Thumb Surgery

[Patty Hann]

So....I have a severely arthritic left thumb, but I am right-handed.

Orthopedic guy that fixes thumbs (and hands and wrists) says it is normal for the non -dominant thumb to show symptoms due to "complementarity of use".
Your dominant hand will hold thing X in a specific way, while your non-dom hand will help hold X but in a manner different from the dominant hand, to achieve whatever it is that requires two hands to do..
Sometimes (in a 2 handed effort) your hands will be acting mirror images of each other, but typically that is not the case.

The "gold standard" fix for this is LRTI ....Ligament Reconstruction and Tendon Interposition. It is outpatient surgery.
[Following is a cut-and-paste description of the surgery]:

The surgery involves removing a small arthritic bone at the base of your thumb called the trapezium. This is performed through a 3 cm incision on the back of the thumb.
Then a tendon from your forearm (taken through a small incision) is used to reconstruct the supporting ligaments at the base of the thumb and to serve as a cushion in lieu of the removed bone.

The procedure is often referred to as a suspensionplasty because the thumb looks suspended on the x-ray after surgery (the interposed tendon does not show up on x-ray so the thumb looks like it’s floating).

It takes about one hour to perform the surgery. You can expect to be at the surgery center for 3-4 hours ...

Although you will be permitted full use of the thumb at 3 months after the surgery, it takes a full year before you will see the final results in terms of recovery of strength and dexterity in the thumb. The reason for this is that the thumb is a highly specialized body part, and it takes that long for the brain cortex to be retrained to use the thumb for highly skilled function and for tasks that require a lot of strength when loading the thumb.
----

Lot of slings and elevating the arm and PT ... the usual.
Then I point blanked asked the doctor exactly what "full use" means (after a year) , how much original strength and R-O-M (range of motion) will I lose permanently due to the nature of surgery?
That is, you never get something for nothing in this world. What will I lose?

He looked at me but didn't speak for some seconds, then said, "You will lose some. You never get it all back. How much? How little? Depends of the individual."
So I replied (rhetorically) , "Well, then full use isn't really full use, is it? Would you have told me that if I hadn't asked?"
Doctor (somewhat annoyed), "No, I would not have told you that if you hadn't asked. Most patients don't ask what 'full use' means."

No, I thought, no, they don't... and sometimes are very unpleasantly surprised months down the road.

So... (after long preliminary info)...Has anyone had this surgery? If so, what can you tell me about it?
....

[Larry Frank]

I have not had thumb surgery but have had wrist surgery. I was not too concerned about full use but was concerned with reduction of pain. I had what is called four corner fusion and took about three hours. The results were good but it was a painful surgery recovery and I hate wearing a cast. It took a year and physical therapy to get to the best it could be. I lost range of motion but gained function and less pain .

[Ron Citerone]

Never had any thumb surgery. I did have stitches from a band saw down the the bone on my middle finger. I was worried losing use but my end result was perfect.

I had both elbows debribed and while not 100% I would give them 90%. 'Shoulder surgery 95%.

I n all cases I was diligent with PT and I believe that makes a big difference in ortho stuff. I asked PT about my elbow expectations nd he said diligent PT gives aroud 90% and he was right. He also said people who don't follow the PT program have lesser results.

Wife had carrpal tunnel surgery much better on pain did not regain full strength.

My 2 cents.

[Bill George]

I have found in my nearly 8 decades that surgery results are not always what was promised. My right index finger surgery was Not as promised and now is much worse and etc, YMMV. I just wanted to add, IF things don't turn out right its always Your fault, not the surgeons.

[Jerry Bruette]

Why yes...yes I have. I had the exact surgery you are considering. You will regain ROM and strength if you do all your therapy. I lost some dexterity. The bigger problem I have is with the ulnar nerve, or the funny bone nerve. After having the thumb surgery I think the ulnar nerve started acting up because of the recovery process. I had surgery to reposition the ulnar nerve but still have numbness in the ring and little finger.

I can post pictures of what your arm will look like with the stitches before casting and with the cast on. You'll be in a cast for 4 weeks and you will lose a lot of mass and strength in the forearm and hand. I laughed at the therapist when the cast was removed and she told me to touch my thumb to my forefinger. You won't be able to.

