CMC Arthroplasty Right Thumb

[jd101861]

Dr. Tomaino, I had a CMC arthroplasty on my right thumb in July 2008. The trapezium bone was removed and a portion of one of my tendons was used in the repair. Since then, the half of the tendon that remained ruptured. In the last two years since the surgery I have suffered pain and weakness. I have had injections, extensive OT with lots of braces, to no avail. I currently have a custom-made brace that works well, but I don't want to have to wear this forever. I need the brace to function, though. Since the 2008 surgery, I was diagnosed with lupus. I had to have the same surgery done on my left thumb in 2002, but in that surgery the trapezium was not excised. I have had good luck with this surgery. Different doctors performed the surgery while I was living in Ohio.

I have consulted two terrific doctors in Michigan and their opinions are different about how to effect the repair. I cannot do the descriptions of what they are proposing justice, but in a nutshell: One doctor wants to pin my thumb on a trial basis, see how it goes, then do a permanent repair. This doctor does not want to use my soft tissue in the repair because of my lupus (previous tendon rupture). The other doctor wants to fuse the joint but has no problem using my soft tissue in the repair. I am hoping you can add your expertise in deciding how best to repair my thumb. Thank you for your help. Jan

[mtomaino]

Hi Jan
I received single xray views of your thumbs from your doctor. I have attached them to this post. Firstly, your left thumb was treated with a ligament reconstruction with retention of the trapezium---probably because your arthritis on that side was mild. This surgery provides improved stability, and was popularized by Dr Richard Eaton of New York City.

On your right side, I think you probably had half of the FCR tendon used to suspend the thumb--and the other half ruptured. Your xrays show a reasonably well maintained arthroplasty space, however, you may have residual bony impingement with the base of the index metacarpal. In addition, there may be residual arthritis between the scaphoid and the trapezoid--it's hard to say based on the xray alone---so that interval needs to be assessed if you have additional surgery.

Assuming that your metacarpophalangeal joint (the next joint towards the tip of the thumb) does not hyperextend when you pinch, I would not recommend any type of fusion. I would certainly not recommend a fusion at the base of the thumb. You will not like the lack of motion, and it will be very difficult to attain a fusion, as well.

If you are still having disabling pain and feel as though you would be willing to have another operation, I would likely do the following, recognising that this is based soley on looking at your xray and having seen similar patients in the past:

1. I would assess the scaphotrapezoidal joint, and if arthritis is present I would perform a partial trapezoid excision.
2. I would remove a bit more of the metacarpal bone at the base to address the persistent bony impingement.
3. I would reconstruct a suspensory ligament to stabilize the thumb, and would use either a technique that utilizes high grade suture, or a piece of your wrist extensor tendon, as described by Dr Uriburu from Argentina. In addition I would pin the joint for 4 weeks.
4. I would immobilize your wrist and thumb for 4 weeks, and then you would wear a splint for another month or so.

In terms of your expectations----based on my experience with revision surgery for your problem, it is possible that you may get pain relief, but unpredictable that you may have significant improvement in strength. And, it may take several months before you are happy. That having been said, it may still be worthwhile in the long run.
Matt

[jd101861]

Dr. Tomaino:

Many, many thanks to you for reviewing my case. I will share this information with my doctor and discuss a plan.

Regards,
Jan