Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Basal Thumb Arthritis

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Basal Thumb Arthritis · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Welcome to the Deep Dive, the show where we really
0:02
try to get to grips with complex medical topics,
0:04
giving you the essential insights while the things
0:06
you need to be truly well informed in your practice.
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Today, we're focusing on a joint that, despite
0:11
its small size, is just absolutely fundamental
0:13
to almost every single thing our patients do
0:15
daily. You know, from intricate surgical tasks
0:17
right down to simply holding a pen. We're talking,
0:20
of course, about the thumb. And when its foundational
0:22
joint, the one right at its very base, is compromised,
0:25
the impact on daily life, and indeed professional
0:27
function, can be profound. profoundly debilitating.
0:31
So this deep dive is dedicated to basal thumb
0:33
arthritis, also widely known, of course, as trapezium
0:36
metacarpal, or sometimes carpal metacarpal joint
0:39
arthritis of the thumb. It's a condition we encounter
0:41
with, well, remarkable frequency in hand clinics
0:44
all across the United Kingdom, presenting a unique
0:46
set of diagnostic and treatment challenges for
0:48
us as clinicians. Our mission today is to explore
0:51
this condition comprehensively. We'll unpack
0:53
its intricate anatomical and physiological mechanisms,
0:57
delve into the various diagnostic approaches
0:59
that guide our clinical decisions, examine the
1:01
current evidence -based treatment paradigms,
1:04
both conservative and surgical, and, crucially,
1:07
shine a much -needed light on the often overlooked
1:10
aspects of patient recovery and their holistic
1:12
well -being. To guide us through this detailed
1:14
discussion, we're incredibly fortunate to have
1:16
an insightful authority in orthopedics and hand
1:18
surgery joining us today. It's a real pleasure
1:20
to be here. This is an incredibly important area
1:23
within hand surgery, one that impacts a significant
1:26
number of our patients quite directly, often
1:28
limiting their ability to work and, you know,
1:31
engage in daily life. So I'm keen to delve into
1:35
the nuances of how we can best support them.
1:37
Thank you for joining us. Let's begin right at
1:39
the start then. When we refer to arthritis, particularly
1:42
in the context of the thumb, how do we precisely
1:45
define this condition and what are the key terms
1:47
that, as medical professionals, we should be
1:49
most familiar with? Right. Well, what's essential
1:51
to understand from the outset is that arthritis,
1:54
at its very core, signifies irritation or, more
1:58
fundamentally, the progressive destruction of
2:00
a joint. This process primarily involves the
2:02
wearing out of the protective articular cartilage
2:05
surface, that smooth layer that normally cushions
2:08
the ends of bones, allowing them to glide smoothly
2:10
against each other. Now in the thumb, the most
2:14
frequent and clinically significant Cypher arthritis
2:16
development is precisely at its base. what we
2:19
refer to as the basal joint, or more technically,
2:22
the thumb carpalmedic -coulmedic carpal joint,
2:25
often abbreviated just to CMC joint. This joint
2:28
is truly the workhorse of the thumb. The CMC
2:30
joint, right. And when we diagnose arthritis
2:32
predominantly affecting this basal joint, we're
2:34
almost invariably referring to osteoarthritis.
2:37
This is synonymous with what's commonly termed
2:39
degenerative arthritis, or perhaps more colloquially,
2:42
wear and tear arthritis. Okay, so degenerative,
2:45
not inflammatory primarily. Exactly. That distinction
2:48
is crucial because it immediately informs our
2:51
understanding of the underlying pathological
2:53
process. It's primarily a mechanical breakdown,
2:57
not an inflammatory process like, say, rheumatoid
2:59
arthritis. In clinical practice, you'll encounter
3:02
several interchangeable terms for this condition,
3:05
and it's helpful to be familiar with them all
3:07
for clear communication. We might hear it called
3:09
Basal or Thumb OA. Thumb carpel metacarpal joint
3:13
OA or CMCJ OA, Thumb trapezium metacarpal joint
3:17
OA or TMCJ OA, or even saddle joint OA, given
3:21
the unique shape of the joint itself. Saddle
3:23
joint, yes. The key insight here is that regardless
3:25
of the specific term used, we're almost always
3:28
dealing with the same fundamental degenerative
3:30
process in this really critical joint. That distinction
3:33
between degenerative and inflammatory arthritis
3:35
is certainly a foundational point. Given it's
3:38
essentially a wear and tear issue, let's explore
3:40
the anatomy a bit more. The thumb -CMC joint
3:42
is often described as a universal joint, what
3:44
makes its architecture so special and perhaps
3:47
paradoxically so vulnerable to these degenerative
3:49
changes. It truly is a remarkable feat of natural
3:53
engineering, actually. The thumb -CMC joint is
3:55
classified as a unique biconcave saddle joint.
3:59
You can sort of imagine two saddles perfectly
4:01
fitted together, allowing movement in multiple
4:03
planes. It's formed by the trapezium bone of
4:05
the wrist and the first metacarpal bone of the
4:08
thumb. This unique architecture is specifically
4:10
designed to facilitate an incredibly wide range
4:13
of movements, swiveling, pivoting, and crucially,
4:17
opposition that unique human ability to bring
4:19
your thumb across your palm to meet your other
4:21
fingers. Which is vital for grip. Absolutely.
4:25
These movements are indispensable for things
4:27
like fine -gripping, grasping, and the precise
4:29
manipulation of objects, which are fundamental
4:31
to nearly every daily activity, from, you know,
4:34
buttoning a shirt to performing intricate surgical
4:37
maneuvers. Normally, the ends of these bones
4:39
are covered by smooth, articular cartilage. This
4:43
cartilage acts like a lubricated, low -friction
4:45
surface, enabling effortless gliding and a wide,
4:49
pain -free range of motion. However, and this
4:52
is the crux of it, this extensive mobility comes
4:54
at a significant biomechanical cost. The CMC
4:58
joint endures substantial stresses. Consider
5:00
this. The reactive force across the CMC joint
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can be up to 13 times the applied pitch force.
5:06
13 times! That's astonishing! It is. To put that
5:09
into perspective, imagine the equivalent of pressing
5:11
down with a small weight, maybe 10 -15 kilos,
5:14
on a joint that's only a few square centimeters
5:16
in size, every single time you pinch something
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forcefully. This astonishing repeatedly applied
5:21
load over many years provides a very clear and
5:23
compelling rationale for its inherent susceptibility
5:25
to degenerative changes. It's hardly surprising
5:28
it wears out, really. That 13 -time statistic
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certainly clarifies the immense stress on such
5:34
a small area. It makes perfect sense, then, why
5:37
it's so prone to wear. But beyond just the forces,
5:40
what about the inherent stability of the joint?
5:42
Are there specific structures designed to hold
5:44
it all together, and how do their roles factor
5:47
into this vulnerability and the progression of
5:49
the disease? Yes. Joint stability is absolutely
5:52
paramount for such a mobile joint, and it relies
5:54
heavily on its sophisticated ligamentous support
5:57
system. The most critical stabilizing ligaments
5:59
are the anterior oblique, often referred to as
6:02
the volar beak ligament, and the dorsal radial
6:04
ligaments. The volar beak ligament is widely
6:07
considered the primary static restraint against
6:09
subluxation, meaning it's the main structure
6:12
preventing the metacarpal from slipping forward,
6:14
sort of volar words, and out of place from the
6:16
trapezium. Okay, the volar beak ligament. And
6:19
the dorsal radial ligament, on the other hand,
6:21
is generally regarded as the strongest and thickest
6:24
primary restraint against dorsal dislocation,
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preventing the thumb from dislocating backwards.
6:29
We also have the inner metacarpal ligament, which
6:31
plays a vital role in resisting radial translation,
6:35
or the thumb moving sideways, radially. These
6:38
ligaments are truly the unsung heroes of thumb
6:40
stability, working constantly to keep that saddle
6:42
joint congruent, nice and lined. However, with
6:45
the high forces, the repetitive motion, and sometimes
6:48
the natural laxity that develops with age, or
6:51
perhaps genetic predisposition, these ligaments
6:53
can stretch, weaken, or even, in some cases,
6:56
rupture. Right. If we connect this to the bigger
6:58
picture, any attenuation or injury to these crucial
7:01
structures immediately compromises the joint's
7:04
intrinsic stability, initiating that cascade
7:06
of degeneration that we talked about. Once that
7:09
crucial ligamentous belt, as it were, loosens,
7:12
the bones are no longer held tightly in their
7:13
optimal position, setting the stage for the cartilage
7:16
damage. So the ligaments, despite their foundational
7:19
role, can indeed be a vulnerable link over time.