You can PM me or ask questions and I can answer them here if you'd like.

Would I do it again? Just to get rid of the constant pain I had....Yes. Voltaren is your friend, takes 7-10 days to help though.

[Patty Hann]

I have found in my nearly 8 decades that surgery results are not always what was promised. My right index finger surgery was Not as promised and now is much worse and etc, YMMV. I just wanted to add, IF things don't turn out right its always Your fault, not the surgeons.

"Surgery results are not always as promised".
Tell me about it. Cataracts surgery (both eyes 6 months apart)...you trade one set of optical problems/aberrations for another.
Yes, it prevents you from going blind but that is the only good thing it does (which is a very good thing, indeed).
Just don't expect problem free vision after the surgeries (artifacts galore in my left eye).

[Patty Hann]

Why yes...yes I have. I had the exact surgery you are considering. You will regain ROM and strength if you do all your therapy. I lost some dexterity. The bigger problem I have is with the ulnar nerve, or the funny bone nerve. After having the thumb surgery I think the ulnar nerve started acting up because of the recovery process. I had surgery to reposition the ulnar nerve but still have numbness in the ring and little finger.

I can post pictures of what your arm will look like with the stitches before casting and with the cast on. You'll be in a cast for 4 weeks and you will lose a lot of mass and strength in the forearm and hand. I laughed at the therapist when the cast was removed and she told me to touch my thumb to my forefinger. You won't be able to.

You can PM me or ask questions and I can answer them here if you'd like.

Would I do it again? Just to get rid of the constant pain I had....Yes. Voltaren is your friend, takes 7-10 days to help though.

Thank you Jerry.... I will PM you later (can't say when)... I have to gather more info so I know what to ask you.
I am not in constant pain, and I can still use my thumb for many things, but it will never get better, only worse (as you know).

[Ron Selzer]

Jerry
"but still have numbness in the ring and little finger."
have battled with this for over 40 years now, a good chiropractor working on my neck makes mine go away, sometimes for days, most of the time for months to a year. Also a round tube shaped pillow under my neck in just the right spot as I sleep on my back.
Hopefully this will help you also
Ron

[Jerry Bruette]

Jerry
"but still have numbness in the ring and little finger."
have battled with this for over 40 years now, a good chiropractor working on my neck makes mine go away, sometimes for days, most of the time for months to a year. Also a round tube shaped pillow under my neck in just the right spot as I sleep on my back.
Hopefully this will help you also
Ron
I asked two different surgeons if the numbness could be coming from further "upstream" and they both poo-pooed that idea. Not to scare anyone, but sometimes I think it came from the nerve block they gave me for the thumb surgery.

[Bill Dufour]

Not something to do with any surgeon. I would not got to Mexico for this. Any good University Medical schools in your area? When i had my hip replaced my 83 year old friend knew who was the best hip surgeon in town. This was from many of his friends having good/bad surgery results.
I would look into getting it done at Stanford. I do not know their reputation for this particular surgery but overall their medical school is probably the best west of New York. Spoken by a child of Berkeley grads.
Cost probably $1,000 more for the plane trip and hotel room not to do it in dog patch.
Bill D

[Bill Dufour]

I asked at PT. They agreed those who only did the work at PT took longer and never got back as good as those, like me, who went to PT twice a week and also did the exercises we learned there at home.
Walmart and Amazon sell the giant rubber bands etc needed.
At PT it seemed like they added a new exercise each week to keep you coming back for more.
Bill D

[Larry Frank]

IMHO, there is no surgery that is 100% There is no surgery that will make you 18 again.

You need to weigh the positives and negatives for your self. When it gets bad enough you will decide. I review the background of any doctor or surgeon very carefully. i look up and read their peer reviewed papers concerning the surgery. I have been fortunate to find good doctors. I have had spinal fusion, hand surgery, hip surgeries and suffer chronic pain . Would I do the surgeries again..... Yes because not doing them would be so much worse.

No one can tell you what you should do... Good Luck

[Jim Allen]

I had arthritic pain in my left (dominate) thumb, my surgeon gave me a cortisone shot, over a year ago and it's still fine.

[Bill George]

I had arthritic pain in my left (dominate) thumb, my surgeon gave me a cortisone shot, over a year ago and it's still fine.

