convey

00:27:13.920 --> 00:27:15.500
to our patients that a significant number of

00:27:15.500 --> 00:27:17.599
them actually achieve satisfactory long -term

00:27:17.680 --> 00:27:20.039
outcomes and excellent pain control with these

00:27:20.039 --> 00:27:22.799
non -surgical approaches alone. This can be very

00:27:22.799 --> 00:27:25.000
reassuring for them to hear. So always start

00:27:25.000 --> 00:27:28.400
conservative. Always. Activity modification is

00:27:28.400 --> 00:27:31.559
paramount. We advise patients on avoiding activities

00:27:31.559 --> 00:27:34.400
that exacerbate their pain, such as less forceful

00:27:34.400 --> 00:27:37.079
pinching or suggesting they alternate hand use

00:27:37.079 --> 00:27:40.380
to reduce strain. Simple but effective changes,

00:27:40.740 --> 00:27:42.799
like using larger diameter writing instruments,

00:27:43.059 --> 00:27:45.579
ergonomic tools, or adaptive kitchen aids like

00:27:45.579 --> 00:27:48.720
jar openers, can significantly reduce the cumulative

00:27:48.720 --> 00:27:51.940
stress on the joint. This empowers patients to

00:27:51.940 --> 00:27:54.339
manage their symptoms actively. Simple changes

00:27:54.339 --> 00:27:56.920
can make a big difference. They really can. For

00:27:56.920 --> 00:27:59.000
pharmacological interventions, over -the -counter

00:27:59.000 --> 00:28:01.500
analgesics and nonsteroidal anti -inflammatory

00:28:01.500 --> 00:28:04.619
drugs like aspirin, ibuprofen, or naproxen are

00:28:04.619 --> 00:28:06.720
often the first line to manage pain and reduce

00:28:06.720 --> 00:28:09.230
inflammation and swelling. When these aren't

00:28:09.230 --> 00:28:12.269
sufficient from mild to moderate disease, intraarticular

00:28:12.269 --> 00:28:14.490
corticosteroid injections directly into the carpal

00:28:14.490 --> 00:28:17.150
-metacarpal joint are a common second -line treatment.

00:28:17.670 --> 00:28:19.630
These typically provide pain relief for several

00:28:19.630 --> 00:28:22.109
months, often between three to six months, maybe

00:28:22.109 --> 00:28:24.150
longer for some. Steroid injections are quite

00:28:24.150 --> 00:28:26.250
effective, then. They can be very effective for

00:28:26.250 --> 00:28:29.569
symptom control, yes. However, Their effect can

00:28:29.569 --> 00:28:32.329
diminish with repeated injections, and they carry

00:28:32.329 --> 00:28:35.529
a theoretical, albeit small, risk of weakening

00:28:35.529 --> 00:28:38.369
capsular support or even compromising articular

00:28:38.369 --> 00:28:41.470
cartilage over the very long term. So it's generally

00:28:41.470 --> 00:28:43.910
advised to limit their frequency, perhaps to

00:28:43.910 --> 00:28:46.289
two or three injections per year at most, into

00:28:46.289 --> 00:28:48.789
one joint. Limit the injections. What about other

00:28:48.789 --> 00:28:52.359
types? Hyaluronic acid. Good question. Current

00:28:52.359 --> 00:28:54.539
evidence does not support the routine use of

00:28:54.539 --> 00:28:57.279
hyaluronic acid injections for basal thumb arthritis.

00:28:58.059 --> 00:28:59.859
Studies have shown no significant difference

00:28:59.859 --> 00:29:02.339
in pain relief or functional improvement compared

00:29:02.339 --> 00:29:05.579
to placebo or corticosteroids. So that's an important

00:29:05.579 --> 00:29:07.319
distinction to make for patients who may have

00:29:07.319 --> 00:29:10.240
heard about them for, say, knee arthritis. Okay,

00:29:10.400 --> 00:29:12.700
no hyaluronic acid. What about glucosamine and

00:29:12.700 --> 00:29:15.740
chondroitin? Ah, the area of chondroprotective

00:29:15.740 --> 00:29:19.039
agents like glucosamine and chondroitin sulfate

00:29:19.039 --> 00:29:21.829
remains quite controversial. While some patients

00:29:21.829 --> 00:29:24.089
may wish to try them, and there's probably little

00:29:24.089 --> 00:29:27.049
harm, it's crucial to caution them about the

00:29:27.049 --> 00:29:29.809
distinct lack of robust clinical evidence for

00:29:29.809 --> 00:29:32.730
their efficacy in repairing cartilage or decelerating

00:29:32.730 --> 00:29:35.349
the degenerative process in this specific joint.

00:29:35.599 --> 00:29:38.339
We must manage patient expectations carefully

00:29:38.339 --> 00:29:40.539
here. So limited evidence for those supplements?

00:29:40.759 --> 00:29:43.039
Very limited, yes. Immobilization and support

00:29:43.039 --> 00:29:46.019
are also key components. Supportive splints are

00:29:46.019 --> 00:29:48.059
highly beneficial in limiting thumb movement

00:29:48.059 --> 00:29:50.359
and allowing the joint to rest and inflammation

00:29:50.359 --> 00:29:53.099
to settle. The most effective is often a well

00:29:53.099 --> 00:29:56.400
-fitted, custom -made thumb spica splint, which

00:29:56.400 --> 00:29:58.799
specifically immobilizes the basal joint while

00:29:58.799 --> 00:30:01.000
allowing other finger movement. A custom splint

00:30:01.000 --> 00:30:03.960
is best. Often, yes, for comfort and precise

00:30:03.960 --> 00:30:06.779
immobilization. Initially, continuous wear for

00:30:06.779 --> 00:30:09.220
maybe three to four weeks is recommended, gradually

00:30:09.220 --> 00:30:11.200
transitioning to intermittent use, perhaps just

00:30:11.200 --> 00:30:13.400
for symptomatic periods or when anticipating

00:30:13.400 --> 00:30:15.480
heavy loads like gardening or gripping tools.

00:30:15.779 --> 00:30:18.670
And finally, exercise and physio. Absolutely

00:30:18.670 --> 00:30:21.470
vital for long -term success. We advocate for

00:30:21.470 --> 00:30:23.789
structured physical therapy program, often led

00:30:23.789 --> 00:30:26.369
by a specialist hand therapist, to enhance function

00:30:26.369 --> 00:30:29.309
and alleviate pain. Specific exercise regimens

00:30:29.309 --> 00:30:32.069
include the hangar, intrinsic and extrinsic muscle

00:30:32.069 --> 00:30:34.650
strengthening exercises to build dynamic stability

00:30:34.650 --> 00:30:37.269
around the joint, thumb IP flexion, bending the

00:30:37.269 --> 00:30:39.750
thumb MP flexion, bending the thumb at the base

00:30:39.750 --> 00:30:41.849
towards the palm and thumb opposition exercises

00:30:41.849 --> 00:30:44.309
to improve grasping and pinching capabilities.

00:30:44.940 --> 00:30:48.000
Manual therapy techniques like gentle joint mobilizations

00:30:48.000 --> 00:30:50.579
to restore movement and soft tissue manipulation

00:30:50.579 --> 00:30:52.559
to break down scar tissue can be integrated.

00:30:53.200 --> 00:30:55.039
Therapeutic taping can also support the joint

00:30:55.039 --> 00:30:58.099
for daily activities. We also recommend assistive

00:30:58.099 --> 00:31:00.099
devices and general joint protection techniques

00:31:00.099 --> 00:31:03.240
to reduce strain. Temperature therapy, using

00:31:03.240 --> 00:31:06.200
heat to decrease pain and enhance motion, or

00:31:06.200 --> 00:31:09.140
cold packs for flare -ups, can provide symptomatic

00:31:09.140 --> 00:31:11.819
relief for some people, though evidence for their

00:31:11.819 --> 00:31:14.200
long -term efficacy in modifying disease progression

00:31:14.200 --> 00:31:17.369
is mixed. The key insight for conservative management

00:31:17.369 --> 00:31:19.730
is that it's about empowering the patient to

00:31:19.730 --> 00:31:21.910
manage their symptoms and protect their joint,

00:31:22.589 --> 00:31:24.670
often achieving significant improvement without

00:31:24.670 --> 00:31:26.890
ever needing surgery. That sounds like a robust

00:31:26.890 --> 00:31:30.069
and multifaceted first line of defense. But as

00:31:30.069 --> 00:31:32.049
you alluded to, what happens when conservative

00:31:32.049 --> 00:31:34.230
measures simply aren't enough? when pain and

00:31:34.230 --> 00:31:36.410
disability persist despite our best efforts.

00:31:36.910 --> 00:31:39.069
When do we start considering surgical interventions

00:31:39.069 --> 00:31:41.269
and what are the overarching principles guiding

00:31:41.269 --> 00:31:43.849
those complex decisions? That's precisely when

00:31:43.849 --> 00:31:46.150
we transition our focus towards surgical options.