7:22
Let's really delve into that cascade, then. How
7:25
does this degeneration actually progress step
7:28
by step from a relatively stable joint to one
7:31
that's causing significant pain and eventually
7:33
visible deformity for the patient. Yes, the pathophysiology
7:36
of basal thumb arthritis truly outlines a sort
7:39
of vicious cycle of degeneration. It often starts
7:42
quite subtly and progresses relentlessly if it's
7:44
unchecked. The initial domino to fall is often
7:47
the weakening or even rupture of the volar oblique
7:50
ligament, that critical anterior oblique ligament
7:52
we just discussed. As individuals age, or sometimes
7:55
due to specific micro traumas from repetitive
7:57
activities, this ligament, so vital for CMC joint
8:00
stability, can lose its integrity. Okay, so ligament
8:03
laxity is the starting point. It's often the
8:05
crucial turning point, yes. This ligamentous
8:08
compromise leads directly to a loss of joint
8:11
congruency. Put simply, the bones no longer fit
8:15
together perfectly like they once did. The first
8:17
metacarpal bone then begins to misalign, or sublux,
8:21
relative to the trapezium. You could perhaps
8:23
imagine a tent pole that's no longer sitting
8:25
squarely on its base. The load isn't distributed
8:28
evenly anymore. This misalignment initiates a
8:31
rapid and destructive cycle of cartilage degradation.
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The cartilage, no longer subjected to perfectly
8:36
distributed loads, begins to thin and erode unevenly,
8:40
much like a car tire wearing out faster on one
8:42
side if the alignment is off. That makes sense.
8:45
As this protective cartilage diminishes, you
8:47
get direct bone -on -bone contact during movement.
8:50
This contact is precisely what causes the deep
8:52
aching pain and grinding friction that patients
8:54
so often describe. Over time, this constant bone
8:57
-on -bone rubbing stimulates the body to try
8:59
and stabilize the joint, leading to the formation
9:02
of osteophytes' bony projections along the joint
9:04
margins. Those bony spurs. Exactly. These osteophytes
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are the body's sort of desperate attempt to add
9:11
stability, but they often contribute to further
9:13
stiffness, pain, and restricted motion, creating
9:16
a painful feedback loop. And this leads to visible
9:19
changes. Yes. Clinically, this degenerative process
9:23
can manifest as visible and often distressing
9:26
deformities. Early on, you might observe a characteristic
9:29
flexed posture of the thumb with a noticeable
9:32
fullness at its base due to the bony changes
9:35
and the subluxation. In more advanced cases,
9:37
this can progress to what's known as a zigzag
9:39
or swan neck deformity. This involves a progressive
9:42
adduction, or drawing inwards towards the palm
9:45
of the first metacarpal bone, coupled with a
9:47
compensatory hyperextension of the metacarpoflangeal,
9:50
or MCP. Joint the middle joint of the thumb.
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Ah, the zigzag shape. That classic deformity
9:55
is a clear, visible sign of significant disease
9:58
progression and chronic instability, making everyday
10:01
tasks even more challenging for the patient.
10:03
That's a very clear step -by -step picture of
10:06
how the joint deteriorates. Given that progression,
10:09
who is most susceptible to developing basal thumb
10:11
arthritis? Are there specific demographics, genetic
10:14
predispositions, or lifestyle factors that, as
10:17
clinicians, we should be particularly aware of
10:19
when assessing our patients? This is a critical
10:21
area for us to understand, both for patient counseling
10:24
and for early identification. Basal thumb arthritis
10:27
is an incredibly common hand arthritis. Indeed,
10:30
second only to distal interphalangeal, or DIP,
10:33
arthritis and prevalence. The pattern we typically
10:35
observe in hand osteoarthritis is that the DIP
10:38
joints are most frequently affected, followed
10:40
by the thumb CMC joint, then the proximal interphalangeal
10:43
PP joints, and finally the metacarpal phalangeal
10:45
MCP joints. So thumb CMC is number two. DIP,
10:48
then CMC, then PIP, then MCP. Yeah. Got it. Precisely.
10:53
Radiographic evidence is quite widespread. Studies
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show it's present in approximately 25 % of women
10:58
over 55 and a striking 40 % of women over 75.
11:03
However, and this is a vital clinical point,
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many individuals with radiographic changes may
11:08
accommodate these symptoms without ever seeking
11:10
medical treatment. So the true symptomatic prevalence
11:13
we see in clinic is often lower than what the
11:15
x -rays might suggest. So radiographic findings
11:18
don't always equal symptoms. Exactly. That disconnect
11:21
is really important. Interestingly, it's also
11:23
more common in Caucasian populations compared
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to other ethnic groups when we look at hand osteoarthritis
11:28
generally. Demographically, there's a significantly
11:30
higher incidence in women compared to men, often
11:33
with a female to male ratio as high as 6 .1 being
11:36
reported. 6 to 1, wow. Yes, it's quite striking.
11:39
It typically emerges after 40 or 50 years of
11:41
age, with a particular predisposition in post
11:44
-menopausal women. This leads directly to the
11:47
strong genetic and hormonal influences at play.
11:50
There seems to be a clear genetic predisposition,
11:53
indicating a familial tendency if your mother
11:55
or grandmother had it, you might be at higher
11:57
risk yourself. Furthermore, the decline in protective
12:00
estrogen levels during menopause seems to play
12:02
a significant role in increasing vulnerability.
12:04
The oestrogen link again. Indeed. Oestrogen is
12:07
thought to have a protective effect on cartilage
12:09
and perhaps joint stability, and its reduction
12:12
seems to remove this buffer, accounting for the
12:15
notably higher incidence in postmenopausal women.
12:18
Traumatic antecedents are also notable predisposing
12:20
factors. Previous injuries or trauma to the thumb.
12:24
such as Rolando or Bennett fractures. These are
12:26
specific fractures involving the articular base
12:29
of the metacarpal can significantly increase
12:31
risk if they heal in a malunited position, disrupting
12:34
the joint's delicate mechanics. So previous injury
12:37
is a big one. It certainly can be. Joint hypermobility
12:40
is another consideration. Excessive basal joint
12:43
laxity or generalized joint hypermobility, often
12:46
more prevalent in younger women, could theoretically
12:48
predispose individuals to premature degenerative
12:51
changes due to repeated loading of sublux joints.
12:55
While this theory has been discussed, for instance
12:57
in the context of conditions like Ehlers -Danlos
12:59
syndrome, direct experimental evidence definitively
13:02
linking generalized hypermobility directly to
13:04
basal thumb osteoarthritis is still perhaps a
13:06
subject of some debate in the literature. It's
13:09
plausible, but not fully proven. Okay, so hypermobility
13:12
is a maybe. What about work and lifestyle? Occupational
13:15
and lifestyle contributions certainly shouldn't
13:17
be overlooked. For patients engaged in manual
13:20
labor, certain crafts, or even extensive use
13:22
of hand tools, activities involving repetitive
13:25
gripping and pinching motions place additional
13:28
sustained stress on the joint. Obesity is another
13:31
lifestyle factor that can exacerbate joint stress,
13:34
potentially through systemic inflammation and
13:37
certainly through increased mechanical load on
13:38
weight -bearing joints, though its direct impact
13:40
on hand joints is perhaps less clear, but still
13:43
considered a factor. Lastly, we must consider
13:46
associated systemic conditions. Inflammatory
13:49
arthritides, such as rheumatoid arthritis, can
13:52
involve the basal joint. Approximately one -third
13:55
of affected rheumatoid arthritis patients may
13:57
experience basal joint involvement. Despite all
14:00
these identifiable risk factors, it's important
14:02
for us to remember that the most common cause
14:04
of symptomatic basal joint arthritis remains
14:06
idiopathic, arising from a complex, often unseen
14:09
interplay of these various elements. That's a
14:12
truly comprehensive overview of the risk factors,
14:14
highlighting the multifactorial nature of this
14:17
condition. Now let's turn to how patients typically
14:20
present in our clinics. What are the cardinal
14:22
symptoms that should immediately raise our clinical
14:24
suspicion and what kind of story does the patient
14:26
usually tell us? The patient's story is often
14:29
remarkably consistent and understanding it is,
14:32
well, half the diagnosis, isn't it? The cardinal
14:35
and most common presenting symptom is pain localized
14:37
directly to the base of the thumb. This pain
14:40
frequently radiates to the Theonar eminence,
14:43
that fleshy part of the palm at the base of the
14:45
thumb, and sometimes even up towards the metacarpoflangel
14:48
or MCP joint, the large knuckle of the thumb.
14:52
Okay, pain at the base, radiating outwards. Yes.
14:55
It was particularly telling is how activity -related
14:57
the pain typically is. It's almost always exacerbated
15:01
by activities requiring fine or forceful grip
15:03
and pinch. Think about the everyday tasks that
15:06
patients often complain about. Turning a key,
15:08
struggling to open jars, unscrewing bottle tops,
15:11
writing for extended periods, or even trying
15:13
to snap their fingers. These seemingly simple
15:16
actions become incredibly painful. Those specific
15:19
activities are key clues. Absolutely. And as
15:22
the condition progresses, this intermittent activity
15:25
-related pain can unfortunately become constant,
15:28
significantly impacting their quality of life
15:30
and independence. Beyond pain, other key manifestations
15:34
include noticeable swelling and tenderness directly
15:37
at the base of the thumb. Patients often report
15:40
an aching discomfort after prolonged use of the
15:43
thumb, a feeling of fatigue in the hand, and
15:45
a marked reduction in grip strength becomes evident,
15:48
directly impacting their functional capabilities.