Ditto, right hip and left knee the knee also gets a Synvisc dose 2 times a year.

[Ken Fitzgerald]

It really becomes a matter of what can you realistically expect from the outcome of the surgery. The question is are you experiencing so much pain that you are willing to accept the potential outcome after diligently going through the PT? If anyone tells you something will be perfect following surgery, I would be skeptical. But understand to a lot of people, the pain could be debilitating. The doctor probably sees a lot of those patients.

I am deaf and hear with a cochlear implant. I have counseled several other CI recipients. I always tell them. Nothing is guaranteed but the odds are your favor of regaining some hearing BUT don't get you hopes up too high. The emotional disappointment can be dramatic as about 1% of recipients get no relief at all from an implant. Many CI-borgs have to practice using the CI to hear for several years to achieve some success. My adage is "Hope for the best, prepare for the worst and celebrate any improvement!"

Good luck with your research and decision.

[Jim Becker]

I hope you heal quickly!!

Interestingly, the thumb joint on my dominant hand (right) is the one giving me pain issues these days in addition to the wrist joint. I had wrist surgery on my left a few years ago because of bone-on-bone (they removed a row of bones) and that side has been 'golden' since, despite having a more limited range of motion. I am starting to feel that I'm going to have to have something done with the right side in the near future which makes me a little sad since I finally have my new shop up and running and am even almost done fixing the landscaping. But I don't think I can wait indefinitely at this point. The potential downside is again, less range of motion. But that's a fair tradeoff relative to increasing levels of pain.

[Patty Hann]

Not something to do with any surgeon. I would not got to Mexico for this. Any good University Medical schools in your area? When i had my hip replaced my 83 year old friend knew who was the best hip surgeon in town. This was from many of his friends having good/bad surgery results.
I would look into getting it done at Stanford. I do not know their reputation for this particular surgery but overall their medical school is probably the best west of New York. Spoken by a child of Berkeley grads.
Cost probably $1,000 more for the plane trip and hotel room not to do it in dog patch.
Bill D
Bill...I would not go to Mexico for this...never even considered it.
Medicare will pay for it.

[Patty Hann]

IMHO, there is no surgery that is 100% There is no surgery that will make you 18 again.

You need to weigh the positives and negatives for your self. When it gets bad enough you will decide. I review the background of any doctor or surgeon very carefully. i look up and read their peer reviewed papers concerning the surgery. I have been fortunate to find good doctors. I have had spinal fusion, hand surgery, hip surgeries and suffer chronic pain . Would I do the surgeries again..... Yes because not doing them would be so much worse.
No one can tell you what you should do... Good Luck


It's not that the results won't restore my thumb like it was when I was 18, or even 38.
It's the assurance by the doctor that "this" (whatever method) will fix the problem.
But no one is defining "fix".

If one is in constant, unrelenting pain, does "fix" mean eliminate the pain, but at the cost of strength and /or ROM?
If one has low tolerable pain level but can't move the thumb, does fix mean you get motion back, but with loss of strength?
If you have thumb weakness (lack of strength) does "fix" mean you get strength back but at the cost of ROM?

I want to know what I'm signing up for. I want to have realistic expectations as to outcome(s).
But quite few doctors don't like having to explain things to peasants.

I read medical abstracts, I read articles on alternative methods. (They really don't like hearing that.)
I have a pretty high IQ (sorry to state that so shamelessly but as Walter Brennan was wont to say of himself [when pressed] "No brag, just fact.")
I understand medical terminology as relates to musculo-skeletal problems (having been very athletic in my younger years...multi-sport).
But many doctors get mightily miffed when I ask what the words "really mean" as they are using them.

[Patty Hann]

I had arthritic pain in my left (dominate) thumb, my surgeon gave me a cortisone shot, over a year ago and it's still fine.

I've had two shots....each lasted 6 months (which was good).
I should have had another one last December, but the thumb wasn't too bad so i held off becaaaaause....
You can only get three in that area of the thumb (four if you are built like a linebacker).
It weakens the tissue such that the thumb support can just totally collapse (go "mushy") without warning.
Then you HAVE to surgery because there is no going back from that.

By way of contrast I've had multiple cortisone shots in my neck over the years.
No limits on those because the bones and tissue have more mass. Bones/tendons in the hand are (comparatively, even in a linebacker) finely structured.