00:31:46.849 --> 00:31:49.130
The clear indications for surgery are persistent

00:31:49.130 --> 00:31:52.609
pain and functional disability that are not adequately

00:31:52.609 --> 00:31:55.369
controlled by comprehensive conservative treatments,

00:31:55.890 --> 00:31:59.230
particularly in a compliant patient who has genuinely

00:31:59.230 --> 00:32:02.390
given conservative measures a fair trial, perhaps

00:32:02.390 --> 00:32:05.500
over three to six months. The staging of the

00:32:05.500 --> 00:32:07.599
disease using that Eaton and Glickle classification

00:32:07.599 --> 00:32:10.359
we discussed becomes absolutely crucial at this

00:32:10.359 --> 00:32:12.740
point as it heavily guides the selection of the

00:32:12.740 --> 00:32:15.079
most appropriate surgical procedure for that

00:32:15.079 --> 00:32:17.720
individual patient. A stage I patient will likely

00:32:17.720 --> 00:32:19.559
be considered for very different interventions

00:32:19.559 --> 00:32:22.359
than a stage five patient. Staging really directs

00:32:22.359 --> 00:32:25.369
the surgical choice. It does. In terms of general

00:32:25.369 --> 00:32:28.170
surgical principles, most operations for basal

00:32:28.170 --> 00:32:30.450
thumb arthritis can typically be performed on

00:32:30.450 --> 00:32:32.589
an outpatient basis, meaning the patient goes

00:32:32.589 --> 00:32:35.650
home the same day. This is usually done under

00:32:35.650 --> 00:32:38.529
general anesthesia or regional anesthesia, an

00:32:38.529 --> 00:32:40.349
arm block which can be beneficial for patient

00:32:40.349 --> 00:32:43.009
recovery. These procedures are generally quite

00:32:43.009 --> 00:32:45.089
efficient, often taking less than an hour of

00:32:45.089 --> 00:32:48.289
operative time, sometimes even quicker. The primary

00:32:48.289 --> 00:32:50.529
goal across all these surgical approaches is

00:32:50.529 --> 00:32:53.029
fundamentally straightforward. to prevent that

00:32:53.029 --> 00:32:55.269
painful bone -on -bone rubbing that is causing

00:32:55.269 --> 00:32:58.109
the symptoms and functional limitation. It's

00:32:58.109 --> 00:33:00.789
about restoring a pain -free articulation or

00:33:00.789 --> 00:33:02.950
removing the source of the pain altogether. Remove

00:33:02.950 --> 00:33:05.369
the rubbing, remove the pain. Essentially, yes.

00:33:06.049 --> 00:33:07.930
The decision regarding the specific surgical

00:33:07.930 --> 00:33:10.750
option is always a collaborative one, a shared

00:33:10.750 --> 00:33:12.410
decision -making process between the surgeon

00:33:12.410 --> 00:33:15.220
and the patient. We carefully consider the patient's

00:33:15.220 --> 00:33:18.500
age, their functional demands, do they need fine

00:33:18.500 --> 00:33:21.559
dexterity or powerful grip, their expectations

00:33:21.559 --> 00:33:23.519
for recovery and future function, and, of course,

00:33:23.700 --> 00:33:25.900
the specific preoperative radiographic findings.

00:33:26.460 --> 00:33:28.579
It's a truly tailored approach because one size

00:33:28.579 --> 00:33:30.700
certainly does not fit all -in -hand surgery,

00:33:31.079 --> 00:33:33.480
especially not here. Given that wide range of

00:33:33.480 --> 00:33:35.279
options and the tailored approach, let's take

00:33:35.279 --> 00:33:37.660
a deep dive into each of the specific surgical

00:33:37.660 --> 00:33:40.480
procedures, starting with first metacarpal osteotomy.

00:33:40.650 --> 00:33:43.069
How does this procedure work and for what type

00:33:43.069 --> 00:33:45.849
of patient is it most suitable? Certainly. A

00:33:45.849 --> 00:33:48.190
first metacarpal osteotomy involves cutting and

00:33:48.190 --> 00:33:50.789
then precisely realigning the metacarpal bone,

00:33:51.089 --> 00:33:53.309
typically through what we call a closing wedge

00:33:53.309 --> 00:33:56.150
dorsal extension osteotomy. The principle here

00:33:56.150 --> 00:33:58.950
is quite clever actually. It aims to essentially

00:33:58.950 --> 00:34:02.450
redirect the forces acting across the joint to

00:34:02.450 --> 00:34:05.009
a more dorsal or back of the hand portion of

00:34:05.009 --> 00:34:07.910
the first CMC joint surface. This less involved,

00:34:08.130 --> 00:34:10.159
often healthier, Part of the joint then takes

00:34:10.159 --> 00:34:12.679
on more of the load, thereby reducing stress

00:34:12.679 --> 00:34:15.159
and pain in the main arthritic damaged area.

00:34:15.639 --> 00:34:17.239
It's a bit like shifting the weight onto a stronger

00:34:17.239 --> 00:34:23.699
part of a foundation. This procedure is primarily

00:34:23.699 --> 00:34:25.780
indicated for patients in the early stages of

00:34:25.780 --> 00:34:29.119
disease, where the joint destruction isn't too

00:34:29.119 --> 00:34:30.980
advanced and there's still a reasonably healthy

00:34:30.980 --> 00:34:33.599
portion of cartilage to offload onto. However,

00:34:33.840 --> 00:34:36.260
it's not suitable for everyone. Contraindications

00:34:36.260 --> 00:34:38.260
include patients with significant hypermobility

00:34:38.260 --> 00:34:40.659
of the joint, a fixed subluxation of the CMC

00:34:40.659 --> 00:34:43.500
joint that cannot be easily reduced, or pre -existing

00:34:43.500 --> 00:34:46.500
MCP hyperextension greater than about 10 degrees,

00:34:46.860 --> 00:34:48.780
as these conditions might not benefit or could

00:34:48.780 --> 00:34:51.039
potentially even be exacerbated by the osteotomy.

00:34:51.300 --> 00:34:54.880
So early stage, stable joint, no hyperextension.

00:34:55.039 --> 00:34:58.219
That's the ideal profile. Despite these limitations,

00:34:58.340 --> 00:35:01.039
it has gained popularity, particularly for younger

00:35:01.039 --> 00:35:04.179
patients with early disease. And reported symptom

00:35:04.179 --> 00:35:06.639
improvement rates can be quite high, maybe as

00:35:06.639 --> 00:35:09.880
high as 93 % at seven years post -procedure in

00:35:09.880 --> 00:35:12.860
some series. It's a good option for specific,

00:35:13.340 --> 00:35:16.099
carefully selected early stage cases where preserving

00:35:16.099 --> 00:35:18.960
length in some motion is really key. That's quite

00:35:18.960 --> 00:35:21.099
a high success rate for the right... patient

00:35:21.099 --> 00:35:24.099
profile. What about trapeziectomy, which I understand

00:35:24.099 --> 00:35:26.500
is perhaps the most commonly performed procedure,

00:35:26.960 --> 00:35:29.400
and how has the approach to it evolved over time,

00:35:29.599 --> 00:35:31.880
particularly regarding managing the space left

00:35:31.880 --> 00:35:35.019
by the removed bone? Yes, trapeziectomy is indeed

00:35:35.019 --> 00:35:37.099
the most commonly performed surgical option for

00:35:37.099 --> 00:35:39.539
basal thumb arthritis globally, and represents

00:35:39.539 --> 00:35:41.900
a real paradigm shift in managing this condition

00:35:41.900 --> 00:35:45.039
compared to, say, fusion. It fundamentally involves

00:35:45.039 --> 00:35:47.510
the complete removal of the trapezium bone. the

00:35:47.510 --> 00:35:49.409
wrist bone that forms one surface of the arthritic

00:35:49.409 --> 00:35:52.070
joint. The core idea is simple and effective.

00:35:52.329 --> 00:35:54.309
If the pain comes from the bone -on -bone rubbing

00:35:54.309 --> 00:35:56.590
of the trapezium against the metacarpal, remove

00:35:56.590 --> 00:35:58.570
the trapezium. Just take out the problem bone.

00:35:59.030 --> 00:36:01.769
Exactly. Historically, this procedure often involved

00:36:01.769 --> 00:36:05.010
quite complex ligament reconstructions or filling

00:36:05.010 --> 00:36:07.769
the created space with a rolled -up tendon, a

00:36:07.769 --> 00:36:10.389
technique known widely as ligament reconstruction

00:36:10.389 --> 00:36:14.750
and tendon interposition, LRT -I. The rationale

00:36:14.750 --> 00:36:17.070
was to prevent the thumb metacarpal from migrating

00:36:17.070 --> 00:36:20.289
proximally, or sort of sinking down, into the

00:36:20.289 --> 00:36:23.309
void left by the excise trapezium and potentially

00:36:23.309 --> 00:36:26.849
hitting the scaphoid. The LRTI technique? I've

00:36:26.849 --> 00:36:28.909
heard of that. Yes, it was very popular for a

00:36:28.909 --> 00:36:31.969
long time. However, contemporary practice has

00:36:31.969 --> 00:36:35.059
seen a fascinating evolution. Some modern practices,

00:36:35.420 --> 00:36:37.920
supported by good evidence, suggest that simply

00:36:37.920 --> 00:36:40.739
excising the trapezium and meticulously repairing

00:36:40.739 --> 00:36:42.960
the joint capsule, allowing the space to fill

00:36:42.960 --> 00:36:45.599
naturally with scar tissue, a process known as

00:36:45.599 --> 00:36:48.420
hematoma arthroplasty, or fibrous interposition,

00:36:48.860 --> 00:36:50.920
yields comparable functional results without

00:36:50.920 --> 00:36:53.500
the added complexity, potential morbidity, and

00:36:53.500 --> 00:36:55.840
operating time of extensive soft tissue procedures

00:36:55.840 --> 00:36:58.280
like tendon harvesting. So maybe the complex

00:36:58.280 --> 00:37:00.480
reconstruction isn't always necessary. That's

00:37:00.480 --> 00:37:03.099
what a lot of evidence suggests now. The body's

00:37:03.099 --> 00:37:05.019
natural healing can be incredibly effective in

00:37:05.019 --> 00:37:08.239
creating a stable pseudoarthrosis, a fibrous

00:37:08.239 --> 00:37:11.519
joint that functions remarkably well. Now, when

00:37:11.519 --> 00:37:13.719
suspension is performed, perhaps in younger patients

00:37:13.719 --> 00:37:15.539
or those with higher demands where maintaining

00:37:15.539 --> 00:37:17.639
length is critical, various tendons can be used

00:37:17.639 --> 00:37:20.900
to support the thumb metacarpal. The flexor carpi

00:37:20.900 --> 00:37:24.320
radialis, FCR tendon, is the most common choice

00:37:24.320 --> 00:37:26.500
for suspending the metacarpal due to its location

00:37:26.500 --> 00:37:29.349
and strength. Other options include the extensor

00:37:29.349 --> 00:37:32.829
carpe radialis longus, ECRL, or using a slip

00:37:32.829 --> 00:37:36.570
of the abductor pollicis longus, APL. More recently,

00:37:36.730 --> 00:37:38.510
newer techniques like suture suspension, for

00:37:38.510 --> 00:37:41.110
example, using a portion of the APL tendon to

00:37:41.110 --> 00:37:43.909
suspend the SCR tendon with strong sutures and

00:37:43.909 --> 00:37:45.989
the mini tightrope system are gaining traction.