15:51
Weakness is a big complaint to them. Yes, weakness
15:53
and pain often go hand in hand. In more advanced
15:56
cases, we start to see more pronounced signs
15:58
on inspection. There might be an enlarged, almost
16:01
out of joint appearance, or a distinct dorsal
16:03
radial prominence, a noticeable bump at the base
16:06
of the thumb. A bony prominence or bump directly
16:09
over the basal joint is also very common. Patients
16:12
will also report limited thumb motion and, quite
16:14
tellingly, crepitus, that gritty, crackling or
16:17
grinding sound or sensation during joint movement.
16:20
Crepitus, that crunching sound. That's the one.
16:23
It strongly implies significant cartilage erosion
16:25
and bone -on -bone friction. All of these symptoms,
16:29
of course, converge to cause significant functional
16:32
impairment, making it difficult for patients
16:34
to perform daily tasks, impacting fine motor
16:37
skills, and sometimes leading to an inability
16:40
to effectively abduct the thumb, meaning they
16:42
struggle to move it away from the palm, limiting
16:45
their ability to grasp larger objects. That paints
16:48
a very clear clinical picture for us. Once we
16:51
have that crucial patient history, What are the
16:53
next crucial steps in the clinical examination
16:55
to confirm the diagnosis and uncover the underlying
16:59
signs that will inform our management? Right.
17:01
A comprehensive clinical examination is where
17:03
we truly bring the history to life. It's vital
17:06
to begin with a detailed history, specifically
17:08
inquiring not just about symptom patterns, but
17:11
any prior hand or thumb injuries and precisely
17:13
which activities aggravate their condition. What's
17:16
often overlooked, but incredibly important, is
17:18
the high prevalence of concomitant conditions
17:20
that frequently accompany basal thumb arthritis.
17:23
We know that up to 50 % of patients with basal
17:25
thumb arthritis can also have carpal tumble syndrome.
17:28
50%, wow. Yes. So we must ask about tingling,
17:32
numbness, or night pain. We also frequently encounter
17:35
scaphotropiesial arthrosis, trigger digits, metacarpal
17:38
phalangeal, MCP, hyperextension, and tenosynovitis
17:42
of the wrist, like decervains. Therefore, it's
17:45
crucial to proactively inquire about and assess
17:48
for these conditions during our comprehensive
17:50
examination to ensure we develop a truly holistic
17:53
and tailored management plan. So check for carpal
17:55
tunnel, decor vanes, trigger finger. Exactly.
17:59
Missing these coexisting issues could lead to
18:01
suboptimal outcomes for our patients. During
18:04
inspection, especially in more advanced cases,
18:06
you'll often observe visible signs such as bony
18:08
swelling or that dorsaradial prominence of the
18:11
thumb metacarpal base. Palpation is key. You'll
18:14
find characteristic localized tenderness directly
18:16
over the thumb carpometacarpal CMC joint. And
18:19
as we discussed earlier, the presence of crepitus
18:20
during the examination that gritty or crackling
18:22
sensation strongly implies significant erosion
18:25
of the articular cartilage. And the specific
18:27
tests. We then move to provocative maneuvers,
18:30
which are invaluable for eliciting specific responses.
18:33
The CMC grind test is a classic and highly informative.
18:37
This is performed by applying axial compression
18:39
through the thumb and simultaneously rotating
18:42
or circumducting the thumb metacarpal base. Grinding
18:44
the joint, essentially. In effect, yes. A positive
18:48
test indicated by the reproduction of pain or
18:50
distinct crunching sensation is highly suggestive
18:54
of underlying degenerative disease in cartilage
18:56
wear. Another useful test is the distraction
18:59
or torque test where you apply gentle axial traction
19:02
while rotating the thumb at a carpal base. A
19:06
positive result here often indicates synovitis
19:08
which is inflammation of the joint lining and
19:10
is more typically associated with milder disease
19:13
stages where inflammation rather than just bone
19:15
-on -bone rubbing might be a prominent feature.
19:18
So grind test for where? Distraction test for
19:20
synovitis. Broadly speaking, yes, though for
19:23
our medical audience, it's worth noting that
19:25
while valuable, these provocative tests are perhaps
19:27
more commonly utilized and refined in specialist
19:30
hand surgery settings, where a precise diagnosis
19:32
is paramount for surgical planning. Okay, that
19:35
makes sense. So we've gathered the patient history,
19:37
performed a thorough clinical exam, including
19:39
looking for those associated conditions, and
19:41
now we need to see what's happening beneath the
19:43
surface to confirm our suspicions and precisely
19:46
stage the disease. What role do imaging studies
19:49
play and how do we use them to categorize the
19:52
severity of the condition? Right. Imaging, particularly
19:55
radiographs, are absolutely fundamental. They
19:58
are essential not just for confirming our clinical
20:00
diagnosis, but crucially for assessing the severity
20:02
of the disease and ruling out other osseous abnormalities
20:06
that might mimic the condition. For standard
20:08
views, we always obtain AP and lateral projections
20:11
of the hand. However, the Roberts view is particularly
20:14
important and really a cornerstone for diagnosing
20:17
basal thumb arthritis. The Roberts view? Okay,
20:20
how is that done? It's a postural anterior view
20:23
of both thumb trapezium metacarpal joints taken
20:26
with the thumb flat on the cassette and hyperpronated.
20:29
This specific positioning provides the best visualization
20:32
of the joint surfaces and any abnormal changes.
20:36
A lateral wrist view can also be immensely useful
20:38
to assess overall alignment and any coexisting
20:42
ligament attenuation in the wider wrist complex.
20:45
And what are we looking for on these x -rays?
20:47
We look for key findings that signify degenerative
20:49
changes. Firstly, Joint space narrowing, which
20:52
directly indicates cartilage loss. Secondly,
20:54
subchondral sclerosis, which is a hardening and
20:56
increased density of the bone directly beneath
20:58
the cartilage, indicating increased stress. And
21:01
thirdly, the formation of osteophytes, those
21:03
extra bony projections along the joint margins,
21:06
which are the body's attempt at stabilization.
21:08
Narrowing sclerosis osteophytes, the classic
21:11
OA signs. Precisely. To systematically assess
21:15
the disease severity and guide our treatment
21:17
decisions, we commonly use the Eaton and Glickle
21:20
classification system. This widely accepted system
21:23
stages pathological changes in the basal joint
21:26
based purely on radiographic appearance, and
21:28
it's crucial for both preoperative planning and
21:31
for effectively educating our patients about
21:32
their condition. Can you briefly outline those
21:34
stages for us? Certainly. Stage 1. Characterized
21:38
by normal trapezium metacarpal joint contours,
21:41
but... perhaps some widening, maybe with less
21:42
than one -third joint subluxation seen on stress
21:45
views. This is considered a pre -arthritis state,
21:48
often with instability but minimal actual cartilage
21:50
damage yet. Stage two, here we see slight TM
21:53
joint narrowing with chlorosis and osteophytes,
21:56
or maybe loose bodies less than two millimeters.
21:59
Instability may also be apparent on stress views,
22:01
with equal to or greater than one -third joint
22:03
subluxation. This indicates early but definite
22:06
degenerative changes. Stage three. shows marked
22:09
TM joint narrowing, prominent subchondral sclerosis,
22:13
and osteophytes or loose bodies greater than
22:15
two millimeters. Significant subluxation equal
22:17
to or greater than one -third typically persists.
22:20
This is clear advanced arthritis of the CMC joint
22:22
itself. Stage 4 represents the most advanced
22:25
disease affecting not only the TM joint, but
22:27
also the scaphedrapezoid STT joint, the joint
22:30
between the scaphoid and trapezium bones. This
22:32
is termed pantrapezoid arthritis involving the
22:34
entire trapezoid complex. Pantrapezoid. So stage
22:37
4 involves the neighboring joint too. Exactly.
22:40
While x -rays are generally the primary imaging
22:42
modality, CT scans may occasionally be used for
22:45
a more detailed view of bone structures, especially
22:48
for complex surgical planning. where precise
22:50
bone anatomy is required. However, it's important
22:54
to remember that magnetic resonance imaging,
22:56
MRI, tomography, or ultrasonography, are generally
22:59
not indicated for routine evaluation of basal
23:02
joint disease. X -rays usually provide sufficient
23:05
information for diagnosis and staging. Good to
23:08
know MRI isn't typically needed here. Yes, and
23:11
a crucial clinical point to reiterate, one that
23:13
often surprises patients, is that there is frequently
23:15
a poor correlation between the radiographic severity
23:18
of degenerative disease and the patient's clinical
23:21
symptomatology. Yes, you mentioned this disconnect.