[Patty Hann]

I asked at PT. They agreed those who only did the work at PT took longer and never got back as good as those, like me, who went to PT twice a week and also did the exercises we learned there at home.
Walmart and Amazon sell the giant rubber bands etc needed.
At PT it seemed like they added a new exercise each week to keep you coming back for more.
Bill D

I've had lower back surgery (PLIF) Fusion with hardware implanted L5-S1 (2011) (2nd degree spondylolisthesis [sports related]).
I've had cervical fusion (ACDF) with hardware implant C5-C6-C7 (2016). (Problem was disc degeneration and some foraminal stenosis from bone spurs)
The PT place is my "second home"
I did the exercises at the PT place, I did the exercises at home between the scheduled appointments, I do the exercises now.
I'm a big fan of staying strong and limber/flexible as possible while aging (gracefully, I hope :rolleyes:)

Edit...tradeoffs:
Lower back... had to stop running (walking is OK), had to alter how I do breast-stroke (no hyper-extending the back, so I had to change my breathing method/motion).

Neck... anything involving the need for head-turning is limited as I can't go much beyond 60 degrees (90 deg is totally gone forever).
For "shoulder checks" while driving I have to partially turn my body.
Swimming freestyle means I have to roll my body to breathe instead of simply turning my head.
HAve to sit in a more upright position on a bike (no hyper-extending the neck)
Also neck gets a bit tired and achy at times.

The "Pros"? no more debilitating pain in either the back or the neck. None. (Cortisone shots in the neck are to combat [age caused] facet joint arthritis.)

[Patty Hann]

It really becomes a matter of what can you realistically expect from the outcome of the surgery. The question is are you experiencing so much pain that you are willing to accept the potential outcome after diligently going through the PT? If anyone tells you something will be perfect following surgery, I would be skeptical. But understand to a lot of people, the pain could be debilitating. The doctor probably sees a lot of those patients.

... My adage is "Hope for the best, prepare for the worst and celebrate any improvement!"

Good luck with your research and decision.
Thanks Ken,... see my answer to Larry Frank.

[Jerry Bruette]

I had arthritic pain in my left (dominate) thumb, my surgeon gave me a cortisone shot, over a year ago and it's still fine.

When I went to the doctor to have my thumb checked they took an x-ray and you know how the x-ray shows the white gaps where your joints are that's the cartilage in the joint. I didn't have any white gap in the MCM joint it was completely black and I was starting to grow excise bone. Doctor said I had three choices injection, topical medicine or surgery. The first two treat the symptoms but don't correct the problem. I chose to rub Volatren on my thumb until I could have the surgery.

I was still working at the time I had the surgery. The pain in my thumb was starting to effect how I did my job. Tough to hold tools and parts, turn wrenches, etc. when your thumb hurts so bad that I couldn't use a grasping hold on anything.

[Larry Frank]

I have had a lot of surgery done and doctors are unlikely to tell you exactly what the outcome will be. With any surgery, you can have great outcome, bad outcome or anywhere in between. If they tell you something specific and it turns out not so good, the patient may sue them.

I have had four corner fusion on both wrists which is a major surgery. My doctor was great and had a CV that was outstanding. He took a lot of time explaining it to me but did not tell me exactly.what the result would be. I read all the articles about the surgery describing the outcomes. The potential outcomes spanned a wide range of great to bad and there were no guarantees. The surgery and recovery were quite painful and the result an improvement in pain but reduced range of motion.

You are not going to get any guarantees on the outcome and you can read the studies on your particular surgery. What I read were fairly positive but only you can decide.

[Patty Hann]

I hope you heal quickly!!

Interestingly, the thumb joint on my dominant hand (right) is the one giving me pain issues these days in addition to the wrist joint. I had wrist surgery on my left a few years ago because of bone-on-bone (they removed a row of bones) and that side has been 'golden' since, despite having a more limited range of motion. I am starting to feel that I'm going to have to have something done with the right side in the near future which makes me a little sad since I finally have my new shop up and running and am even almost done fixing the landscaping. But I don't think I can wait indefinitely at this point. The potential downside is again, less range of motion. But that's a fair tradeoff relative to increasing levels of pain.