00:37:46.869 --> 00:37:48.570
The mini tightrope in particular is a procedure

00:37:48.570 --> 00:37:51.110
I personally prefer for many cases as it effectively

00:37:51.110 --> 00:37:54.090
restores CMC joint stability using an internal

00:37:54.090 --> 00:37:56.659
brace ligament augmentation. A mini tightrope,

00:37:56.780 --> 00:37:58.500
like the ones used elsewhere in orthopedics.

00:37:58.840 --> 00:38:01.380
Precisely a similar concept adapted for the thumb's

00:38:01.380 --> 00:38:04.360
CMC joint. It provides a robust and predictable

00:38:04.360 --> 00:38:06.500
solution for maintaining the thumb's length and

00:38:06.500 --> 00:38:09.099
stability post -trapeziectomy, using a strong

00:38:09.099 --> 00:38:11.239
synthetic suture device rather than harvesting

00:38:11.239 --> 00:38:13.480
more tendon, which simplifies the procedure.

00:38:13.900 --> 00:38:16.119
Interesting. And who's trapeziectomy suitable

00:38:16.119 --> 00:38:19.599
for? Which stages? Trapeziatomy is highly versatile,

00:38:19.900 --> 00:38:22.360
suitable for a wide range of disease stages from

00:38:22.360 --> 00:38:25.019
stage I, particularly if symptomatic and feeling

00:38:25.019 --> 00:38:27.099
conservative care, all the way through to stage

00:38:27.099 --> 00:38:29.619
IV. It's particularly indicated when there is

00:38:29.619 --> 00:38:32.699
concomitant scaphotropesia arthrosis, meaning

00:38:32.699 --> 00:38:34.820
arthritis also affecting the joint between the

00:38:34.820 --> 00:38:37.280
scaphoid and trapezium bones, which is present

00:38:37.280 --> 00:38:39.619
in a significant number of cases, perhaps up

00:38:39.619 --> 00:38:43.340
to 62%, especially in stage IV disease. In such

00:38:43.340 --> 00:38:45.380
instances, excision of the proximal third of

00:38:45.380 --> 00:38:47.719
the trapezoid bone might also be considered to

00:38:47.719 --> 00:38:50.119
address the broader degeneration if the STT joint

00:38:50.119 --> 00:38:52.679
is also severely affected. So it covers most

00:38:52.679 --> 00:38:55.179
stages, even the advanced ones. What are the

00:38:55.179 --> 00:38:57.780
potential downsides or complications? As with

00:38:57.780 --> 00:38:59.579
any surgery, there are potential complications.

00:39:00.280 --> 00:39:02.199
These can include injury to the radial artery,

00:39:02.619 --> 00:39:04.639
though the risk is generally lower at the TMC

00:39:04.639 --> 00:39:08.219
joint level compared to, say, more... proximal

00:39:08.219 --> 00:39:10.599
wrist surgery, and injury to the superficial

00:39:10.599 --> 00:39:13.400
radial nerve, which runs nearby. Nerve injury

00:39:13.400 --> 00:39:15.480
can lead to areas of sensory deficits or occasionally

00:39:15.480 --> 00:39:18.719
a persistent painful neuroma. A notable specific

00:39:18.719 --> 00:39:20.940
complication occurring in perhaps around 5 %

00:39:20.940 --> 00:39:23.639
of cases is symptomatic proximal migration of

00:39:23.639 --> 00:39:26.059
the thumb metacarpal. This is where the metacarpal

00:39:26.059 --> 00:39:28.480
drops down into the space created by the excised

00:39:28.480 --> 00:39:31.079
trapezium and potentially impinges on the scaphoid.

00:39:31.260 --> 00:39:34.139
If this becomes symptomatic, causing pain or

00:39:34.139 --> 00:39:36.360
weakness, it can be quite difficult to stabilize

00:39:36.360 --> 00:39:38.739
and may necessitate further procedures, such

00:39:38.739 --> 00:39:41.199
as a sling -type reconstruction or even fusion

00:39:41.199 --> 00:39:43.719
to the index metacarpal in severe cases. This

00:39:43.719 --> 00:39:45.760
is particularly concerning in younger, more active

00:39:45.760 --> 00:39:48.079
individuals, where maintaining long -term thumb

00:39:48.079 --> 00:39:50.599
length and function is paramount. So that thumb

00:39:50.599 --> 00:39:53.000
shortening or collapse is the main specific risk?

00:39:53.320 --> 00:39:55.159
It's certainly one of the key procedure -specific

00:39:55.159 --> 00:39:57.900
risks we counsel patients about. Despite these

00:39:57.900 --> 00:40:00.239
potential issues, the outcomes of trapeziectomy

00:40:00.239 --> 00:40:03.480
are generally very positive. It typically provides

00:40:03.480 --> 00:40:06.179
significant pain relief and allows for continued

00:40:06.179 --> 00:40:09.019
useful motion of the thumb. While some degree

00:40:09.019 --> 00:40:11.719
of proximal metacarpal subsidence, maybe around

00:40:11.719 --> 00:40:14.820
25 % on average seen on radiographs, can occur

00:40:14.820 --> 00:40:17.460
postoperatively, this typically does not impact

00:40:17.460 --> 00:40:20.139
the functional outcome significantly. Patients

00:40:20.139 --> 00:40:22.739
often experience improved grip and pinch strengths

00:40:22.739 --> 00:40:25.019
compared to their preoperative state, leading

00:40:25.019 --> 00:40:27.530
to high satisfaction rates overall. It's fascinating

00:40:27.530 --> 00:40:29.670
how the surgical approach continues to evolve

00:40:29.670 --> 00:40:32.449
for trapeziectomy. What about joint fusion or

00:40:32.449 --> 00:40:34.829
arthrodesis? When is that considered and what

00:40:34.829 --> 00:40:36.630
are the distinct trade -offs for the patient?

00:40:37.110 --> 00:40:40.829
CMC arthrodesis, or joint fusion, involves permanently

00:40:40.829 --> 00:40:43.550
fusing the bones of the joint specifically, the

00:40:43.550 --> 00:40:45.670
trapezium and the base of the thumb metacarpal

00:40:45.670 --> 00:40:48.849
together to create a solid immobile unit. The

00:40:48.849 --> 00:40:51.349
goal here is simple and direct. By eliminating

00:40:51.349 --> 00:40:53.889
all movement at that specific joint, we eliminate

00:40:53.889 --> 00:40:56.579
the pain originating from it. The joint is typically

00:40:56.579 --> 00:40:58.739
fused in a functional position, commonly around

00:40:58.739 --> 00:41:01.480
35 degrees of radial abduction, 30 degrees of

00:41:01.480 --> 00:41:03.900
palmar abduction, and maybe 15 degrees of pronation,

00:41:04.320 --> 00:41:06.400
to ensure optimal functionality for grasping

00:41:06.400 --> 00:41:08.780
and pinching activities, despite the complete

00:41:08.780 --> 00:41:11.559
stiffness at the fused joint. Fused in a useful

00:41:11.559 --> 00:41:14.329
position, who is this best for? This procedure

00:41:14.329 --> 00:41:17.030
is primarily recommended for physically high

00:41:17.030 --> 00:41:19.550
-demand patients, particularly younger males,

00:41:20.050 --> 00:41:22.429
typically maybe under 50 years of age, where

00:41:22.429 --> 00:41:24.670
preserving maximal grip strength and maintaining

00:41:24.670 --> 00:41:27.010
the absolute stability of the thumb column are

00:41:27.010 --> 00:41:29.949
prioritized over range of motion. Think of a

00:41:29.949 --> 00:41:32.250
carpenter, a builder, or perhaps a weightlifter,

00:41:32.949 --> 00:41:34.949
individuals whose livelihoods or activities depend

00:41:34.949 --> 00:41:38.000
on a powerful stable pinching grip. It's generally

00:41:38.000 --> 00:41:40.340
contraindicated if there's significant coexisting

00:41:40.340 --> 00:41:43.699
schaefer -tropiezoidal STT arthritis, because

00:41:43.699 --> 00:41:46.199
fusing the CMC joint would simply transfer the

00:41:46.199 --> 00:41:49.099
painful stresses to the adjacent already arthritic

00:41:49.099 --> 00:41:51.719
STT joint, likely leading to persistent pain

00:41:51.719 --> 00:41:54.619
just proximal to the fusion site. So check the

00:41:54.619 --> 00:41:56.679
STT joint carefully before considering fusion.