23:23
Indeed. You might find patients with minimal
23:25
joint space narrowing and experiencing disabling
23:28
pain, while conversely, some asymptomatic patients
23:31
may incidentally present with stage 5 -E disease
23:33
on radiographs. It really underscores that we
23:36
treat the patient, not just the picture. That's
23:38
a vital reminder that the imaging doesn't always
23:40
tell the whole story when it comes to patient
23:42
experience, and our clinical assessment remains
23:45
paramount. Before we delve into treatment strategies,
23:49
what other conditions might present similarly
23:51
to basal thumb arthritis, potentially confusing
23:54
the diagnosis, and how do we accurately differentiate
23:57
them? Distinguishing basal thumb arthritis from
24:00
conditions that mimic its symptoms is absolutely
24:02
essential for accurate diagnosis and, critically,
24:06
for ensuring we provide the appropriate and effective
24:08
management. It really prompts the question, what
24:11
else could this be that presents with similar
24:13
thumb and wrist pain? The differential diagnosis.
24:16
Precisely. One condition to consider is C6 radiculopathy.
24:19
This is characterized by pain radiating from
24:22
the neck with peristhesias or numbness and tingling
24:25
primarily affecting the thumb and index finger.
24:27
This suggests a nerve root issue in the cervical
24:30
spine rather than a primary joint problem in
24:32
the hand. We differentiate this through neck
24:35
examination, specific neurological tests, and
24:38
potentially imaging of the cervical spine. So
24:40
always consider the neck. Always. Decurvain's
24:43
tenosynovitis is another common mimic. This is
24:46
an inflammation of the tendons in the first dorsal
24:48
compartment on the thumb side of the wrist. It's
24:51
distinguished by a positive Finkelstein's test,
24:54
where pain is reproduced when the thumb is flexed
24:56
into the palm, the fingers are wrapped over it,
24:59
and the wrist is then sharply deviated towards
25:01
the ulna. This specifically irritates the affected
25:04
tendons, differentiating it from CMC joint pain.
25:07
Finkelstein's for Decurvain's. Spot on. Scaphotropiesial
25:11
STT arthritis causes pain and tenderness typically
25:14
localized just proximal or closer to the wrist
25:17
compared to the TMC joint itself. Because of
25:20
the close anatomical relationship it can be easily
25:23
confused. Diagnostic injections precisely into
25:26
the STT joint or specific radiographic views
25:28
focusing on this area may be needed to differentiate
25:31
it. So location of tenderness is key there? It
25:33
helps, yes. We also must actively look for conditions
25:37
like scaphoid non -union advanced collapse, as
25:40
in a Steve's wrist, and radioscaphoid arthritis.
25:43
These are chronic conditions stemming from previous
25:46
scaphoid fractures or long -term degenerative
25:48
changes in the wrist. Both are usually evident
25:51
on standard wrist radiographs and their distinct
25:53
radiographic patterns help us differentiate them
25:56
as they require very different management strategies
25:58
than basal thumb arthritis. Okay. Check the wrist
26:01
x -rays carefully, too. And finally, given its
26:04
high co -occurrence with basal thumb arthritis,
26:06
as we mentioned, up to 50 % of patients, it's
26:09
absolutely crucial to assess for signs of carpal
26:11
tunnel syndrome. This is compression to the median
26:14
nerve at the wrist. Patients might report numbness,
26:18
tingling, or pain in the thumb, index middle,
26:21
and half of the ring finger, particularly symptoms
26:23
that wake them at night. If suspected, nerve
26:25
conduction studies may be required to confirm
26:28
this diagnosis. Right. Never forget the carpal
26:30
tunnel. The careful differentiation of all these
26:33
conditions ensures we're treating the correct
26:35
pathology or, as is often the case, multiple
26:38
pathologies simultaneously, leading to much more
26:41
effective patient care. With a confirmed diagnosis
26:43
and a clear understanding of potential mimics,
26:46
let's explore the treatment landscape. What's
26:48
the initial approach we should always consider?
26:50
And how far can conservative management realistically
26:54
take a patient before we consider surgical options?
26:57
Conservative management truly forms the indispensable
27:00
foundation of care for basal thumb arthritis.
27:03
It's the absolute mainstay of initial treatment,
27:06
even sometimes in later stages of the disease,
27:08
particularly for patients presenting with mild
27:11
to moderate symptoms. It's important to convey
27:13
to our patients that a significant number of
27:15
them actually achieve satisfactory long -term
27:17
outcomes and excellent pain control with these
27:20
non -surgical approaches alone. This can be very
27:22
reassuring for them to hear. So always start
27:25
conservative. Always. Activity modification is
27:28
paramount. We advise patients on avoiding activities
27:31
that exacerbate their pain, such as less forceful
27:34
pinching or suggesting they alternate hand use
27:37
to reduce strain. Simple but effective changes,
27:40
like using larger diameter writing instruments,
27:43
ergonomic tools, or adaptive kitchen aids like
27:45
jar openers, can significantly reduce the cumulative
27:48
stress on the joint. This empowers patients to
27:51
manage their symptoms actively. Simple changes
27:54
can make a big difference. They really can. For
27:56
pharmacological interventions, over -the -counter
27:59
analgesics and nonsteroidal anti -inflammatory
28:01
drugs like aspirin, ibuprofen, or naproxen are
28:04
often the first line to manage pain and reduce
28:06
inflammation and swelling. When these aren't
28:09
sufficient from mild to moderate disease, intraarticular
28:12
corticosteroid injections directly into the carpal
28:14
-metacarpal joint are a common second -line treatment.
28:17
These typically provide pain relief for several
28:19
months, often between three to six months, maybe
28:22
longer for some. Steroid injections are quite
28:24
effective, then. They can be very effective for
28:26
symptom control, yes. However, Their effect can
28:29
diminish with repeated injections, and they carry
28:32
a theoretical, albeit small, risk of weakening
28:35
capsular support or even compromising articular
28:38
cartilage over the very long term. So it's generally
28:41
advised to limit their frequency, perhaps to
28:43
two or three injections per year at most, into
28:46
one joint. Limit the injections. What about other
28:48
types? Hyaluronic acid. Good question. Current
28:52
evidence does not support the routine use of
28:54
hyaluronic acid injections for basal thumb arthritis.
28:58
Studies have shown no significant difference
28:59
in pain relief or functional improvement compared
29:02
to placebo or corticosteroids. So that's an important
29:05
distinction to make for patients who may have
29:07
heard about them for, say, knee arthritis. Okay,
29:10
no hyaluronic acid. What about glucosamine and
29:12
chondroitin? Ah, the area of chondroprotective
29:15
agents like glucosamine and chondroitin sulfate
29:19
remains quite controversial. While some patients
29:21
may wish to try them, and there's probably little
29:24
harm, it's crucial to caution them about the
29:27
distinct lack of robust clinical evidence for
29:29
their efficacy in repairing cartilage or decelerating
29:32
the degenerative process in this specific joint.
29:35
We must manage patient expectations carefully
29:38
here. So limited evidence for those supplements?
29:40
Very limited, yes. Immobilization and support
29:43
are also key components. Supportive splints are
29:46
highly beneficial in limiting thumb movement
29:48
and allowing the joint to rest and inflammation
29:50
to settle. The most effective is often a well
29:53
-fitted, custom -made thumb spica splint, which
29:56
specifically immobilizes the basal joint while
29:58
allowing other finger movement. A custom splint
30:01
is best. Often, yes, for comfort and precise
30:03
immobilization. Initially, continuous wear for
30:06
maybe three to four weeks is recommended, gradually
30:09
transitioning to intermittent use, perhaps just
30:11
for symptomatic periods or when anticipating
30:13
heavy loads like gardening or gripping tools.
30:15
And finally, exercise and physio. Absolutely
30:18
vital for long -term success. We advocate for
30:21
structured physical therapy program, often led
30:23
by a specialist hand therapist, to enhance function
30:26
and alleviate pain. Specific exercise regimens
30:29
include the hangar, intrinsic and extrinsic muscle
30:32
strengthening exercises to build dynamic stability
30:34
around the joint, thumb IP flexion, bending the
30:37
thumb MP flexion, bending the thumb at the base
30:39
towards the palm and thumb opposition exercises
30:41
to improve grasping and pinching capabilities.
30:44
Manual therapy techniques like gentle joint mobilizations
30:48
to restore movement and soft tissue manipulation
30:50
to break down scar tissue can be integrated.
