Most of the people that contact our office looking for treatment for their thumb pain have already had a long history of treatments with limited success. In fact, many will confess that their doctors are now recommending pain management (anti-inflammatories and painkillers) as their primary treatments now that splints, physical therapy, and a generous amount of ice are no longer helping. These people will receive pain management until the decision is made to go to surgery or “live with it.” For many, the benchmark of when to proceed to surgery is when cortisone injections fail to offer relief and is in fact giving the person more pain.

So what do we do for these bone on bone thumb people who have basically lost the use of the hands because they have no grip strength and are being pain managed? We offer a physical examination, and assessment of their pain and functional challenges, and when appropriate a recommendation for stem cell therapy into the thumb joint.

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Can stem cell therapy help avoid surgery?

Surgery should always be considered the last option. For some people, damage in the joint is so severe and significant that surgery may be the only way. For many others, surgery can realistically be avoided and the thumb joint rebuilt with regenerative medicine injections.

Why should you avoid surgery? Let’s let the surgeons tell us.

Concerns surrounding trapeziometacarpal surgery.

Trapeziometacarpal joint osteoarthritis or rhizarthrosis is degeneration at the trapezium bone at the wrist and the first metacarpal bone of the thumb. The Trapeziometacarpal joint is a tricky joint to repair with surgery. This according to surgeons publishing research in the American Journal of hand surgery (June 2019). The surgeons expressed concerns that failure rates of trapeziometacarpal implants were considered high because of aseptic loosening, dislocation, and persisting pain.(1) This followed an April 2018 study (2) that also questioned whether thumb joint replacement surgery at the trapeziometacarpal joint provided significant benefits for the patient.

A brief look at this study reveals that doctors looked at four women diagnosed with stage III osteoarthritis at the Trapeziometacarpal who underwent total joint 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.

The irony is is that people have this surgery because they have limited range of motion and functionality of the thumb. Many came out of the surgery the same way. Now the goal of surgery differs for many patients. For some, it is pain relief, but for many it is a return to normal thumb motion so that they can return to work or increase the quality of life in retirement. Pain relief while a successful benefit of surgery, is not for many, the goal of restoring functionality to their thumb. Pain relief and restoration of movement is.

Trapeziectomy concerns

Trapeziectomy is the removal of the trapezium bone at the thumb’s base. Why remove a bone, even a small one? Because the bone is thought to be the primary cause of pain as it has become misshapen by osteoarthritis. In the trapeziectomy with LRTI surgery, a ligament reconstruction procedure is also performed to help the thumb function better anatomically. 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.

Why say, if successful? A study in the medical journal Hand.(3)

Here we have a study from doctors at the University of Massachusetts Medical School. In this study the patient charts of 179 patients who had a thumb surgery were examined. Noted is that 21 patients had both thumbs undergo surgery.

The patients in this study had:

• simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization, or a Weilby procedure. (Tendon reconstruction replaces the void left by the bone removal).
• The average follow-up was 11.6 months
• Seventy hands had a postoperative complication. (That is 70 out of 200 or 35%).
• Ten of these complications were considered major, defined as requiring antibiotics, reoperation, or other aggressive interventions. (That is 5% of all patients).

CONCLUSIONS: Patients undergoing trapeziectomy with LRTI or Weilby had a greater incidence of reported complications when compared with trapeziectomy alone. These results suggest an advantage of simple trapeziectomy.

Why is there a risk that total joint replacement of the Trapeziometacarpal will not reduce pain?

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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. The purpose of this study was to identify patients at risk of no clinically important improvement following operative treatment of osteoarthritis of the TMC joint.

• The researchers included 287 consecutive patients (225 women, 62 men) treated with total joint replacement of the trapeziometacarpal joint due to osteoarthritis with an average age of 58.9 years (range 41-80) in a prospective cohort study.
• Looking for who would have the greatest risk for no improvement following the surgery, the researchers found there was an increased risk of no clinically important improvement in hand function for patients with high preoperative grip strength. Also, we found an increased risk of no clinically important improvement in female patients.

But I am young, I need the surgery to get back to work or sport activities

Above we spoke about the realistic 3 – 6 month recovery time that will include splints, medications, therapies. Some doctors believe that the surgical repair of Trapeziometacarpal osteoarthritis is too aggressively recommended and this can lead to unwanted complication.