00:41:57.219 --> 00:41:59.619
Absolutely critical. The outcomes are generally

00:41:59.619 --> 00:42:01.780
excellent in terms of providing profound pain

00:42:01.780 --> 00:42:04.340
relief, unwavering stability, and excellent length

00:42:04.340 --> 00:42:07.409
preservation of the thumb column. However, the

00:42:07.409 --> 00:42:10.210
obvious and significant tradeoff is a drastically

00:42:10.210 --> 00:42:12.210
decreased range of motion at the base of the

00:42:12.210 --> 00:42:15.050
thumb. For example, patients will find it impossible

00:42:15.050 --> 00:42:17.570
to lay their thumb flat against a table, which

00:42:17.570 --> 00:42:20.880
requires CMC motion. There's also a non -union

00:42:20.880 --> 00:42:23.980
rate, meaning the bone ends fail to join solidly,

00:42:24.039 --> 00:42:26.340
of around 12%, maybe slightly higher in some

00:42:26.340 --> 00:42:29.219
series. Despite the stiffness and the risk of

00:42:29.219 --> 00:42:31.619
non -union, most patients who are carefully selected

00:42:31.619 --> 00:42:34.380
for this procedure find the pain -free and strong

00:42:34.380 --> 00:42:37.059
thumb highly satisfactory, especially those whose

00:42:37.059 --> 00:42:39.559
professional or recreational activities demand

00:42:39.559 --> 00:42:42.539
that powerful grip and absolute stability. The

00:42:42.539 --> 00:42:45.199
core insight here is that fusion sacrifices motion

00:42:45.199 --> 00:42:47.719
for guaranteed stability and strength. That's

00:42:47.719 --> 00:42:50.039
a clear case of prioritizing strength over mobility

00:42:50.039 --> 00:42:52.519
for specific patient profiles. What about joint

00:42:52.519 --> 00:42:54.920
replacement or prosthetic arthroplasty? Is that

00:42:54.920 --> 00:42:57.260
a growing trend for the thumb CMC joint, perhaps

00:42:57.260 --> 00:43:00.400
similar to hip or knee replacements? CMC prosthetic

00:43:00.400 --> 00:43:03.099
arthroplasty or joint replacement is indeed a

00:43:03.099 --> 00:43:05.940
concept that has gained some traction, particularly

00:43:05.940 --> 00:43:08.079
in parts of Europe, although it's still relatively

00:43:08.079 --> 00:43:10.900
newer as a primary option here in the UK compared

00:43:10.900 --> 00:43:14.420
to trapeziectomy or fusion. This procedure involves

00:43:14.420 --> 00:43:16.820
removing the arthritic ends of the bones, the

00:43:16.820 --> 00:43:19.380
trapezium and the metacarpal base, and inserting

00:43:19.380 --> 00:43:22.380
a new artificial joint, often described as similar

00:43:22.380 --> 00:43:26.039
in principle to a mini hip replacement. Historically,

00:43:26.260 --> 00:43:28.239
silicone implants were quite widely used in this

00:43:28.239 --> 00:43:31.300
context, though newer metal on polyethylene or

00:43:31.300 --> 00:43:34.239
pyrocarbon designs exist now too. A mini thumb

00:43:34.239 --> 00:43:36.800
replacement? Sounds appealing. Is it recommended?

00:43:37.159 --> 00:43:39.320
Well, while it theoretically offers the benefit

00:43:39.320 --> 00:43:41.219
of maintaining motion and potentially providing

00:43:41.219 --> 00:43:43.579
a stronger thumb compared to simple trapeziectomy

00:43:43.579 --> 00:43:46.559
and can sometimes yield good results, it is currently

00:43:46.559 --> 00:43:49.019
generally not recommended as a primary first

00:43:49.019 --> 00:43:51.420
-line surgical option in the UK for most patients.

00:43:51.739 --> 00:43:53.739
Why the caution? The reason for this caution

00:43:53.739 --> 00:43:56.760
lies primarily in the specific risks and the

00:43:56.760 --> 00:43:58.980
relatively higher complication rates associated

00:43:58.980 --> 00:44:02.300
with implant use in this demanding joint. These

00:44:02.300 --> 00:44:05.079
include the potential for implant fracture or,

00:44:05.179 --> 00:44:07.519
more commonly, loosening over time, remember

00:44:07.519 --> 00:44:11.199
those 13x forces. There's also the risk of subluxation

00:44:11.199 --> 00:44:13.679
or dislocation of the implant itself, and the

00:44:13.679 --> 00:44:16.219
possibility of particle wear disease, like silicone

00:44:16.219 --> 00:44:18.739
synovitis with older implants, which is an inflammatory

00:44:18.739 --> 00:44:20.659
reaction to debris that can cause significant

00:44:20.659 --> 00:44:23.119
problems and require revision surgery. So implant

00:44:23.119 --> 00:44:25.519
longevity and complications are the main concerns?

00:44:26.019 --> 00:44:28.820
Precisely. Furthermore, this procedure is generally

00:44:28.820 --> 00:44:30.920
not suitable for patients with the most severe,

00:44:31.260 --> 00:44:34.119
stage 4, arthritis, as their joint may be too

00:44:34.119 --> 00:44:36.940
damaged or the surrounding bone quality insufficient

00:44:36.940 --> 00:44:39.619
to adequately support an implant long term. This

00:44:39.619 --> 00:44:41.659
makes it a less versatile option compared to

00:44:41.659 --> 00:44:44.619
trapeziectomy for advanced cases. The real challenge

00:44:44.619 --> 00:44:46.579
here is finding an implant that can reliably

00:44:46.579 --> 00:44:49.039
withstand the immense forces acting across the

00:44:49.039 --> 00:44:51.619
thumb's CMC joint without loosening, wearing

00:44:51.619 --> 00:44:53.739
out, or failing over the patient's lifetime,

00:44:54.159 --> 00:44:56.019
particularly in younger, active individuals.

00:44:56.349 --> 00:44:59.250
The long -term data just isn't as robust as for

00:44:59.250 --> 00:45:01.789
trapeziectomy yet. It sounds like while promising

00:45:01.789 --> 00:45:04.130
in theory, it comes with its own distinct set

00:45:04.130 --> 00:45:06.269
of challenges, particularly long -term ones.

00:45:06.769 --> 00:45:09.250
What about denervation, the procedure that involves

00:45:09.250 --> 00:45:11.389
selectively cutting nerves to interrupt pain

00:45:11.389 --> 00:45:13.969
signals? That seems like a very different approach

00:45:13.969 --> 00:45:17.570
entirely. Indeed, CMC denervation is a distinct

00:45:17.570 --> 00:45:20.289
and perhaps often underappreciated approach that

00:45:20.289 --> 00:45:22.750
focuses purely on pain modulation rather than

00:45:22.750 --> 00:45:25.409
joint reconstruction or removal. This procedure

00:45:25.409 --> 00:45:27.429
involves selectively identifying and cutting

00:45:27.429 --> 00:45:30.489
small sensory nerve branches that transmit pain

00:45:30.489 --> 00:45:33.030
signals directly from the arthritic CMC joint.

00:45:33.829 --> 00:45:35.409
It can be performed through one or two small

00:45:35.409 --> 00:45:38.170
incisions, precisely targeting nerves such as

00:45:38.170 --> 00:45:40.329
the fanar cutaneous branch of the median nerve,

00:45:40.809 --> 00:45:42.809
the palmar cutaneous branch of the median nerve,

00:45:43.289 --> 00:45:45.670
the superficial branch of the radial nerve via

00:45:45.670 --> 00:45:47.989
the dorsal articular nerve of the first interosseous

00:45:47.989 --> 00:45:50.389
space, and sometimes the branch of cruvillier

00:45:50.389 --> 00:45:52.949
from the lateral antibrachial cutaneous nerve.

00:45:53.119 --> 00:45:55.559
The precise anatomical knowledge and mapping

00:45:55.559 --> 00:45:58.000
of these nerves allows for targeted pain relief

00:45:58.000 --> 00:46:00.480
while preserving other motor and critical sensory

00:46:00.480 --> 00:46:02.639
functions of the hand. Just cutting the pain

00:46:02.639 --> 00:46:05.260
wires, essentially. Who is it for? This technique

00:46:05.260 --> 00:46:08.119
is potentially applicable across all stages of

00:46:08.119 --> 00:46:10.380
the disease from stage I right through to stage

00:46:10.380 --> 00:46:13.000
IV, although its specific indications are still

00:46:13.000 --> 00:46:15.500
evolving as we gather more long -term outcome

00:46:15.500 --> 00:46:18.929
data. The primary specific complication is potential

00:46:18.929 --> 00:46:21.329
injury to a sensory branch of the radial nerve,

00:46:21.650 --> 00:46:23.630
which can lead to areas of numbness on the back

00:46:23.630 --> 00:46:26.630
of the thumb, or, less commonly, a painful neuroma

00:46:26.630 --> 00:46:29.769
if a nerve ending gets irritated. Careful surgical

00:46:29.769 --> 00:46:32.389
technique minimizes this risk, of course. It's

00:46:32.389 --> 00:46:34.130
also important to note that as with any pain

00:46:34.130 --> 00:46:36.449
-modulating procedure, not all patients achieve

00:46:36.449 --> 00:46:38.730
significant or complete improvement, and some

00:46:38.730 --> 00:46:40.809
may still experience some residual discomfort.

00:46:40.929 --> 00:46:43.190
But for those it works for? For those who do

00:46:43.190 --> 00:46:46.090
respond well. Outcomes often include improved

00:46:46.090 --> 00:46:48.829
hand function, enhanced grip strength, likely

00:46:48.829 --> 00:46:51.670
due to pain reduction, and significant pain relief.

00:46:52.769 --> 00:46:55.210
In terms of pain control, results can be comparable

00:46:55.210 --> 00:46:57.949
to trapeziectomy and CMC arthrodesis in some

00:46:57.949 --> 00:47:00.590
studies, but with the distinct advantage of preserving

00:47:00.590 --> 00:47:02.510
the patient's natural range of motion compared

00:47:02.510 --> 00:47:05.329
to fusion. This makes it an attractive option

00:47:05.329 --> 00:47:07.849
for certain patients who prioritize motion, perhaps

00:47:07.849 --> 00:47:09.949
wish to avoid more extensive joint reconstruction,

00:47:10.329 --> 00:47:12.429
or maybe aren't suitable candidates for other

00:47:12.429 --> 00:47:15.409
procedures. The key insight, as you said, is

00:47:15.409 --> 00:47:17.409
that it targets the symptom of pain directly

00:47:17.409 --> 00:47:19.550
rather than the underlying degenerative joint

00:47:19.550 --> 00:47:22.369
itself. And finally, a minimally invasive option,

00:47:22.909 --> 00:47:25.690
arthroscopic debridement. When is that indicated

00:47:25.690 --> 00:47:28.929
and what does it entail? CMC arthroscopic debridement

00:47:28.929 --> 00:47:31.730
is indeed a minimally invasive surgical approach.