30:53
Therapeutic taping can also support the joint
30:55
for daily activities. We also recommend assistive
30:58
devices and general joint protection techniques
31:00
to reduce strain. Temperature therapy, using
31:03
heat to decrease pain and enhance motion, or
31:06
cold packs for flare -ups, can provide symptomatic
31:09
relief for some people, though evidence for their
31:11
long -term efficacy in modifying disease progression
31:14
is mixed. The key insight for conservative management
31:17
is that it's about empowering the patient to
31:19
manage their symptoms and protect their joint,
31:22
often achieving significant improvement without
31:24
ever needing surgery. That sounds like a robust
31:26
and multifaceted first line of defense. But as
31:30
you alluded to, what happens when conservative
31:32
measures simply aren't enough? when pain and
31:34
disability persist despite our best efforts.
31:36
When do we start considering surgical interventions
31:39
and what are the overarching principles guiding
31:41
those complex decisions? That's precisely when
31:43
we transition our focus towards surgical options.
31:46
The clear indications for surgery are persistent
31:49
pain and functional disability that are not adequately
31:52
controlled by comprehensive conservative treatments,
31:55
particularly in a compliant patient who has genuinely
31:59
given conservative measures a fair trial, perhaps
32:02
over three to six months. The staging of the
32:05
disease using that Eaton and Glickle classification
32:07
we discussed becomes absolutely crucial at this
32:10
point as it heavily guides the selection of the
32:12
most appropriate surgical procedure for that
32:15
individual patient. A stage I patient will likely
32:17
be considered for very different interventions
32:19
than a stage five patient. Staging really directs
32:22
the surgical choice. It does. In terms of general
32:25
surgical principles, most operations for basal
32:28
thumb arthritis can typically be performed on
32:30
an outpatient basis, meaning the patient goes
32:32
home the same day. This is usually done under
32:35
general anesthesia or regional anesthesia, an
32:38
arm block which can be beneficial for patient
32:40
recovery. These procedures are generally quite
32:43
efficient, often taking less than an hour of
32:45
operative time, sometimes even quicker. The primary
32:48
goal across all these surgical approaches is
32:50
fundamentally straightforward. to prevent that
32:53
painful bone -on -bone rubbing that is causing
32:55
the symptoms and functional limitation. It's
32:58
about restoring a pain -free articulation or
33:00
removing the source of the pain altogether. Remove
33:02
the rubbing, remove the pain. Essentially, yes.
33:06
The decision regarding the specific surgical
33:07
option is always a collaborative one, a shared
33:10
decision -making process between the surgeon
33:12
and the patient. We carefully consider the patient's
33:15
age, their functional demands, do they need fine
33:18
dexterity or powerful grip, their expectations
33:21
for recovery and future function, and, of course,
33:23
the specific preoperative radiographic findings.
33:26
It's a truly tailored approach because one size
33:28
certainly does not fit all -in -hand surgery,
33:31
especially not here. Given that wide range of
33:33
options and the tailored approach, let's take
33:35
a deep dive into each of the specific surgical
33:37
procedures, starting with first metacarpal osteotomy.
33:40
How does this procedure work and for what type
33:43
of patient is it most suitable? Certainly. A
33:45
first metacarpal osteotomy involves cutting and
33:48
then precisely realigning the metacarpal bone,
33:51
typically through what we call a closing wedge
33:53
dorsal extension osteotomy. The principle here
33:56
is quite clever actually. It aims to essentially
33:58
redirect the forces acting across the joint to
34:02
a more dorsal or back of the hand portion of
34:05
the first CMC joint surface. This less involved,
34:08
often healthier, Part of the joint then takes
34:10
on more of the load, thereby reducing stress
34:12
and pain in the main arthritic damaged area.
34:15
It's a bit like shifting the weight onto a stronger
34:17
part of a foundation. This procedure is primarily
34:23
indicated for patients in the early stages of
34:25
disease, where the joint destruction isn't too
34:29
advanced and there's still a reasonably healthy
34:30
portion of cartilage to offload onto. However,
34:33
it's not suitable for everyone. Contraindications
34:36
include patients with significant hypermobility
34:38
of the joint, a fixed subluxation of the CMC
34:40
joint that cannot be easily reduced, or pre -existing
34:43
MCP hyperextension greater than about 10 degrees,
34:46
as these conditions might not benefit or could
34:48
potentially even be exacerbated by the osteotomy.
34:51
So early stage, stable joint, no hyperextension.
34:55
That's the ideal profile. Despite these limitations,
34:58
it has gained popularity, particularly for younger
35:01
patients with early disease. And reported symptom
35:04
improvement rates can be quite high, maybe as
35:06
high as 93 % at seven years post -procedure in
35:09
some series. It's a good option for specific,
35:13
carefully selected early stage cases where preserving
35:16
length in some motion is really key. That's quite
35:18
a high success rate for the right... patient
35:21
profile. What about trapeziectomy, which I understand
35:24
is perhaps the most commonly performed procedure,
35:26
and how has the approach to it evolved over time,
35:29
particularly regarding managing the space left
35:31
by the removed bone? Yes, trapeziectomy is indeed
35:35
the most commonly performed surgical option for
35:37
basal thumb arthritis globally, and represents
35:39
a real paradigm shift in managing this condition
35:41
compared to, say, fusion. It fundamentally involves
35:45
the complete removal of the trapezium bone. the
35:47
wrist bone that forms one surface of the arthritic
35:49
joint. The core idea is simple and effective.
35:52
If the pain comes from the bone -on -bone rubbing
35:54
of the trapezium against the metacarpal, remove
35:56
the trapezium. Just take out the problem bone.
35:59
Exactly. Historically, this procedure often involved
36:01
quite complex ligament reconstructions or filling
36:05
the created space with a rolled -up tendon, a
36:07
technique known widely as ligament reconstruction
36:10
and tendon interposition, LRT -I. The rationale
36:14
was to prevent the thumb metacarpal from migrating
36:17
proximally, or sort of sinking down, into the
36:20
void left by the excise trapezium and potentially
36:23
hitting the scaphoid. The LRTI technique? I've
36:26
heard of that. Yes, it was very popular for a
36:28
long time. However, contemporary practice has
36:31
seen a fascinating evolution. Some modern practices,
36:35
supported by good evidence, suggest that simply
36:37
excising the trapezium and meticulously repairing
36:40
the joint capsule, allowing the space to fill
36:42
naturally with scar tissue, a process known as
36:45
hematoma arthroplasty, or fibrous interposition,
36:48
yields comparable functional results without
36:50
the added complexity, potential morbidity, and
36:53
operating time of extensive soft tissue procedures
36:55
like tendon harvesting. So maybe the complex
36:58
reconstruction isn't always necessary. That's
37:00
what a lot of evidence suggests now. The body's
37:03
natural healing can be incredibly effective in
37:05
creating a stable pseudoarthrosis, a fibrous
37:08
joint that functions remarkably well. Now, when
37:11
suspension is performed, perhaps in younger patients
37:13
or those with higher demands where maintaining
37:15
length is critical, various tendons can be used
37:17
to support the thumb metacarpal. The flexor carpi
37:20
radialis, FCR tendon, is the most common choice
37:24
for suspending the metacarpal due to its location
37:26
and strength. Other options include the extensor
37:29
carpe radialis longus, ECRL, or using a slip
37:32
of the abductor pollicis longus, APL. More recently,
37:36
newer techniques like suture suspension, for
37:38
example, using a portion of the APL tendon to
37:41
suspend the SCR tendon with strong sutures and
37:43
the mini tightrope system are gaining traction.
37:46
The mini tightrope in particular is a procedure
37:48
I personally prefer for many cases as it effectively
37:51
restores CMC joint stability using an internal
37:54
brace ligament augmentation. A mini tightrope,
37:56
like the ones used elsewhere in orthopedics.
37:58
Precisely a similar concept adapted for the thumb's
38:01
CMC joint. It provides a robust and predictable
38:04
solution for maintaining the thumb's length and
38:06
stability post -trapeziectomy, using a strong
38:09
synthetic suture device rather than harvesting
38:11
more tendon, which simplifies the procedure.
38:13
Interesting. And who's trapeziectomy suitable
38:16
for? Which stages? Trapeziatomy is highly versatile,
38:19
suitable for a wide range of disease stages from
38:22
stage I, particularly if symptomatic and feeling
38:25
conservative care, all the way through to stage
38:27
IV. It's particularly indicated when there is
38:29
concomitant scaphotropesia arthrosis, meaning
38:32
arthritis also affecting the joint between the
38:34
scaphoid and trapezium bones, which is present
38:37
in a significant number of cases, perhaps up
38:39
to 62%, especially in stage IV disease. In such
38:43
instances, excision of the proximal third of
38:45
the trapezoid bone might also be considered to
38:47
address the broader degeneration if the STT joint
38:50
is also severely affected. So it covers most
38:52
stages, even the advanced ones. What are the
38:55
potential downsides or complications? As with
38:57
any surgery, there are potential complications.