Sorry to hear that...just when you think you are (more or less) back on track to do [whatever], something else comes up.

499681
Thank you for the well wishes. Not scheduled yet, tho'....
I've still got one shot left, and in the interim... a year? two years?....I'm hoping the LRTI changes to where the recovery process is not so onerous, especially wearing a cast....I am dreading that more than the loss of the use of my thumb for 2-3 months.

[Patty Hann]

I have had a lot of surgery done and doctors are unlikely to tell you exactly what the outcome will be. With any surgery, you can have great outcome, bad outcome or anywhere in between. If they tell you something specific and it turns out not so good, the patient may sue them.

I have had four corner fusion on both wrists which is a major surgery. My doctor was great and had a CV that was outstanding. He took a lot of time explaining it to me but did not tell me exactly.what the result would be. I read all the articles about the surgery describing the outcomes. The potential outcomes spanned a wide range of great to bad and there were no guarantees. The surgery and recovery were quite painful and the result an improvement in pain but reduced range of motion.

You are not going to get any guarantees on the outcome and you can read the studies on your particular surgery. What I read were fairly positive but only you can decide.
I''ll eventually have to have it done....most people of "joint surgery" forums that have had it are glad they did it.
I just like to know what to expect (good and bad).

[Patty Hann]

FWIW to anyone with this problem now or in the future.....
I have just read 12 abstracts/articles/papers on LRTI , specifically Trapeziectomy with LRTI vs Simple Trapeziectomy.

By way of explanation the first procedure is the one I detailed in my original post.
Short version: trapezium bone is removed and space is filled with tendon material removed (as in "cut") from your forearm.
Simple trapeziectomy: bone is removed. That's it.

All the abstracts (from 2005 to 2022) said basically the same thing, to wit:
Pain resolution, pinch strength, ROM, function...results are no different between the two procedures evaluated 2-5 years form the surgery. (First year out is still considered a "recovery period")

Differences... Complications 3 months following surgery (the initial recovery period) Trap + LRTI high rate of problems, as a result of the added surgery of removing the tendon.
Simple trap procedure... low rate of complications

Also the Trap+LRTI is more expensive (no surprise there).

Conclusion of every abstract I read: No reason to do the Trapeziectomy + LRTI over the simple Trapeziectomy.

[Jerry Bruette]

FWIW to anyone with this problem now or in the future.....
I have just read 12 abstracts on LRTI , specifically Trapeziectomy with LRTI vs Simple Trapeziectomy.

By way of explanation the first procedure is the one I detailed in my original post.
Short version: trapezium bone is removed and space is filled with tendon material removed (as in "cut") from your forearm.
Simple trapeziectomy: bone is removed. That's it.

All the abstracts (from 2005 to 2022) said basically the same thing, to wit:
Pain resolution, pinch strength, ROM, function...results are no different between the two procedures evaluated 2-5 years form the surgery. (First year out is still considered a "recovery period")

Differences... Complications 3 months following surgery (the initial recovery period) Trap + LRTI high rate of problems, as a result of the added surgery of removing the tendon.
Simple trap procedure... low rate of complications

Also the Trap+LRTI is more expensive (no surprise there).

Conclusion of every abstract I read: No reason to do the Trapeziectomy + LRTI over the simple Trapeziectomy.
What fills the void if they remove the Trapezium and don't fill it with the "anchovy"? When I had my surgery the doctor took a tendon in the forearm and split it. Then he stripped it back rolled it up like a anchovy stitched it together and used it to fill the void where the trapezium was. This also creates a cushion where the cartilage used to be. I had no complications from using the split tendon.

[Patty Hann]

The void is not filled with anything.
To be honest I thought it was odd, also.
Some of the abstracts mentioned the "anchovv".
But they all said there was no appreciable difference in "long term out come".