00:47:32.199 --> 00:47:35.019
It involves using an arthroscope, a small camera

00:47:35.019 --> 00:47:38.480
about 2 -3mm wide inserted through tiny incisions

00:47:38.480 --> 00:47:41.260
or portals to visualize the inside of the joint

00:47:41.260 --> 00:47:44.320
directly. The surgeon can then debride or clean

00:47:44.320 --> 00:47:47.199
out any damaged tissue such as inflamed synovium,

00:47:47.460 --> 00:47:50.119
joint lining, or loose cartilage fragments floating

00:47:50.119 --> 00:47:52.739
in the joint. It may sometimes be combined with

00:47:52.739 --> 00:47:55.059
thermal shrinkage of lax capsule or ligaments

00:47:55.059 --> 00:47:57.440
or even fat grafting where a small amount of

00:47:57.440 --> 00:47:59.860
the patient's own fat is harvested and injected

00:47:59.860 --> 00:48:02.619
into the joint space to potentially provide some

00:48:02.619 --> 00:48:05.460
cushioning and support, perhaps aiding in lubrication

00:48:05.460 --> 00:48:10.730
and reducing friction. This procedure is primarily

00:48:10.730 --> 00:48:12.750
indicated for patients in the early stages of

00:48:12.750 --> 00:48:15.170
the disease, typically stage one or perhaps early

00:48:15.170 --> 00:48:17.610
stage two, where the cartilage damage is still

00:48:17.610 --> 00:48:19.750
relatively contained and potentially reversible

00:48:19.750 --> 00:48:22.670
and significant bone -on -bone changes or large

00:48:22.670 --> 00:48:25.309
osteophytes have not yet occurred. It's generally

00:48:25.309 --> 00:48:27.409
less effective once the joint has severely collapsed

00:48:27.409 --> 00:48:30.369
or developed extensive bony spurs. So for early,

00:48:30.530 --> 00:48:33.630
primarily inflammatory or unstable cases? That's

00:48:33.630 --> 00:48:36.119
generally the target group, yes. The technique

00:48:36.119 --> 00:48:39.099
typically utilizes specific portals, such as

00:48:39.099 --> 00:48:41.639
the dorsal 1R portal, which is just radial to

00:48:41.639 --> 00:48:44.619
the abductor pollicis longus, APL tendon, and

00:48:44.619 --> 00:48:47.380
the dorsal 1U portal, which is ulnar to the extensor

00:48:47.380 --> 00:48:50.539
pollicis brevis, EPB tendon, lying between the

00:48:50.539 --> 00:48:53.340
extensor pollicis longus, EPL, and EPB tendons.

00:48:53.980 --> 00:48:56.340
These precise small porters allow surgeons to

00:48:56.340 --> 00:48:58.380
access the joint with minimal tissue disruption,

00:48:58.920 --> 00:49:00.900
which can lead to faster initial recovery times

00:49:00.900 --> 00:49:03.769
compared to more open procedures. The core idea

00:49:03.769 --> 00:49:06.489
is early intervention with minimal invasiveness

00:49:06.489 --> 00:49:09.210
for carefully selected patients. That's a truly

00:49:09.210 --> 00:49:11.489
comprehensive look at the various surgical pathways

00:49:11.489 --> 00:49:13.710
available, each with its specific indications

00:49:13.710 --> 00:49:16.269
and considerations. Now, once a patient undergoes

00:49:16.269 --> 00:49:18.710
treatment, particularly surgery, what does the

00:49:18.710 --> 00:49:20.670
rehabilitation and recovery journey look like?

00:49:20.929 --> 00:49:22.769
And what can we tell them to expect in terms

00:49:22.769 --> 00:49:25.280
of timelines and return to function? The journey

00:49:25.280 --> 00:49:27.739
to regain function post -treatment, especially

00:49:27.739 --> 00:49:30.480
after surgery, is a structured and really vital

00:49:30.480 --> 00:49:33.019
process that we must prepare our patients for

00:49:33.019 --> 00:49:35.960
thoroughly. In the immediate post -operative

00:49:35.960 --> 00:49:38.320
period, one of the great benefits, as we mentioned,

00:49:38.699 --> 00:49:40.579
is that patients are typically able to go home

00:49:40.579 --> 00:49:43.599
on the same day as the operation. It's usually

00:49:43.599 --> 00:49:47.119
day -case surgery. Simple oral analgesia, like

00:49:47.119 --> 00:49:49.900
paracetamol and perhaps some short -term codeine

00:49:49.900 --> 00:49:52.699
or NSAIDs, if appropriate, is usually sufficient

00:49:52.699 --> 00:49:55.639
for post -operative pain control. It's crucial

00:49:55.639 --> 00:49:57.900
for patients to elevate the hand as much as possible

00:49:57.900 --> 00:50:00.420
for the first five days or so to minimize swelling,

00:50:01.039 --> 00:50:03.480
which significantly aids in comfort and healing.

00:50:04.300 --> 00:50:06.219
Gentle bending and straightening of the fingers

00:50:06.219 --> 00:50:08.800
should commence from day one to prevent stiffness

00:50:08.800 --> 00:50:10.920
in the digits not directly involved in the thumb

00:50:10.920 --> 00:50:13.460
surgery. Keep everything else moving. Elevation

00:50:13.460 --> 00:50:16.059
and finger movement right away. Then the cast.

00:50:16.269 --> 00:50:19.050
For the immobilization phase, the initial bulky

00:50:19.050 --> 00:50:22.110
plaster of Paraslab applied in theater is generally

00:50:22.110 --> 00:50:24.489
removed within the first week, usually at their

00:50:24.489 --> 00:50:27.469
first post -op clinic visit. At this point, the

00:50:27.469 --> 00:50:29.690
wound is cleaned and redressed, and a custom

00:50:29.690 --> 00:50:32.349
-made thermoplastic therapy splint, where sometimes

00:50:32.349 --> 00:50:35.750
a lighter fiberglass cast is applied. This splint

00:50:35.750 --> 00:50:38.090
or cast is typically worn for approximately six

00:50:38.090 --> 00:50:40.590
to eight weeks, though the exact duration depends

00:50:40.590 --> 00:50:42.610
heavily on the specific procedure performed.

00:50:43.119 --> 00:50:45.300
Each surgical technique has different requirements

00:50:45.300 --> 00:50:48.260
for initial stability and healing time. A fusion,

00:50:48.280 --> 00:50:50.619
for instance, will require longer, more rigid

00:50:50.619 --> 00:50:53.460
immobilization than a simple trapeziectomy. Six

00:50:53.460 --> 00:50:55.500
to eight weeks in a splint or cast, depending

00:50:55.500 --> 00:50:59.199
on the op, then therapy. Absolutely. A comprehensive

00:50:59.199 --> 00:51:02.420
rehabilitation program, ideally involving a dedicated

00:51:02.420 --> 00:51:05.119
specialist hand therapist, is essential for optimal

00:51:05.119 --> 00:51:07.880
outcomes. This therapy focuses initially on regaining

00:51:07.880 --> 00:51:10.280
mobility, then progressively restoring strength,

00:51:10.679 --> 00:51:12.739
and ultimately improving overall hand function

00:51:12.739 --> 00:51:16.179
and dexterity. While some discomfort may be experienced

00:51:16.179 --> 00:51:18.159
during the initial stages of rehabilitation,

00:51:18.639 --> 00:51:20.840
as tissues heal, stretch and strengthen, this

00:51:20.840 --> 00:51:23.460
usually lessens considerably over time. It's

00:51:23.460 --> 00:51:25.440
important to manage patient expectations here.

00:51:25.780 --> 00:51:28.460
The road to full recovery is gradual, not instantaneous.

00:51:28.920 --> 00:51:30.760
How gradual? What are the typical timelines?

00:51:31.179 --> 00:51:33.599
Patients usually notice that the sharp, constant

00:51:33.599 --> 00:51:36.539
arthritic pain they had before surgery has resolved

00:51:36.539 --> 00:51:39.059
within about eight weeks, once the initial post

00:51:39.059 --> 00:51:42.599
-op soreness settles. However, significant improvements

00:51:42.599 --> 00:51:45.980
in strength, endurance, and overall comfort continue

00:51:45.980 --> 00:51:48.480
for several months after that. Full recovery,

00:51:48.639 --> 00:51:50.599
in terms of getting back maximal strength and

00:51:50.599 --> 00:51:53.320
function, often takes up to a year. We even see

00:51:53.320 --> 00:51:55.579
some patients reporting continued subtle enhancements

00:51:55.579 --> 00:51:58.079
in strength and comfort for years after the procedure,

00:51:58.599 --> 00:52:00.860
which is a fascinating aspect of the body's adaptation

00:52:00.860 --> 00:52:03.860
and neuroplasticity. But realistically, initial

00:52:03.860 --> 00:52:05.820
functional recovery typically spans around three

00:52:05.820 --> 00:52:08.380
months, allowing a return to most light daily

00:52:08.380 --> 00:52:10.739
activities. Three months for light activity is

00:52:10.739 --> 00:52:13.659
up to a year for full recovery. What about practical