39:00
These can include injury to the radial artery,
39:02
though the risk is generally lower at the TMC
39:04
joint level compared to, say, more... proximal
39:08
wrist surgery, and injury to the superficial
39:10
radial nerve, which runs nearby. Nerve injury
39:13
can lead to areas of sensory deficits or occasionally
39:15
a persistent painful neuroma. A notable specific
39:18
complication occurring in perhaps around 5 %
39:20
of cases is symptomatic proximal migration of
39:23
the thumb metacarpal. This is where the metacarpal
39:26
drops down into the space created by the excised
39:28
trapezium and potentially impinges on the scaphoid.
39:31
If this becomes symptomatic, causing pain or
39:34
weakness, it can be quite difficult to stabilize
39:36
and may necessitate further procedures, such
39:38
as a sling -type reconstruction or even fusion
39:41
to the index metacarpal in severe cases. This
39:43
is particularly concerning in younger, more active
39:45
individuals, where maintaining long -term thumb
39:48
length and function is paramount. So that thumb
39:50
shortening or collapse is the main specific risk?
39:53
It's certainly one of the key procedure -specific
39:55
risks we counsel patients about. Despite these
39:57
potential issues, the outcomes of trapeziectomy
40:00
are generally very positive. It typically provides
40:03
significant pain relief and allows for continued
40:06
useful motion of the thumb. While some degree
40:09
of proximal metacarpal subsidence, maybe around
40:11
25 % on average seen on radiographs, can occur
40:14
postoperatively, this typically does not impact
40:17
the functional outcome significantly. Patients
40:20
often experience improved grip and pinch strengths
40:22
compared to their preoperative state, leading
40:25
to high satisfaction rates overall. It's fascinating
40:27
how the surgical approach continues to evolve
40:29
for trapeziectomy. What about joint fusion or
40:32
arthrodesis? When is that considered and what
40:34
are the distinct trade -offs for the patient?
40:37
CMC arthrodesis, or joint fusion, involves permanently
40:40
fusing the bones of the joint specifically, the
40:43
trapezium and the base of the thumb metacarpal
40:45
together to create a solid immobile unit. The
40:48
goal here is simple and direct. By eliminating
40:51
all movement at that specific joint, we eliminate
40:53
the pain originating from it. The joint is typically
40:56
fused in a functional position, commonly around
40:58
35 degrees of radial abduction, 30 degrees of
41:01
palmar abduction, and maybe 15 degrees of pronation,
41:04
to ensure optimal functionality for grasping
41:06
and pinching activities, despite the complete
41:08
stiffness at the fused joint. Fused in a useful
41:11
position, who is this best for? This procedure
41:14
is primarily recommended for physically high
41:17
-demand patients, particularly younger males,
41:20
typically maybe under 50 years of age, where
41:22
preserving maximal grip strength and maintaining
41:24
the absolute stability of the thumb column are
41:27
prioritized over range of motion. Think of a
41:29
carpenter, a builder, or perhaps a weightlifter,
41:32
individuals whose livelihoods or activities depend
41:34
on a powerful stable pinching grip. It's generally
41:38
contraindicated if there's significant coexisting
41:40
schaefer -tropiezoidal STT arthritis, because
41:43
fusing the CMC joint would simply transfer the
41:46
painful stresses to the adjacent already arthritic
41:49
STT joint, likely leading to persistent pain
41:51
just proximal to the fusion site. So check the
41:54
STT joint carefully before considering fusion.
41:57
Absolutely critical. The outcomes are generally
41:59
excellent in terms of providing profound pain
42:01
relief, unwavering stability, and excellent length
42:04
preservation of the thumb column. However, the
42:07
obvious and significant tradeoff is a drastically
42:10
decreased range of motion at the base of the
42:12
thumb. For example, patients will find it impossible
42:15
to lay their thumb flat against a table, which
42:17
requires CMC motion. There's also a non -union
42:20
rate, meaning the bone ends fail to join solidly,
42:24
of around 12%, maybe slightly higher in some
42:26
series. Despite the stiffness and the risk of
42:29
non -union, most patients who are carefully selected
42:31
for this procedure find the pain -free and strong
42:34
thumb highly satisfactory, especially those whose
42:37
professional or recreational activities demand
42:39
that powerful grip and absolute stability. The
42:42
core insight here is that fusion sacrifices motion
42:45
for guaranteed stability and strength. That's
42:47
a clear case of prioritizing strength over mobility
42:50
for specific patient profiles. What about joint
42:52
replacement or prosthetic arthroplasty? Is that
42:54
a growing trend for the thumb CMC joint, perhaps
42:57
similar to hip or knee replacements? CMC prosthetic
43:00
arthroplasty or joint replacement is indeed a
43:03
concept that has gained some traction, particularly
43:05
in parts of Europe, although it's still relatively
43:08
newer as a primary option here in the UK compared
43:10
to trapeziectomy or fusion. This procedure involves
43:14
removing the arthritic ends of the bones, the
43:16
trapezium and the metacarpal base, and inserting
43:19
a new artificial joint, often described as similar
43:22
in principle to a mini hip replacement. Historically,
43:26
silicone implants were quite widely used in this
43:28
context, though newer metal on polyethylene or
43:31
pyrocarbon designs exist now too. A mini thumb
43:34
replacement? Sounds appealing. Is it recommended?
43:37
Well, while it theoretically offers the benefit
43:39
of maintaining motion and potentially providing
43:41
a stronger thumb compared to simple trapeziectomy
43:43
and can sometimes yield good results, it is currently
43:46
generally not recommended as a primary first
43:49
-line surgical option in the UK for most patients.
43:51
Why the caution? The reason for this caution
43:53
lies primarily in the specific risks and the
43:56
relatively higher complication rates associated
43:58
with implant use in this demanding joint. These
44:02
include the potential for implant fracture or,
44:05
more commonly, loosening over time, remember
44:07
those 13x forces. There's also the risk of subluxation
44:11
or dislocation of the implant itself, and the
44:13
possibility of particle wear disease, like silicone
44:16
synovitis with older implants, which is an inflammatory
44:18
reaction to debris that can cause significant
44:20
problems and require revision surgery. So implant
44:23
longevity and complications are the main concerns?
44:26
Precisely. Furthermore, this procedure is generally
44:28
not suitable for patients with the most severe,
44:31
stage 4, arthritis, as their joint may be too
44:34
damaged or the surrounding bone quality insufficient
44:36
to adequately support an implant long term. This
44:39
makes it a less versatile option compared to
44:41
trapeziectomy for advanced cases. The real challenge
44:44
here is finding an implant that can reliably
44:46
withstand the immense forces acting across the
44:49
thumb's CMC joint without loosening, wearing
44:51
out, or failing over the patient's lifetime,
44:54
particularly in younger, active individuals.
44:56
The long -term data just isn't as robust as for
44:59
trapeziectomy yet. It sounds like while promising
45:01
in theory, it comes with its own distinct set
45:04
of challenges, particularly long -term ones.
45:06
What about denervation, the procedure that involves
45:09
selectively cutting nerves to interrupt pain
45:11
signals? That seems like a very different approach
45:13
entirely. Indeed, CMC denervation is a distinct
45:17
and perhaps often underappreciated approach that
45:20
focuses purely on pain modulation rather than
45:22
joint reconstruction or removal. This procedure
45:25
involves selectively identifying and cutting
45:27
small sensory nerve branches that transmit pain
45:30
signals directly from the arthritic CMC joint.
45:33
It can be performed through one or two small
45:35
incisions, precisely targeting nerves such as
45:38
the fanar cutaneous branch of the median nerve,
45:40
the palmar cutaneous branch of the median nerve,
45:43
the superficial branch of the radial nerve via
45:45
the dorsal articular nerve of the first interosseous
45:47
space, and sometimes the branch of cruvillier
45:50
from the lateral antibrachial cutaneous nerve.
45:53
The precise anatomical knowledge and mapping
45:55
of these nerves allows for targeted pain relief
45:58
while preserving other motor and critical sensory
46:00
functions of the hand. Just cutting the pain
46:02
wires, essentially. Who is it for? This technique
46:05
is potentially applicable across all stages of
46:08
the disease from stage I right through to stage
46:10
IV, although its specific indications are still
46:13
evolving as we gather more long -term outcome
46:15
data. The primary specific complication is potential
46:18
injury to a sensory branch of the radial nerve,
46:21
which can lead to areas of numbness on the back
46:23
of the thumb, or, less commonly, a painful neuroma
46:26
if a nerve ending gets irritated. Careful surgical
46:29
technique minimizes this risk, of course. It's
46:32
also important to note that as with any pain
46:34
-modulating procedure, not all patients achieve
46:36
significant or complete improvement, and some
46:38
may still experience some residual discomfort.
46:40
But for those it works for? For those who do
46:43
respond well. Outcomes often include improved
46:46
hand function, enhanced grip strength, likely
46:48
due to pain reduction, and significant pain relief.
