Thumb arthritis, medically termed carpometacarpal (CMC) joint arthritis, affects the joint at the base of the thumb where the first metacarpal bone meets the trapezium bone in the wrist. This highly mobile joint allows the thumb to swivel, pivot, and pinch, making it highly susceptible to wear-and-tear. When the smooth, protective cartilage wears down, the bones rub directly against one another, causing pain, swelling, and loss of strength. While initial treatment focuses on non-surgical methods like splinting, medications, and steroid injections, surgery becomes necessary when these conservative measures no longer provide lasting relief. There is no single best procedure; instead, several effective surgical options exist, each tailored to the individual patient’s needs and lifestyle.
Understanding Surgical Goals
The decision to proceed with surgery is driven by two primary goals aimed at restoring quality of life. The most immediate objective is the permanent elimination of chronic pain that limits daily activities like gripping and pinching. This pain results from bone-on-bone friction within the degenerated CMC joint, and surgery is designed to remove the source of that friction entirely.
The second goal focuses on restoring or maintaining thumb function and strength. Surgeons strive to stabilize the thumb base, allowing for effective pinch and grip strength while preserving an adequate range of motion. The success of any procedure is measured by a patient’s ability to return to pain-free function. Surgical techniques achieve these goals through different mechanical approaches, often leading to trade-offs between strength and mobility.
Primary Surgical Options for Thumb Arthritis
The three main surgical categories for treating advanced thumb arthritis involve removing the damaged joint surface, fusing the bones, or replacing the joint with an implant.
Trapeziectomy and LRTI
The most frequently performed procedure is a trapeziectomy, which involves surgically removing the entire trapezium bone. Removing this small wrist bone eliminates the painful, arthritic joint surface, creating a space that fills with scar tissue over time. Trapeziectomy is often augmented with Ligament Reconstruction and Tendon Interposition (LRTI) to stabilize the thumb and prevent the metacarpal from collapsing. In LRTI, a portion of a wrist tendon is harvested. One end is anchored to the thumb metacarpal to reconstruct a stabilizing ligament, and the remaining tendon is placed into the void to act as a cushion. Although LRTI provides long-term pain relief, studies show it can result in a decrease in pinch strength and slight shortening of the thumb.
Arthrodesis (Joint Fusion)
Arthrodesis, or joint fusion, permanently fixes the two bones of the CMC joint together using pins, screws, or plates. This technique entirely eliminates motion in the affected joint, guaranteeing a pain-free and stable thumb platform. Fusion is beneficial for younger, high-demand patients or those requiring heavy manual labor, as the fused joint can withstand considerable force and retain greater pinch strength than LRTI. The disadvantage is the complete loss of movement at the CMC joint, which can sometimes place increased stress on neighboring joints.
Total Joint Replacement (Arthroplasty)
The third major option is Total Joint Replacement, or Arthroplasty, which removes the damaged joint and replaces it with an artificial implant or synthetic spacer. These implants are typically made of metal and polyethylene or pyrocarbon, designed to restore smooth movement while maintaining thumb length and stability. Joint replacement procedures generally offer a more rapid return to functional mobility and better thumb opposition compared to LRTI. However, the long-term durability of the implants is a concern, as they can loosen or wear out over time, potentially necessitating a revision surgery.
The Post-Operative Journey
A structured rehabilitation program is a necessary component of the post-operative journey, requiring significant patient commitment regardless of the procedure performed. Immediately following surgery, the hand is immobilized in a dressing or splint to protect the surgical site. This is typically replaced after one or two weeks with a rigid cast or a thumb spica splint, worn continuously for four to six weeks.
During immobilization, patients should keep the hand elevated to minimize swelling and move their fingers to prevent stiffness in non-operative joints. Once the splint is removed, formal hand therapy begins, focusing first on regaining gentle range of motion. The hand therapist guides the patient through exercises designed to mobilize the thumb joint without compromising the surgical repair.
The next stage focuses on strengthening, typically starting around six to eight weeks post-surgery. The return of full strength is a gradual process, often continuing to improve for six months to a full year. Most individuals can return to light daily activities, such as writing and eating, within two to three months. However, a full return to heavy lifting and strenuous work usually takes longer.
Criteria for Choosing the Right Procedure
The selection of the most appropriate surgical intervention is a highly individualized decision based on several key criteria.
Severity of Arthritis
The specific stage and severity of the arthritis, often determined by X-ray changes, plays a significant role. For instance, less advanced stages might be treated with less invasive ligament reconstruction techniques. Severe, end-stage arthritis typically requires trapeziectomy or arthroplasty.
Age and Activity Level
A patient’s age and activity level are the most influential factors. A younger patient with physically demanding work is generally a better candidate for arthrodesis, which prioritizes long-term stability and maximum strength, accepting the trade-off of lost motion. Conversely, an older, less active patient who prioritizes flexibility and a faster recovery may be better suited for a trapeziectomy with LRTI or a joint replacement.
Patient Preference
The patient’s personal preference regarding the balance between strength and mobility is a major consideration. Individuals who rely heavily on a powerful pinch grip may lean toward fusion. Those who value the ability to perform fine motor tasks with a greater range of motion might select joint replacement or trapeziectomy with LRTI. Ultimately, the best surgery aligns the technical requirements of the joint with the patient’s lifestyle goals, offering the greatest chance for long-term pain relief and functional success.