Thumb osteoarthritis treatments: Surgery or injections?

A long medical history and treatments with limited success is what usually sends someone to our office seeking other possible remedies. Most of the people we see are now in pain management (anti-inflammatories and painkillers) as their primary treatments along with splints and wrist braces.

The path many of these people took to a more severe thumb arthritis is that path that many have.

  • They have been using ice on a daily basis.
  • They take anti-inflammatories to bring down the swelling and help restore some function.
  • They wear the splint, sometimes all day, sometimes all night, sometimes the splint never comes off.
  • They have had physical therapy.
  • They have had corticosteroid. Many of these people can no longer have the cortisone because the injection is no longer beneficial or in some cases now doing more harm than good.

It is at this point that surgery may be recommended.

So what can we offer these bone on bone thumb people who have lost a great deal of thumb function and the basic use of their hands because they have no grip strength? We offer a physical examination, and assessment of their pain and functional challenges, and when appropriate a recommendation for stem cell therapy or bone marrow aspirate concentrate or Platlete Rich Plasma Therapy injections into the thumb joint.

Can thumb surgery really be avoided?

Surgery should always be considered the last option. For some people, damage in the thumb joints are so severely damaged that surgery may be the only way. For many others, surgery can realistically be avoided and the thumb joint mended with regenerative medicine injections. People will contact me and ask me about what do I think about a thumb fusion surgery. I explain to them in general terms that this procedure is used for people who have significant pain and would trade off pain relief for a near elimination of the thumb’s ability to move. As far as thumb joint replacement, many people can have good success. Some people will not have good success.

Research on the thumb osteoarthritis surgery

Orthopedic surgeons in Germany published a  September 2020 study (1) discuss surgical treatment options and their observations on outcomes:

“Resection arthroplasty (a thumb replacement were the thumb bones are repositioned around the prosthetic device with the hope of better function and less pain after surgery) still is the gold standard for the treatment of basal thumb arthritis. In most patients, satisfactory results can be expected. However, the few patients with persisting problems are a challenge for the hand surgeon. They may complain of neuromas, tendinitis of the flexor carpi radialis tendon, impingement and/or proximalization of the first metacarpal, arthritis of the scaphotrapezoidal joint or carpal collapse in the case of pre-existing scapholunate instability.”

The Trapeziometacarpal joint is a tricky joint to repair with surgery. According to surgeons publishing research in the American Journal of hand surgery there is expressed concerns that high failure rates of trapeziometacarpal implants were the result of aseptic loosening, dislocation, and persisting pain.(2) This followed an April 2018 study (3) that also questioned whether thumb joint replacement surgery at the trapeziometacarpal joint provided significant benefits for the patient. In this study, four patients (four women) diagnosed with stage III Trapeziometacarpal  osteoarthritis underwent total thumb replacement surgery. What the surgeons found was the surgery was able to restore some thumb function but did not fully replicate the movements of a healthy trapeziometacarpal joint.

Trapeziectomy concerns

Trapeziectomy is the removal of the trapezium bone at the thumb’s base. The trapezium bone is thought to be the primary pain generator as it may have been misshapen by osteoarthritis. In the surgery, a ligament reconstruction procedure is also performed to help the anatomical thumb function. To someone who uses their hands a lot, as in physically demanding work, the recover time of this procedure is 4 to 6 months. If successful. A study from March 2020 (4) suggests that total joint replacement of the trapeziometacarpal joint provides good restoration of the thumb motion and pain relief in most patients. But there is also a risk of no improvement following the operation.

Non-surgical options PRP injections or cortisone?

Above I presented the studies from the surgeons above the challenges they face providing thumb surgery. In this section I will present the options that include injections treatments.

PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected into the thumb/wrist area to stimulate healing and regeneration. The platelets contain healing and growth factors that can act as injury healers.

A  study in the journal Cartilage (5) offered this comparison between PRP injections and cortisone injections.

To the research – the summary learning points:

  • A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the trapeziometacarpal joint (grades: I-III) was conducted.
  • Group A patients (16 patients) received 2 ultrasound-guided intra-articular-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval.
    • Patients were evaluated prior to and at 3 and 12 months after the second injection.
    • After 12 months’ follow-up, the intra-articular-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of pain relief, better function, and patients’ satisfaction.

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Bone marrow derived Stem Cell Therapy for thumb osteoarthritis

In our experience of over 23 years seeing patients with thumb osteoarthritis we have seen positive results with PRP and with bone marrow derived stem cell. There is research coming suggesting that the positive effects of stem cell therapy studied and documented in the large joints, the hips and knees for example, can be demonstrated in the small joints, those of the thumb for example. This was suggested and shown by research in the journal Plastic and reconstructive surgery. Global open. (6)

Stem cells offered in the thumb region act in the same manner as those injected into the knee. In our observations we have noted:

  • We found that in the short-term, receiving multiple injections into a painful joint is more effective than receiving a single stem cell injection.
  • Functionality score increased after first treatment, illustrating that patients experienced an immediate benefit in performing everyday activities with less difficulty.
  • By the second injection, patients began to report improvement with pain at rest. Patients then experienced additional decreases in resting pain with each treatment thereafter.
  • The increase in mean functionality score with successive stem cell treatments shows that increasing the number of BMC treatments improves patient performance in daily activities.