46:52
In terms of pain control, results can be comparable
46:55
to trapeziectomy and CMC arthrodesis in some
46:57
studies, but with the distinct advantage of preserving
47:00
the patient's natural range of motion compared
47:02
to fusion. This makes it an attractive option
47:05
for certain patients who prioritize motion, perhaps
47:07
wish to avoid more extensive joint reconstruction,
47:10
or maybe aren't suitable candidates for other
47:12
procedures. The key insight, as you said, is
47:15
that it targets the symptom of pain directly
47:17
rather than the underlying degenerative joint
47:19
itself. And finally, a minimally invasive option,
47:22
arthroscopic debridement. When is that indicated
47:25
and what does it entail? CMC arthroscopic debridement
47:28
is indeed a minimally invasive surgical approach.
47:32
It involves using an arthroscope, a small camera
47:35
about 2 -3mm wide inserted through tiny incisions
47:38
or portals to visualize the inside of the joint
47:41
directly. The surgeon can then debride or clean
47:44
out any damaged tissue such as inflamed synovium,
47:47
joint lining, or loose cartilage fragments floating
47:50
in the joint. It may sometimes be combined with
47:52
thermal shrinkage of lax capsule or ligaments
47:55
or even fat grafting where a small amount of
47:57
the patient's own fat is harvested and injected
47:59
into the joint space to potentially provide some
48:02
cushioning and support, perhaps aiding in lubrication
48:05
and reducing friction. This procedure is primarily
48:10
indicated for patients in the early stages of
48:12
the disease, typically stage one or perhaps early
48:15
stage two, where the cartilage damage is still
48:17
relatively contained and potentially reversible
48:19
and significant bone -on -bone changes or large
48:22
osteophytes have not yet occurred. It's generally
48:25
less effective once the joint has severely collapsed
48:27
or developed extensive bony spurs. So for early,
48:30
primarily inflammatory or unstable cases? That's
48:33
generally the target group, yes. The technique
48:36
typically utilizes specific portals, such as
48:39
the dorsal 1R portal, which is just radial to
48:41
the abductor pollicis longus, APL tendon, and
48:44
the dorsal 1U portal, which is ulnar to the extensor
48:47
pollicis brevis, EPB tendon, lying between the
48:50
extensor pollicis longus, EPL, and EPB tendons.
48:53
These precise small porters allow surgeons to
48:56
access the joint with minimal tissue disruption,
48:58
which can lead to faster initial recovery times
49:00
compared to more open procedures. The core idea
49:03
is early intervention with minimal invasiveness
49:06
for carefully selected patients. That's a truly
49:09
comprehensive look at the various surgical pathways
49:11
available, each with its specific indications
49:13
and considerations. Now, once a patient undergoes
49:16
treatment, particularly surgery, what does the
49:18
rehabilitation and recovery journey look like?
49:20
And what can we tell them to expect in terms
49:22
of timelines and return to function? The journey
49:25
to regain function post -treatment, especially
49:27
after surgery, is a structured and really vital
49:30
process that we must prepare our patients for
49:33
thoroughly. In the immediate post -operative
49:35
period, one of the great benefits, as we mentioned,
49:38
is that patients are typically able to go home
49:40
on the same day as the operation. It's usually
49:43
day -case surgery. Simple oral analgesia, like
49:47
paracetamol and perhaps some short -term codeine
49:49
or NSAIDs, if appropriate, is usually sufficient
49:52
for post -operative pain control. It's crucial
49:55
for patients to elevate the hand as much as possible
49:57
for the first five days or so to minimize swelling,
50:01
which significantly aids in comfort and healing.
50:04
Gentle bending and straightening of the fingers
50:06
should commence from day one to prevent stiffness
50:08
in the digits not directly involved in the thumb
50:10
surgery. Keep everything else moving. Elevation
50:13
and finger movement right away. Then the cast.
50:16
For the immobilization phase, the initial bulky
50:19
plaster of Paraslab applied in theater is generally
50:22
removed within the first week, usually at their
50:24
first post -op clinic visit. At this point, the
50:27
wound is cleaned and redressed, and a custom
50:29
-made thermoplastic therapy splint, where sometimes
50:32
a lighter fiberglass cast is applied. This splint
50:35
or cast is typically worn for approximately six
50:38
to eight weeks, though the exact duration depends
50:40
heavily on the specific procedure performed.
50:43
Each surgical technique has different requirements
50:45
for initial stability and healing time. A fusion,
50:48
for instance, will require longer, more rigid
50:50
immobilization than a simple trapeziectomy. Six
50:53
to eight weeks in a splint or cast, depending
50:55
on the op, then therapy. Absolutely. A comprehensive
50:59
rehabilitation program, ideally involving a dedicated
51:02
specialist hand therapist, is essential for optimal
51:05
outcomes. This therapy focuses initially on regaining
51:07
mobility, then progressively restoring strength,
51:10
and ultimately improving overall hand function
51:12
and dexterity. While some discomfort may be experienced
51:16
during the initial stages of rehabilitation,
51:18
as tissues heal, stretch and strengthen, this
51:20
usually lessens considerably over time. It's
51:23
important to manage patient expectations here.
51:25
The road to full recovery is gradual, not instantaneous.
51:28
How gradual? What are the typical timelines?
51:31
Patients usually notice that the sharp, constant
51:33
arthritic pain they had before surgery has resolved
51:36
within about eight weeks, once the initial post
51:39
-op soreness settles. However, significant improvements
51:42
in strength, endurance, and overall comfort continue
51:45
for several months after that. Full recovery,
51:48
in terms of getting back maximal strength and
51:50
function, often takes up to a year. We even see
51:53
some patients reporting continued subtle enhancements
51:55
in strength and comfort for years after the procedure,
51:58
which is a fascinating aspect of the body's adaptation
52:00
and neuroplasticity. But realistically, initial
52:03
functional recovery typically spans around three
52:05
months, allowing a return to most light daily
52:08
activities. Three months for light activity is
52:10
up to a year for full recovery. What about practical
52:13
things like driving and work? Good points. For
52:17
the return to activities of daily living, Wounds
52:19
should obviously be kept covered and dry for
52:21
the first 10 days to two weeks until they have
52:23
fully healed. The splint or cast must also be
52:27
kept dry throughout its use and is gradually
52:29
weaned off under the supervision of the hand
52:31
therapist, often with specific exercises being
52:34
introduced as the immobilization decreases. Regarding
52:38
driving, it's generally advisable to delay return
52:41
until full control of the steering wheel and
52:43
gear stick is achieved, and crucially, the patient
52:45
feels safe and confident to react appropriately
52:48
in an emergency situation. This typically might
52:51
be between 8 and 12 weeks post -surgery, but
52:53
individual variations certainly exist based on
52:56
the surgery type, the patient's recovery, and
52:58
the type of vehicle. 8 to 12 weeks for driving,
53:00
potentially. Had work. For return to work, especially
53:03
involving heavy manual labor, it should generally
53:06
be avoided for approximately eight weeks at minimum,
53:09
sometimes longer depending on the procedure and
53:11
the job demands. Specific advice should always
53:15
be sought from the surgeon based on the individual's
53:17
specific role and the precise physical demands
53:19
of their job. A phased return is often helpful.
53:23
The overall prognosis for basal joint arthritis
53:26
after appropriate treatment is very positive.
53:29
It's considered a very treatable condition, with
53:31
high satisfaction rates, often exceeding 85 -90
53:34
% of patients reporting positive outcomes after
53:36
treatment, particularly regarding pain relief.
53:39
Crucially, patients who do not achieve adequate
53:41
relief with non -surgical treatment very often
53:43
have a good or excellent result following surgery,
53:46
with strength potentially exceeding preoperative
53:48
levels within a year. That's a truly encouraging
53:50
prospect for those suffering significant disability.
53:53
It's reassuring to hear such high satisfaction
53:55
rates and a clear, albeit gradual, recovery path.
53:59
However, no surgical procedure is entirely without
54:02
its risks. What are the potential complications,
54:05
both general surgical risks and those specific
54:08
to thumb surgery, that we as clinicians should
54:10
be carefully aware of and discuss thoroughly
54:13
with our patients? That's a critical aspect of
54:15
our preoperative patient counseling, ensuring
54:18
fully informed consent. First, we always acknowledge
54:21
the universal risks associated with any surgical
54:24
procedure. These include general complications
54:27
related to anesthesia, which are always meticulously
54:29
assessed preoperatively by the anesthetic team,
54:32
general nerve injury, which can theoretically
54:34
occur anywhere near the surgical field despite
54:37
carol technique, and the risk of infection at
54:39
the surgical site, which is usually low. around
54:42
1%, but always a possibility. These are standard
54:45
considerations for any operation we undertake.