[Patty Hann]

Just a few of the abstracts... for me (right now) I'm thinking I'll avoid the LRTI and just go "simple".
But also, my thumb is not anywhere near ready for surgery.
Maybe when it is, the specialists will have figured out what works best.
Or maybe it's like most surgical procedures... you go with one that gives you the results you want (or the nearest thing to it)

http://https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5060089/

https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-3045-7

https://www.researchgate.net/publication/313281650_Evidence-Based_Practice_in_the_Surgical_Treatment_of_Thumb_ Carpometacarpal_Joint_Arthritis

https://pubmed.ncbi.nlm.nih.gov/32903125/

https://www.researchgate.net/publication/348581818_Differences_between_simple_trapeziectomy _and_trapeziectomy_with_ligament_reconstruction_an d_tendon_interposition_for_the_treatment_of_trapez iometacarpal_osteoarthritis_a_systematic_review_an d_meta-ana


https://upload.orthobullets.com/journalclub/pubmed_central/27418894.pdf

[Mark Paavola]

Good evening Patty. I had the surgery just about 1 year ago. I did the one with with the anchovy. I was in a splint for 2 weeks then a cast for 2 additional weeks. After the surgery there was PT.
The thumb will be useless for a while and you may have some numbness. I just went to the surgeon today for a final checkup. Everything works good with no pain. The thunb still does not have full range of motion. Maybe 90 percent. I had no complications and everything went well for me. I would do the surgery on my right hand if I needed it.
The only drawback for me was I was told if there were problems then they can't go back and do it again.

Mark

[Patty Hann]

Good evening Patty. I had the surgery just about 1 year ago. I did the one with with the anchovy. I was in a splint for 2 weeks then a cast for 2 additional weeks. After the surgery there was PT.
The thumb will be useless for a while and you may have some numbness. I just went to the surgeon today for a final checkup. Everything works good with no pain. The thunb still does not have full range of motion. Maybe 90 percent. I had no complications and everything went well for me. I would do the surgery on my right hand if I needed it.
The only drawback for me was I was told if there were problems then they can't go back and do it again.

Mark

Thank you Mark.... good info to have.
A few questions:
(@Jerry Bruette also if you wouldn't mind answering them)
How far up your arm did the cast go?
What was your PT schedule like (meaning # of times per week and number of weeks)
What was it like not having a thumb for a month or so?
Did the surgeon ( or anyone...e.g. PA etc) explain why there is no redo/do over?

[Jerry Bruette]

I'm including some pictures from the surgery and two that I took today showing the splint I had to wear after the cast came off and the whole time I did therapy.

The two incisions are about 4" apart and the cast covered both, and ended about 3" before the inside of the elbow.

PT was two times a week for 6 weeks with the therapist and of course twice daily exercises at home. I had some issues with swelling and had to use a compression glove and did contrast baths with my hand. Two minutes in hot water then two minutes in cold water for a total of twelve minutes. I was off work for a total of 12 weeks and when I went back t work there were certain things I wouldn't do. I wouldn't hold anything in my left hand that was going to be struck with a hammer, cold chisel, pin punch etc. You will be without a thumb for longer than "a month or so".

There's a lady on Youtube who documented her whole process, surgery, recovery, therapy etc. My experience wasn't exactly like hers but it gives you a good idea of the experience. Look up GloryB-TV. I don't know what type of anesthesia she had but they gave me a nerve block form the neck down and my whole arm was like a block of wood for about 36 hours. I had no control of my arm and didn't feel any pain at all, be prepared for when that block wears off though.

Never asked asked the doctor about a redo but if you watch a video of the surgery I don't know how they would do it over again. I know there are different versions of the repair where they put a artificial piece in but I don't know the specifics of that surgery, is it out dated, when is it appropriate etc.

Anyway onto the illustrations.

499862499863499864499865

[Bernie Kopfer]

Patty, I had the surgery you’ve described about 10 years ago. Severe debilitating pain started 2 months after I retired from dentistry. Recovery took months and it was a year before I had the strength and dexterity to safely do extractions again. Other than some permanent strength loss it functions quite well. Now I worry about my left thumb which occasionally gives me that same pain. I really don’t want to go through that recovery period again.

[Mark Paavola]

Patty, my experience was very similar to Jerry's regarding the cast and recovery. After the cast comes off the thumb will take awhile to become useful. It was probably six weeks after surgery before I could pick anything up. It was probably three months before it was gettting back to normal and 6 months for full range of motion. I was told they cannot redo the surgery due to the tendon removal from the arm There were no "spares" left. Typical full recovery can take six months to a full year.
I felt it was well worth it to have the surgery. No more pain and use of the thumb again.