00:52:13.659 --> 00:52:17.000
things like driving and work? Good points. For

00:52:17.000 --> 00:52:19.429
the return to activities of daily living, Wounds

00:52:19.429 --> 00:52:21.550
should obviously be kept covered and dry for

00:52:21.550 --> 00:52:23.889
the first 10 days to two weeks until they have

00:52:23.889 --> 00:52:27.170
fully healed. The splint or cast must also be

00:52:27.170 --> 00:52:29.429
kept dry throughout its use and is gradually

00:52:29.429 --> 00:52:31.449
weaned off under the supervision of the hand

00:52:31.449 --> 00:52:34.349
therapist, often with specific exercises being

00:52:34.349 --> 00:52:38.139
introduced as the immobilization decreases. Regarding

00:52:38.139 --> 00:52:41.059
driving, it's generally advisable to delay return

00:52:41.059 --> 00:52:43.139
until full control of the steering wheel and

00:52:43.139 --> 00:52:45.760
gear stick is achieved, and crucially, the patient

00:52:45.760 --> 00:52:48.119
feels safe and confident to react appropriately

00:52:48.119 --> 00:52:51.039
in an emergency situation. This typically might

00:52:51.039 --> 00:52:53.900
be between 8 and 12 weeks post -surgery, but

00:52:53.900 --> 00:52:56.099
individual variations certainly exist based on

00:52:56.099 --> 00:52:58.460
the surgery type, the patient's recovery, and

00:52:58.460 --> 00:53:00.500
the type of vehicle. 8 to 12 weeks for driving,

00:53:00.800 --> 00:53:03.639
potentially. Had work. For return to work, especially

00:53:03.639 --> 00:53:06.340
involving heavy manual labor, it should generally

00:53:06.340 --> 00:53:09.260
be avoided for approximately eight weeks at minimum,

00:53:09.900 --> 00:53:11.900
sometimes longer depending on the procedure and

00:53:11.900 --> 00:53:15.400
the job demands. Specific advice should always

00:53:15.400 --> 00:53:17.760
be sought from the surgeon based on the individual's

00:53:17.760 --> 00:53:19.960
specific role and the precise physical demands

00:53:19.960 --> 00:53:23.139
of their job. A phased return is often helpful.

00:53:23.690 --> 00:53:26.150
The overall prognosis for basal joint arthritis

00:53:26.150 --> 00:53:28.730
after appropriate treatment is very positive.

00:53:29.210 --> 00:53:31.369
It's considered a very treatable condition, with

00:53:31.369 --> 00:53:34.369
high satisfaction rates, often exceeding 85 -90

00:53:34.369 --> 00:53:36.449
% of patients reporting positive outcomes after

00:53:36.449 --> 00:53:38.650
treatment, particularly regarding pain relief.

00:53:39.429 --> 00:53:41.389
Crucially, patients who do not achieve adequate

00:53:41.389 --> 00:53:43.730
relief with non -surgical treatment very often

00:53:43.730 --> 00:53:45.869
have a good or excellent result following surgery,

00:53:46.309 --> 00:53:48.110
with strength potentially exceeding preoperative

00:53:48.110 --> 00:53:50.869
levels within a year. That's a truly encouraging

00:53:50.869 --> 00:53:53.070
prospect for those suffering significant disability.

00:53:53.239 --> 00:53:55.880
It's reassuring to hear such high satisfaction

00:53:55.880 --> 00:53:58.840
rates and a clear, albeit gradual, recovery path.

00:53:59.519 --> 00:54:02.579
However, no surgical procedure is entirely without

00:54:02.579 --> 00:54:05.639
its risks. What are the potential complications,

00:54:05.880 --> 00:54:08.480
both general surgical risks and those specific

00:54:08.480 --> 00:54:10.960
to thumb surgery, that we as clinicians should

00:54:10.960 --> 00:54:13.239
be carefully aware of and discuss thoroughly

00:54:13.239 --> 00:54:15.960
with our patients? That's a critical aspect of

00:54:15.960 --> 00:54:18.380
our preoperative patient counseling, ensuring

00:54:18.380 --> 00:54:21.659
fully informed consent. First, we always acknowledge

00:54:21.659 --> 00:54:24.340
the universal risks associated with any surgical

00:54:24.340 --> 00:54:27.019
procedure. These include general complications

00:54:27.019 --> 00:54:29.679
related to anesthesia, which are always meticulously

00:54:29.679 --> 00:54:32.099
assessed preoperatively by the anesthetic team,

00:54:32.639 --> 00:54:34.800
general nerve injury, which can theoretically

00:54:34.800 --> 00:54:37.079
occur anywhere near the surgical field despite

00:54:37.079 --> 00:54:39.500
carol technique, and the risk of infection at

00:54:39.500 --> 00:54:42.090
the surgical site, which is usually low. around

00:54:42.090 --> 00:54:45.269
1%, but always a possibility. These are standard

00:54:45.269 --> 00:54:47.469
considerations for any operation we undertake.

00:54:47.630 --> 00:54:50.230
The standard surgical risks. What about thumb

00:54:50.230 --> 00:54:53.110
-specific ones? Yes, there are specific complications

00:54:53.110 --> 00:54:55.869
more unique to thumb -based surgery. One is the

00:54:55.869 --> 00:54:58.760
failure to completely resolve symptoms. While

00:54:58.760 --> 00:55:01.739
relatively rare after appropriate surgery, this

00:55:01.739 --> 00:55:04.639
can occur. Sometimes it's due to pre -existing

00:55:04.639 --> 00:55:07.059
or subsequently developing arthritis in adjacent

00:55:07.059 --> 00:55:10.579
joints, for example, the STT joint, or even wrist

00:55:10.579 --> 00:55:12.800
arthritis that were not the primary target of

00:55:12.800 --> 00:55:15.400
the surgery but become symptomatic later. If

00:55:15.400 --> 00:55:18.219
this occurs and is problematic, it may necessitate

00:55:18.219 --> 00:55:21.559
further investigation or even intervention. Residual

00:55:21.559 --> 00:55:24.380
weakness is also a possibility. The thumb may

00:55:24.380 --> 00:55:27.400
initially feel weaker on the operated side, particularly

00:55:27.400 --> 00:55:29.659
after trapeziectomy where the trapezium's buttress

00:55:29.659 --> 00:55:32.260
effect is removed. While it typically improves

00:55:32.260 --> 00:55:34.760
significantly with time and dedicated rehabilitation,

00:55:35.320 --> 00:55:37.719
it may never fully return to its absolute original

00:55:37.719 --> 00:55:40.199
prearthritis strength, although function usually

00:55:40.199 --> 00:55:42.559
improves dramatically due to pain relief. We

00:55:42.559 --> 00:55:44.780
must set realistic expectations about strength

00:55:44.780 --> 00:55:47.980
return. Okay, incomplete relief and some weakness

00:55:47.980 --> 00:55:49.800
are possible. What about the migration issue

00:55:49.800 --> 00:55:52.929
after trapeziectomy? Yes. A specific concern

00:55:52.929 --> 00:55:55.449
following trapeziectomy, occurring symptomatically

00:55:55.449 --> 00:55:59.070
in perhaps around 5 % of cases, is proximal migration

00:55:59.070 --> 00:56:02.690
of the thumb metacarpal. As we discussed, this

00:56:02.690 --> 00:56:04.829
is where the thumb metacarpal, no longer supported

00:56:04.829 --> 00:56:07.829
by the trapezium, drops down into the space left

00:56:07.829 --> 00:56:10.489
by the removed bone and can potentially impinge

00:56:10.489 --> 00:56:13.530
on the scaphoid or distal radius. If this migration

00:56:13.530 --> 00:56:15.809
becomes symptomatic, causing significant pain,

00:56:16.070 --> 00:56:18.429
instability, or weakness, it can be quite challenging

00:56:18.429 --> 00:56:20.809
to manage and may require further procedures,

00:56:21.210 --> 00:56:23.329
such as a sling -type reconstruction using a

00:56:23.329 --> 00:56:26.230
tendon, or, in more severe or refractory cases,

00:56:26.730 --> 00:56:28.949
even fusion to the index metacarpal to provide

00:56:28.949 --> 00:56:31.750
rigid support. This particular complication is

00:56:31.750 --> 00:56:33.969
a major concern, especially in younger, high

00:56:33.969 --> 00:56:35.989
-demand individuals where maintaining long -term

00:56:35.989 --> 00:56:38.250
stability and function is paramount. That sounds

00:56:38.250 --> 00:56:40.730
like a difficult complication to fix. It can

00:56:40.730 --> 00:56:44.619
be. For cases of CMCJ fusion arthrodesis, there's

00:56:44.619 --> 00:56:47.420
the risk of nonunion, where the bone ends fail

00:56:47.420 --> 00:56:50.119
to join together solidly. This occurs in about

00:56:50.119 --> 00:56:53.280
5 -10 % of cases, maybe higher in smokers or

00:56:53.280 --> 00:56:56.260
those with comorbidities. If this nonunion remains

00:56:56.260 --> 00:56:58.960
painless and stable, it can sometimes be accepted

00:56:58.960 --> 00:57:01.429
and left alone. But if it becomes symptomatic

00:57:01.429 --> 00:57:04.050
and painful, revision surgery, such as repeating

00:57:04.050 --> 00:57:06.050
the operation perhaps with a bone graft to promote

00:57:06.050 --> 00:57:08.590
healing or sometimes converting the failed fusion

00:57:08.590 --> 00:57:12.110
to a trapeziectomy, may be required. Non -union

00:57:12.110 --> 00:57:14.929
after fusion. What about implants? When an implant

00:57:14.929 --> 00:57:18.110
is used in CMC prosthetic arthroplasty, there's

00:57:18.110 --> 00:57:20.550
a known risk of dislocation of the implant itself.

