First Carpo-metacarpal Reconstructions

Introduction

Arthritis at the base of the thumb is a painful form of osteoarthritis that affects hand function and is common with aging. It occurs when the cartilage wears away from the end of the bones that form your thumb joint – known as the carpometacarpal joint.

Pain is the first symptom of thumb arthritis and is aggravated by using the thumb such as opening jars, twisting door handles and turning keys. Other symptoms include swelling, stiffness and tenderness at the base of the thumb with decreased strength and range of movements. There is often an abnormal appearance of the base of the thumb.

Indications for surgery

The diagnosis of basal thumb arthritis is usually made on clinical history and physical examination. An X-ray will show signs of osteoarthritis and confirm the diagnosis. The X-ray will show narrowing of the joint space, extra bony growths called osteophytes and changes in quality of the bone on either side of the joint.

In the early stages of thumb arthritis, Dr Lane may suggest conservative or non-surgical treatments. This includes:

  • Modifying activities.
  • Referral to a hand therapist to provide a splint that can be worn to support the thumb.
  • Pain relief with paracetamol and anti-inflammatory drugs such as Naprosyn, Brufen or Celebrex.
  • Corticosteroid injection can offer temporary pain relief and reduce inflammation.

If conservative treatments fail to offer adequate pain relief and pain continues to be constant and unbearable with severe limitations in thumb movement, then Dr Lane may recommend surgery.

Dr Lane performs the surgical procedure “Trapeziectomy and suspension arthroplasty” – removal of trapezium bone and then using half of one of the tendons on the front of the wrist to create a sling to support the remaining bones in position. This operation provides a durable joint which provides good pain relief and has permanent results.

Pre-operative Instructions

Once surgery is recommended, Dr Lane will provide his patient with comprehensive information covering the procedure, surgical risks and after care. If there are any concerns, further consultation is encouraged.

Anti-inflammatory drugs such as Feldene, Naprosyn, Brufen, Indocid, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin and other blood thinning drug use prior to surgery should be discussed with Dr Lane as this would depend on the patients underlying medical condition. The hand and wrist to be operated on should be free of abrasions, cuts or sores as this would increase the risk of infection. If there is damaged skin in the area that has to be operated on, them it is likely that the operation will be postponed until the skin is healed.

This surgery is usually performed as a day procedure. You will be given clear instructions from the reception staff when to attend the day hospital depending on your surgery time. Please take your Medicare, DVA or Private Health care cards. Do not eat or drink 6 hours before surgery.

Prior to surgery:

  • You will be admitted by the duty nurse and baseline observation taken.
  • Theatre gown given to wear.
  • The hand and wrist will be washed with an anti-septic solution and covered by a sterile drape by the nursing staff.
  • You will be given TED stockings to wear on your legs to reduce the risk of deep venous thrombosis after surgery.

The nursing staff will take you into the theatre complex and then into the anaesthetic bay where you will meet your anaesthetist and Dr Lane. Trapeziectomy and suspension arthroplasty is performed under a general anaesthetic.

Procedure

When you are asleep in theatre, a tourniquet will be placed on your upper arm to provide a bloodless field in which to operate. The hand and arm are then prepped with an anti-septic solution and covered with sterile drapes leaving a window for the hand and wrist. A 3cm incision is made over the base of the thumb and two smaller incisions at the wrist and front of the forearm, to harvest half the tendon for the sling arthroplasty. The surgery takes about 60 minutes. The incisions are closed with sutures and local anaesthetic infiltrated around the operative site to help post-operative pain. The wounds are covered with primapore and then dressed with wool and crepe bandage. A splint is applied.

After surgery, you will be taken to the recovery room. When you are adequately awake, observations stable and able to eat and drink, you are ready for discharge home. Your arm will be placed in a high arm sling which you should wear until seen at Dr Lane’s rooms in 12 to 14 days.  You will be given a script from the anaesthetist for pain relief. It is important that you have someone to take you home.

Post-operative Instructions

It is important to keep the dressings clean and dry and wear the high arm sling as able-this will help reduce swelling particularly in the early days after surgery. Please make an appointment with Dr Lane in his rooms 12 to 14 days after surgery. At this time, the dressings and sutures will be removed. Further water proof dressing will be placed over the wound and should remain over the wound for the next 4 days. Dr Lane will give you a referral to see a hand therapist to have a splint made to mould over the thumb and wrist. This should be worn for the next 4 to 6 weeks and should be worn at all times. You will be given simple exercises to do at home by the therapist. The hand at this time should not be used for lifting or gripping. You will be seen by Dr Lane again 6 weeks after the procedure and further hand and thumb strengthening programme advised by therapist. From 6 to 12 weeks following surgery, the splint is usually just worn at night. At 10-12 weeks after surgery, normal use of the hand is resumed if joint stable.

Risks

General risks associated with Anaesthetic (rare)

  • Death.
  • Myocardial Infarction (heart attack).
  • Stroke.
  • Deep venous thrombosis.

Local Risk (uncommon)

  • Bleeding.
  • Infection which may lead to wound breakdown and joint infection.
  • Nerve damage which may cause temporary or permanent numbness or neuroma formation (painful lump extremely sensitive to touch.
  • Complex Regional Pain Syndrome (CRPS) - a bad reaction to surgery leading to stiff painful hand.
  • Stiff weak thumb.
  • Excessive swelling.

Patients who are smokers, diabetic or have multiple pre-existing medical conditions have a higher risk of complications.