Independent research: “Many patients showed improved quality of life and pain relief. These injections appear to be an effective means of postponing surgery”

A November 2021 study (7) evaluated the effect of bone marrow aspirate concentrate (BMAC) in the treatment of osteoarthritis of the thumb first carpometacarpal joint. Injections were carried out in 27 thumbs.

According to the Dell classification (a scoring system to determine the severity of the thumb osteoarthritis from Stage I less joint space narrowing to Stage IV severe osteoarthritis), there were:

  • 2 stage I,
  • 11 stage II,
  • 13 stage III
  • and 1 stage IV cases examined.

The bone marrow was aspirated from the iliac crest, concentrated by centrifugation, and injected under fluoroscopic control into the pathological thumb. Results were assessed at a average 16 months’ follow-up.

Clinical evaluation comprised of:

  • QuickDASH (A disability scoring system that ranges from – 0 (no disability) to 100 (complete disability) and PRWE (Patient-Rated Wrist Evaluation – A disability scoring system for the wrist that ranges from – 0 (no disability) to 100 (complete disability) scores, pain at rest on a numerical analog scale (NAS a zero – 10 (worst) scoring system), and thumb column abduction.
    • QuickDASH and PRWE scores were 59 (range, 27-82) and 88 range, 37-125) preoperatively and 29 (range, 0-64) and 50 (range, 1-99) postoperatively, respectively.
    • Mean pain at rest on NAS improved from 7 (range, 1-10) to 4 (range, 0-9).
    • Thumb abduction improved by a mean 18° over preoperative data.
    • No postoperative complications were found.
    • Two patients had to be operated on for inefficacy of injection.

The researchers noted: “This is the first article presenting the effect of an intra-articular injection of bone marrow aspirate concentrate in the thumb first carpometacarpal joint and the results were encouraging. Many patients showed improved quality of life and pain relief. These injections appear to be an effective means of postponing surgery.”

Research summary

PRP and stem cell therapy can help many people. A 2021 paper (8) offers us a summary of the research:

“The intra-articular injection of therapeutic agents is an attractive strategy for the local treatment of Thumb-Base Osteoarthritis. . . However, the current evidence remains equivocal. The main reason behind this is related to the poor methodology of the available scientific studies, which makes the results quite inconclusive. Some data supported the clinical usefulness of intra-articular hyaluronic acid, especially in improving functional capacity and of intra-articular corticosteroids in reducing painful symptomatology; new emerging and encouraging results derived from PRP and mesenchymal-derived stem cell populations, but they are still preliminary. At this regard, we auspicate a growing development of the scientific evidence in the field of regenerative medicine until now poorly explored in Thumb-Base Osteoarthritis. “

Do you have questions? Ask Dr. Darrow

References:
1
Löw S, Kiesel S, Spies CK. Revision surgery after resection arthroplasty of the thumb saddle joint. Der Orthopade. 2020 Sep 1;49(9):762-70.
2 Ganhewa AD, Wu R, Chae MP, Tobin V, Miller GS, Smith JA, Rozen WM, Hunter-Smith DJ. Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review. The Journal of hand surgery. 2019 Jun 28.
3 D’Agostino P, Dourthe B, Kerkhof F, Vereecke EE, Stockmans F. Impact of Osteoarthritis and Total Joint Arthroplasty on the Kinematics of the Trapeziometacarpal Joint: A Pilot Study. The Journal of hand surgery. 2018 Apr 1;43(4):382-e1.
4  Mosegaard SB, Stilling M, Hansen TB. Risk factors for limited improvement after total trapeziometacarpal joint arthroplasty. Health and Quality of Life Outcomes. 2020 Dec;18:1-8.
5 Malahias MA, Roumeliotis L, Nikolaou VS, Chronopoulos E, Sourlas I, Babis GC. Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial. Cartilage. 2018 Oct 20:1947603518805230.
6 Murphy MP, Buckley C, Sugrue C, Carr E, O’Reilly A, O’Neill S, Carroll SM. ASCOT: Autologous Bone Marrow Stem Cell Use for Osteoarthritis of the Thumb-First Carpometacarpal Joint. Plast Reconstr Surg Glob Open. 2017 Sep 19;5(9):e1486. doi: 10.1097/GOX.0000000000001486. PubMed PMID: 29062653; PubMed Central PMCID: PMC5640358.—
7 Daoudi I, Pélissier P, Dargai F, Choughri H, Delgove A. Intra-articular injection of autologous bone marrow aspirate concentrate in the treatment of osteoarthritis of the thumb first carpometacarpal joint: A pilot study. Hand Surgery and Rehabilitation. 2021 Nov 11.
8 Tenti S, Cheleschi S, Mondanelli N, Giannotti S, Fioravanti A. New Trends in Injection-Based Therapy for Thumb-Base Osteoarthritis: Where Are We and where Are We Going?. Frontiers in Pharmacology. 2021 Apr 13;12:498.

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