00:57:20.809 --> 00:57:23.409
also perhaps in the 5 -10 % range, depending

00:57:23.409 --> 00:57:26.130
on the implant type and technique. If an implant

00:57:26.130 --> 00:57:28.590
dislocates repeatedly or cannot be reduced, it

00:57:28.590 --> 00:57:31.070
may necessitate its removal and subsequent conversion

00:57:31.070 --> 00:57:34.170
to an alternative surgical approach, like trapeziectomy,

00:57:34.349 --> 00:57:36.550
to manage the resulting joint space and symptoms.

00:57:37.429 --> 00:57:39.170
Loosening and wear, as mentioned earlier, are

00:57:39.170 --> 00:57:41.150
the other major long -term concerns with implants.

00:57:41.409 --> 00:57:43.570
Dislocation and loosening with implants. Anything

00:57:43.570 --> 00:57:46.449
else? Finally, we must consider MCP hyperextension

00:57:46.449 --> 00:57:48.550
deformity, which can develop or worsen after

00:57:48.550 --> 00:57:51.699
CMC surgery. This is where the middle joint of

00:57:51.699 --> 00:57:54.340
the thumb hyperextends excessively, often as

00:57:54.340 --> 00:57:56.840
a compensatory mechanism for lost CMC motion

00:57:56.840 --> 00:58:00.239
or due to inherent laxity. Its management depends

00:58:00.239 --> 00:58:02.300
on the degree of hyperextension and whether it's

00:58:02.300 --> 00:58:05.070
causing functional problems. If it's mild, less

00:58:05.070 --> 00:58:07.690
than 10 degrees, typically no specific surgical

00:58:07.690 --> 00:58:10.530
intervention is needed. For 10 to 20 degrees,

00:58:10.869 --> 00:58:13.010
percutaneous pinning of the MCP joint and slight

00:58:13.010 --> 00:58:14.889
flashing for about four weeks during the initial

00:58:14.889 --> 00:58:17.309
post -op period may be performed, potentially

00:58:17.309 --> 00:58:20.869
combined with an extensor policies brevis EPB,

00:58:21.050 --> 00:58:22.929
pinned and transfer later to reinforce the joint

00:58:22.929 --> 00:58:25.989
dynamically. If the hyperextension is more significant,

00:58:26.409 --> 00:58:29.829
between 20 and 40 degrees, a volar capsulodesus,

00:58:29.989 --> 00:58:31.690
tightening the joint capsule on the palm side,

00:58:32.070 --> 00:58:34.469
or sesamoidesus, using the small sesamoid bones

00:58:34.469 --> 00:58:37.269
for stability, might be required. And for severe

00:58:37.269 --> 00:58:39.750
cases greater than 40 degrees of hyperextension,

00:58:40.030 --> 00:58:42.489
an MCP joint fusion may become necessary to permanently

00:58:42.489 --> 00:58:44.170
stabilize the thumb in a functional position,

00:58:44.469 --> 00:58:46.789
creating a stiff but stable and pain -free joint.

00:58:46.969 --> 00:58:49.449
That's a lot to consider beyond the immediate

00:58:49.449 --> 00:58:52.289
surgical site, truly underscoring the complexities

00:58:52.289 --> 00:58:54.409
and the potential long -term journey in hand

00:58:54.409 --> 00:58:57.309
surgery. Beyond the physical and surgical aspects

00:58:57.309 --> 00:58:59.949
we've meticulously discussed, how does living

00:58:59.949 --> 00:59:02.469
with basal thumb arthritis profoundly impact

00:59:02.469 --> 00:59:04.710
a patient's emotional and psychological well

00:59:04.710 --> 00:59:07.630
-being? This is an area that unfortunately can

00:59:07.630 --> 00:59:09.829
sometimes be overlooked in a purely physical

00:59:09.829 --> 00:59:12.630
treatment model, isn't it? It is indeed an often

00:59:12.630 --> 00:59:15.730
overlooked yet profoundly important aspect that

00:59:15.730 --> 00:59:19.280
we as clinicians must never forget. Living with

00:59:19.280 --> 00:59:21.780
chronic pain, particularly in the hands which

00:59:21.780 --> 00:59:24.219
are so integral to our interaction with the world,

00:59:24.739 --> 00:59:27.239
extends far beyond the physical limitations it

00:59:27.239 --> 00:59:30.619
imposes. It can significantly influence a patient's

00:59:30.619 --> 00:59:32.679
entire emotional and psychological well -being.

00:59:33.280 --> 00:59:35.400
What's truly fascinating and often distressing

00:59:35.400 --> 00:59:37.619
to witness clinically is the deep connection

00:59:37.619 --> 00:59:39.840
between chronic pain, regardless of its source,

00:59:40.039 --> 00:59:42.960
and mental health. This isn't simply a secondary

00:59:42.960 --> 00:59:45.579
reaction, it's often an interwoven reality for

00:59:45.579 --> 00:59:48.480
the patient. The mind -body link. Precisely.

00:59:49.019 --> 00:59:51.219
Patients often experience a wide spectrum of

00:59:51.219 --> 00:59:54.159
challenging emotions. Frustration is incredibly

00:59:54.159 --> 00:59:56.579
common, stemming from the sheer inability to

00:59:56.579 --> 00:59:59.599
perform seemingly simple, everyday tasks independently.

01:00:00.800 --> 01:00:02.860
Imagine the constant struggle to turn a key,

01:00:03.360 --> 01:00:06.719
open a jar, button a shirt, use cutlery, or even

01:00:06.719 --> 01:00:08.739
just hold a grandchild's hand without significant

01:00:08.739 --> 01:00:11.929
pain. This daily struggle can easily lead to

01:00:11.929 --> 01:00:14.070
deeper feelings of sadness, and in some cases

01:00:14.070 --> 01:00:16.309
it can contribute to clinical depression and

01:00:16.309 --> 01:00:19.590
anxiety. A pervasive sense of isolation can also

01:00:19.590 --> 01:00:22.349
develop, especially if hobbies or social activities

01:00:22.349 --> 01:00:24.989
are curtailed. That loss of independence must

01:00:24.989 --> 01:00:28.130
be incredibly hard. It is. When someone can no

01:00:28.130 --> 01:00:30.449
longer engage in hobbies they once loved, or

01:00:30.449 --> 01:00:32.630
perhaps perform their professional duties effectively,

01:00:33.250 --> 01:00:35.110
it inevitably diminishes their quality of life

01:00:35.110 --> 01:00:37.860
significantly. This can lead to feelings of helplessness,

01:00:38.119 --> 01:00:40.300
guilt about their perceived limitations, or even

01:00:40.300 --> 01:00:42.179
jealousy when observing others perform these

01:00:42.179 --> 01:00:44.179
actions effortlessly. I've had patients tell

01:00:44.179 --> 01:00:46.659
me how utterly disheartening it is to watch their

01:00:46.659 --> 01:00:48.699
spouse easily open a bottle they've struggled

01:00:48.699 --> 01:00:50.840
with for minutes. It chips away at their self

01:00:50.840 --> 01:00:52.840
-esteem. And does this emotional state affect

01:00:52.840 --> 01:00:55.860
the physical symptoms? Absolutely. The mind -body

01:00:55.860 --> 01:00:58.320
interconnection is particularly strong in chronic

01:00:58.320 --> 01:01:01.400
pain conditions. Stress, anxiety, and low mood

01:01:01.400 --> 01:01:05.179
can demonstrably amplify pain perception. It

01:01:05.179 --> 01:01:07.539
creates a challenging feedback loop, where the

01:01:07.539 --> 01:01:09.940
emotional distress exacerbates physical symptoms,

01:01:10.340 --> 01:01:12.219
which in turn increases the emotional distress,

01:01:12.639 --> 01:01:15.179
making recovery much more difficult. Untreated

01:01:15.179 --> 01:01:17.219
mental health conditions such as anxiety and

01:01:17.219 --> 01:01:19.659
depression are clearly linked in research to

01:01:19.659 --> 01:01:22.039
heightened pain perception, slower rehabilitation

01:01:22.039 --> 01:01:24.860
progress, and ultimately poorer functional outcomes

01:01:24.860 --> 01:01:27.440
in patients with thumb arthritis and indeed many

01:01:27.440 --> 01:01:29.539
other chronic conditions. So addressing the mental

01:01:29.539 --> 01:01:31.659
health aspect is crucial for physical recovery

01:01:31.659 --> 01:01:34.449
too. It really is. This raises an important question

01:01:34.449 --> 01:01:37.030
for us. If we only treat the physical joint,

01:01:37.530 --> 01:01:40.070
the cartilage, the bone, the ligaments, are we

01:01:40.070 --> 01:01:42.869
truly treating the whole patient? Ignoring the

01:01:42.869 --> 01:01:45.110
emotional tolls akin to addressing only half

01:01:45.110 --> 01:01:47.590
of their suffering. In our pursuit of holistic

01:01:47.590 --> 01:01:50.570
care, that's simply not good enough. fostering

01:01:50.570 --> 01:01:53.389
a positive mental state, providing psychological

01:01:53.389 --> 01:01:56.050
support where needed, and acknowledging the emotional

01:01:56.050 --> 01:01:58.650
burden are crucial, not only for enhancing a

01:01:58.650 --> 01:02:01.130
patient's ability to cope with pain, but also

01:02:01.130 --> 01:02:03.269
for encouraging them to actively participate

01:02:03.269 --> 01:02:05.869
in their rehabilitation and regain their confidence

01:02:05.869 --> 01:02:08.750
and independence. That's a powerful reminder

01:02:08.750 --> 01:02:11.650
of the holistic approach required and the profound

01:02:11.650 --> 01:02:14.719
impact beyond the physical joint itself. Building

01:02:14.719 --> 01:02:17.260
on that, what proactive measures can individuals

01:02:17.260 --> 01:02:20.000
take, and what long -term strategies can we empower

01:02:20.000 --> 01:02:22.079
our patients with to effectively manage this

01:02:22.079 --> 01:02:24.820
condition both before and after any potential

01:02:24.820 --> 01:02:26.980
intervention, ensuring their overall well -being?