A study in the journal Hand Surgery and Rehabilitation, (5) they suggests:

“The demand for surgical treatment is growing and the patients are becoming younger, adding to the challenge. Surgery can only be proposed after failure of well-conducted conservative treatment and requires a complete X-ray assessment. . . The ideal arthroplasty (joint replacement) technique has yet to be defined but nevertheless, the chosen technique must be well-suited to the patient’s condition. Although many studies have been published on this topic, they do not help us define the treatment indications.

Prospective studies focusing on the patient rather than evaluating a certain surgical technique are needed. Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications. Arthrodesis, interposition or arthroplasty are also viable therapeutic options. The patient must be sufficiently informed to be able to contribute to choosing the indication.”

PRP injection can help rebuild the thumb joint. A comparison of PRP to 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 Platelet Rich Plasma injections and stem cell therapy injections.

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. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.

A 2018 study in the journal Cartilage (6) offered this comparison between PRP injections and cortisone injections. Before I start with this study I would like to point out that many people reach out to me and tell me how painful the actual cortisone injection was for them. The problem is the size of the needle and the size of the joint space. When we inject into this area we typically use a freeze spray and very fine needles. This provides the patient with a lot of comfort during the procedure. Also we do not offer a single injection of PRP. We inject into various areas of the wrist and thumb area to maximize the healing effect of the PRP injection.

To the research – the summary learning points:

• Various systematic reviews have recently shown that intra-articular platelet-rich plasma can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb.
• 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 IA-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 IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of pain relief, better function, and patients’ satisfaction.

A study published in January 2021 compared PRP to cortisone in patients with trapeziometacarpal joint arthritis

A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III) was conducted.(7)

• 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 using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient’s subjective satisfaction.
• After 12 months’ follow-up, the intra-articular PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score, Q-DASH score , and patients’ satisfaction. Corticosteroids offer short-term relief of symptoms, but intra-articular PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic trapeziometacarpal joint arthritis.

Doctors at the University of Malaga in Spain presented this case study of a concert pianist helped by PRP

This case review (8) was published in October 2019:

“Thumb carpometacarpal osteoarthritis is a progressively disabling, debilitating condition presenting with thumb base pain and hand functional impairment. Platelet-rich plasma has been used widely for the management of musculoskeletal pathologies, osteoarthritis being among them.

• A 59-year-old male professional pianist presented with chronic, mild onset of right thumb base pain involving a progressive lack of pinch strength in his right hand, and severe difficulties with playing.
• Three PRP injections were administered to the Thumb carpometacarpal joint on a 1-week interval regime.
• Clinical outcomes were assessed by using standard scoring scales including those for pain, grip and pinch strength
• Functional outcome was excellent according to patient’s capability with daily living activities and specific playing demands.
• At 12 months follow-up, no recurrences or complications were identified, with the musician returning to his previous level of performance 2 weeks before the end of this period.

“Patient self-reported satisfaction was high and he reported to return to his routine piano activity with no limitations. This case-based review study documents the clinical efficacy of PRP treatment from both functional and perceived-pain perspectives in a professional pianist. Presenting this case, our aim is to draw attention of healthcare providers dealing with Thumb carpometacarpal osteoarthritis to PRP as a safe, beneficial therapy for this condition which needs further assessment in randomized controlled trials.”

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. (9)

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.

Do you have questions? Ask Dr. Darrow

 

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

References:
1 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.
2 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.
3 Brandt KD, Radin P, Dieppe P, Putte L. Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis. 2006;65(10):1261-1264.
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 Gay AM, Cerlier A, Iniesta A, Legré R. Surgery for trapeziometacarpal osteoarthritis. Hand Surgery and Rehabilitation. 2016 Sep 30;35(4):238-49.
6 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.
7 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.
8 Medina-Porqueres I, Martin-Garcia P, Sanz-De Diego S, Reyes-Eldblom M, Cantero-Tellez R. Platelet-rich plasma for thumb carpometacarpal joint osteoarthritis in a professional pianist: case-based review. Rheumatology international. 2019 Oct 14:1-9.
9 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.

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