01:02:27.320 --> 01:02:29.139
Empowering patients with proactive strategies

01:02:29.139 --> 01:02:31.739
for prevention, where possible, and certainly

01:02:31.739 --> 01:02:34.579
for long -term management, is absolutely crucial

01:02:34.579 --> 01:02:37.059
for their sustained well -being and functional

01:02:37.059 --> 01:02:39.599
independence. This isn't just about treating

01:02:39.599 --> 01:02:41.719
the joint when it becomes painful. It's about

01:02:41.719 --> 01:02:44.260
equipping them for a lifetime of joint health

01:02:44.260 --> 01:02:47.360
awareness. A primary recommendation is to adopt

01:02:47.360 --> 01:02:50.300
a proactive approach, starting with activity

01:02:50.300 --> 01:02:52.940
modification even before symptoms become severe,

01:02:53.139 --> 01:02:56.360
if possible. This includes being mindful of and

01:02:56.360 --> 01:02:58.420
consistently avoiding or adapting activities

01:02:58.420 --> 01:03:01.219
that place excessive, repetitive strain or cause

01:03:01.219 --> 01:03:03.500
pain in the thumb joint. Listen to your body.

01:03:03.719 --> 01:03:06.320
Regular physical activity, particularly specific

01:03:06.320 --> 01:03:08.360
exercises that strengthen the muscles surrounding

01:03:08.360 --> 01:03:11.440
the CMC joint, like the venar muscles, and improve

01:03:11.440 --> 01:03:14.000
pain -free range of motion, is essential. This

01:03:14.000 --> 01:03:16.300
isn't about working through sharp pain, but building

01:03:16.300 --> 01:03:18.760
robust dynamic support around the joint to potentially

01:03:18.760 --> 01:03:20.800
stabilize it and offload the stress cartilage.

01:03:20.980 --> 01:03:23.360
Strengthening the supporting muscles. Yes, dynamic

01:03:23.360 --> 01:03:26.280
stability is key. Ergonomic adjustments are another

01:03:26.280 --> 01:03:29.239
really important area. We strongly advise patients

01:03:29.239 --> 01:03:31.440
on the judicious use of assistive devices and

01:03:31.440 --> 01:03:34.260
ergonomic tools. Simple items like specialized

01:03:34.260 --> 01:03:37.380
jar openers, key turners, ergonomic pens with

01:03:37.380 --> 01:03:40.219
wider grips, or even large handled utensils can

01:03:40.219 --> 01:03:42.780
significantly alleviate stress on the joint during

01:03:42.780 --> 01:03:46.199
daily tasks. Education on joint protection techniques

01:03:46.199 --> 01:03:48.840
and proper hand positioning is vital for maintaining

01:03:48.840 --> 01:03:52.079
functionality while minimizing pain. For example,

01:03:52.360 --> 01:03:54.179
instead of using a tight pinch grip with just

01:03:54.179 --> 01:03:56.059
the thumb and index finger to lift something,

01:03:56.539 --> 01:03:58.440
we encourage patients to use the whole hand or

01:03:58.440 --> 01:04:00.920
both hands to grasp, distributing forces more

01:04:00.920 --> 01:04:03.539
broadly across stronger joints. Smart techniques

01:04:03.539 --> 01:04:06.519
to reduce the load. Precisely. For individuals

01:04:06.519 --> 01:04:09.099
experiencing early symptoms, early intervention

01:04:09.099 --> 01:04:11.440
strategies are highly effective and can potentially

01:04:11.440 --> 01:04:14.380
alter the disease trajectory or at least manage

01:04:14.380 --> 01:04:17.849
symptoms effectively for longer. Prompt conservative

01:04:17.849 --> 01:04:20.070
treatments, such as custom -made splints for

01:04:20.070 --> 01:04:23.050
support during activities and judicious use of

01:04:23.050 --> 01:04:25.349
analgesic and anti -inflammatory medications,

01:04:25.670 --> 01:04:28.429
oral or topical, to manage pain and inflammation

01:04:28.429 --> 01:04:31.570
can make a significant difference. Early engagement

01:04:31.570 --> 01:04:34.489
in manual therapy with a hand therapist and the

01:04:34.489 --> 01:04:37.130
consistent use of therapeutic taping, like kinesiotape,

01:04:37.449 --> 01:04:39.409
can also contribute to joint stability and provide

01:04:39.409 --> 01:04:41.989
pain relief, potentially delaying or even preventing

01:04:41.989 --> 01:04:44.010
the need for surgical intervention for years

01:04:44.010 --> 01:04:46.630
in some individuals. So, acting early with conservative

01:04:46.630 --> 01:04:49.400
measures is beneficial. Definitely. Finally,

01:04:49.579 --> 01:04:51.480
we need to empower patients with comprehensive

01:04:51.480 --> 01:04:53.699
long -term management strategies that go beyond

01:04:53.699 --> 01:04:56.360
just the physical. This includes ongoing education

01:04:56.360 --> 01:04:59.099
about lifestyle modifications, such as maintaining

01:04:59.099 --> 01:05:01.840
a healthy weight to reduce overall systemic inflammation

01:05:01.840 --> 01:05:05.360
and joint stress, and advising on workplace ergonomics

01:05:05.360 --> 01:05:07.960
tailored to their specific roles. Crucially,

01:05:08.280 --> 01:05:10.599
it involves fostering self -management techniques

01:05:10.599 --> 01:05:12.880
and developing effective coping strategies for

01:05:12.880 --> 01:05:14.960
dealing with chronic pain flares when they occur.

01:05:15.119 --> 01:05:17.440
This could mean incorporating stress reduction

01:05:17.440 --> 01:05:20.519
techniques like mindfulness, meditation, or Tai

01:05:20.519 --> 01:05:23.300
Chi. Practicing deep breathing exercises can

01:05:23.300 --> 01:05:26.280
help manage acute pain episodes. Seeking support

01:05:26.280 --> 01:05:28.900
from counseling services or arthritis specific

01:05:28.900 --> 01:05:31.400
support groups like those run by visor arthritis

01:05:31.400 --> 01:05:34.039
can be invaluable, allowing patients to connect

01:05:34.039 --> 01:05:36.460
with others facing similar challenges and sheer

01:05:36.460 --> 01:05:38.679
coping strategies. Focusing on the whole person

01:05:38.679 --> 01:05:41.739
again. Absolutely. What's truly fascinating and

01:05:41.739 --> 01:05:44.320
powerful here is the positive impact of encouraging

01:05:44.320 --> 01:05:46.900
patients to focus on enjoyable aspects of life,

01:05:47.280 --> 01:05:49.820
maintaining strong social connections, and continuing

01:05:49.820 --> 01:05:51.960
to engage in hobbies and activities that bring

01:05:51.960 --> 01:05:54.539
them joy, even if those activities need to be

01:05:54.539 --> 01:05:57.500
adapted slightly. These elements, while seemingly

01:05:57.500 --> 01:05:59.940
separate from orthopedics, are fundamental to

01:05:59.940 --> 01:06:02.599
enhancing overall quality of life, reducing the

01:06:02.599 --> 01:06:04.579
perceived burden of the condition and allowing

01:06:04.579 --> 01:06:06.579
patients to thrive despite living with chronic

01:06:06.579 --> 01:06:09.190
pain. This has been an incredibly insightful

01:06:09.190 --> 01:06:12.710
deep dive into basal thumb arthritis, covering

01:06:12.710 --> 01:06:15.769
everything from the intricate anatomy and pathophysiology

01:06:15.769 --> 01:06:18.570
right through the diverse range of conservative

01:06:18.570 --> 01:06:21.679
and surgical treatments, and critically, finishing

01:06:21.679 --> 01:06:23.880
on that holistic journey of recovery and well

01:06:23.880 --> 01:06:27.500
-being for our patients. As we consider the significant

01:06:27.500 --> 01:06:29.940
forces at play in such a small but vital joint,

01:06:30.480 --> 01:06:33.000
it truly underscores the remarkable resilience

01:06:33.000 --> 01:06:36.739
of the human hand and perhaps the often underestimated

01:06:36.739 --> 01:06:39.019
mental fortitude required to navigate chronic

01:06:39.019 --> 01:06:42.130
conditions like basal thumb arthritis. It leaves

01:06:42.130 --> 01:06:44.809
me wondering, what more could we as medical professionals

01:06:44.809 --> 01:06:46.889
perhaps do to better support our patients not

01:06:46.889 --> 01:06:50.030
just surgically or pharmacologically, but truly

01:06:50.030 --> 01:06:52.329
holistically in their long -term journey with

01:06:52.329 --> 01:06:54.650
chronic conditions like this? That is a profound

01:06:54.650 --> 01:06:56.530
question and it really speaks to the evolving

01:06:56.530 --> 01:06:58.710
nature of medicine, doesn't it? Perhaps our greatest

01:06:58.710 --> 01:07:01.309
future challenge and indeed opportunity is not

01:07:01.309 --> 01:07:03.849
just to fix the specific anatomical part, but

01:07:03.849 --> 01:07:06.329
to truly care for the whole person, integrating

01:07:06.329 --> 01:07:08.750
all aspects of their fixable emotional and social

01:07:08.750 --> 01:07:10.909
well -being into every single treatment plan

01:07:10.909 --> 01:07:13.429
we devise. Thank you for such an enlightening

01:07:13.429 --> 01:07:15.650
discussion today. If you found this deep dive

01:07:15.650 --> 01:07:18.250
valuable, please do consider rating and sharing

01:07:18.250 --> 01:07:19.869
this with your colleagues. It really helps us

01:07:19.869 --> 01:07:22.210
reach more professionals. Thank you for tuning

01:07:22.210 --> 01:07:23.789
in to the deep dive.