54:47
The standard surgical risks. What about thumb
54:50
-specific ones? Yes, there are specific complications
54:53
more unique to thumb -based surgery. One is the
54:55
failure to completely resolve symptoms. While
54:58
relatively rare after appropriate surgery, this
55:01
can occur. Sometimes it's due to pre -existing
55:04
or subsequently developing arthritis in adjacent
55:07
joints, for example, the STT joint, or even wrist
55:10
arthritis that were not the primary target of
55:12
the surgery but become symptomatic later. If
55:15
this occurs and is problematic, it may necessitate
55:18
further investigation or even intervention. Residual
55:21
weakness is also a possibility. The thumb may
55:24
initially feel weaker on the operated side, particularly
55:27
after trapeziectomy where the trapezium's buttress
55:29
effect is removed. While it typically improves
55:32
significantly with time and dedicated rehabilitation,
55:35
it may never fully return to its absolute original
55:37
prearthritis strength, although function usually
55:40
improves dramatically due to pain relief. We
55:42
must set realistic expectations about strength
55:44
return. Okay, incomplete relief and some weakness
55:47
are possible. What about the migration issue
55:49
after trapeziectomy? Yes. A specific concern
55:52
following trapeziectomy, occurring symptomatically
55:55
in perhaps around 5 % of cases, is proximal migration
55:59
of the thumb metacarpal. As we discussed, this
56:02
is where the thumb metacarpal, no longer supported
56:04
by the trapezium, drops down into the space left
56:07
by the removed bone and can potentially impinge
56:10
on the scaphoid or distal radius. If this migration
56:13
becomes symptomatic, causing significant pain,
56:16
instability, or weakness, it can be quite challenging
56:18
to manage and may require further procedures,
56:21
such as a sling -type reconstruction using a
56:23
tendon, or, in more severe or refractory cases,
56:26
even fusion to the index metacarpal to provide
56:28
rigid support. This particular complication is
56:31
a major concern, especially in younger, high
56:33
-demand individuals where maintaining long -term
56:35
stability and function is paramount. That sounds
56:38
like a difficult complication to fix. It can
56:40
be. For cases of CMCJ fusion arthrodesis, there's
56:44
the risk of nonunion, where the bone ends fail
56:47
to join together solidly. This occurs in about
56:50
5 -10 % of cases, maybe higher in smokers or
56:53
those with comorbidities. If this nonunion remains
56:56
painless and stable, it can sometimes be accepted
56:58
and left alone. But if it becomes symptomatic
57:01
and painful, revision surgery, such as repeating
57:04
the operation perhaps with a bone graft to promote
57:06
healing or sometimes converting the failed fusion
57:08
to a trapeziectomy, may be required. Non -union
57:12
after fusion. What about implants? When an implant
57:14
is used in CMC prosthetic arthroplasty, there's
57:18
a known risk of dislocation of the implant itself.
57:20
also perhaps in the 5 -10 % range, depending
57:23
on the implant type and technique. If an implant
57:26
dislocates repeatedly or cannot be reduced, it
57:28
may necessitate its removal and subsequent conversion
57:31
to an alternative surgical approach, like trapeziectomy,
57:34
to manage the resulting joint space and symptoms.
57:37
Loosening and wear, as mentioned earlier, are
57:39
the other major long -term concerns with implants.
57:41
Dislocation and loosening with implants. Anything
57:43
else? Finally, we must consider MCP hyperextension
57:46
deformity, which can develop or worsen after
57:48
CMC surgery. This is where the middle joint of
57:51
the thumb hyperextends excessively, often as
57:54
a compensatory mechanism for lost CMC motion
57:56
or due to inherent laxity. Its management depends
58:00
on the degree of hyperextension and whether it's
58:02
causing functional problems. If it's mild, less
58:05
than 10 degrees, typically no specific surgical
58:07
intervention is needed. For 10 to 20 degrees,
58:10
percutaneous pinning of the MCP joint and slight
58:13
flashing for about four weeks during the initial
58:14
post -op period may be performed, potentially
58:17
combined with an extensor policies brevis EPB,
58:21
pinned and transfer later to reinforce the joint
58:22
dynamically. If the hyperextension is more significant,
58:26
between 20 and 40 degrees, a volar capsulodesus,
58:29
tightening the joint capsule on the palm side,
58:32
or sesamoidesus, using the small sesamoid bones
58:34
for stability, might be required. And for severe
58:37
cases greater than 40 degrees of hyperextension,
58:40
an MCP joint fusion may become necessary to permanently
58:42
stabilize the thumb in a functional position,
58:44
creating a stiff but stable and pain -free joint.
58:46
That's a lot to consider beyond the immediate
58:49
surgical site, truly underscoring the complexities
58:52
and the potential long -term journey in hand
58:54
surgery. Beyond the physical and surgical aspects
58:57
we've meticulously discussed, how does living
58:59
with basal thumb arthritis profoundly impact
59:02
a patient's emotional and psychological well
59:04
-being? This is an area that unfortunately can
59:07
sometimes be overlooked in a purely physical
59:09
treatment model, isn't it? It is indeed an often
59:12
overlooked yet profoundly important aspect that
59:15
we as clinicians must never forget. Living with
59:19
chronic pain, particularly in the hands which
59:21
are so integral to our interaction with the world,
59:24
extends far beyond the physical limitations it
59:27
imposes. It can significantly influence a patient's
59:30
entire emotional and psychological well -being.
59:33
What's truly fascinating and often distressing
59:35
to witness clinically is the deep connection
59:37
between chronic pain, regardless of its source,
59:40
and mental health. This isn't simply a secondary
59:42
reaction, it's often an interwoven reality for
59:45
the patient. The mind -body link. Precisely.
59:49
Patients often experience a wide spectrum of
59:51
challenging emotions. Frustration is incredibly
59:54
common, stemming from the sheer inability to
59:56
perform seemingly simple, everyday tasks independently.
1:00:00
Imagine the constant struggle to turn a key,
1:00:03
open a jar, button a shirt, use cutlery, or even
1:00:06
just hold a grandchild's hand without significant
1:00:08
pain. This daily struggle can easily lead to
1:00:11
deeper feelings of sadness, and in some cases
1:00:14
it can contribute to clinical depression and
1:00:16
anxiety. A pervasive sense of isolation can also
1:00:19
develop, especially if hobbies or social activities
1:00:22
are curtailed. That loss of independence must
1:00:24
be incredibly hard. It is. When someone can no
1:00:28
longer engage in hobbies they once loved, or
1:00:30
perhaps perform their professional duties effectively,
1:00:33
it inevitably diminishes their quality of life
1:00:35
significantly. This can lead to feelings of helplessness,
1:00:38
guilt about their perceived limitations, or even
1:00:40
jealousy when observing others perform these
1:00:42
actions effortlessly. I've had patients tell
1:00:44
me how utterly disheartening it is to watch their
1:00:46
spouse easily open a bottle they've struggled
1:00:48
with for minutes. It chips away at their self
1:00:50
-esteem. And does this emotional state affect
1:00:52
the physical symptoms? Absolutely. The mind -body
1:00:55
interconnection is particularly strong in chronic
1:00:58
pain conditions. Stress, anxiety, and low mood
1:01:01
can demonstrably amplify pain perception. It
1:01:05
creates a challenging feedback loop, where the
1:01:07
emotional distress exacerbates physical symptoms,
1:01:10
which in turn increases the emotional distress,
1:01:12
making recovery much more difficult. Untreated
1:01:15
mental health conditions such as anxiety and
1:01:17
depression are clearly linked in research to
1:01:19
heightened pain perception, slower rehabilitation
1:01:22
progress, and ultimately poorer functional outcomes
1:01:24
in patients with thumb arthritis and indeed many
1:01:27
other chronic conditions. So addressing the mental
1:01:29
health aspect is crucial for physical recovery
1:01:31
too. It really is. This raises an important question
1:01:34
for us. If we only treat the physical joint,
1:01:37
the cartilage, the bone, the ligaments, are we
1:01:40
truly treating the whole patient? Ignoring the
1:01:42
emotional tolls akin to addressing only half
1:01:45
of their suffering. In our pursuit of holistic
1:01:47
care, that's simply not good enough. fostering
1:01:50
a positive mental state, providing psychological
1:01:53
support where needed, and acknowledging the emotional
1:01:56
burden are crucial, not only for enhancing a
1:01:58
patient's ability to cope with pain, but also
1:02:01
for encouraging them to actively participate
1:02:03
in their rehabilitation and regain their confidence
1:02:05
and independence. That's a powerful reminder
1:02:08
of the holistic approach required and the profound
1:02:11
impact beyond the physical joint itself. Building
1:02:14
on that, what proactive measures can individuals
1:02:17
take, and what long -term strategies can we empower
1:02:20
our patients with to effectively manage this
1:02:22
condition both before and after any potential
1:02:24
intervention, ensuring their overall well -being?
1:02:27
Empowering patients with proactive strategies
1:02:29
for prevention, where possible, and certainly
1:02:31
for long -term management, is absolutely crucial
1:02:34
for their sustained well -being and functional
1:02:37
independence. This isn't just about treating
1:02:39
the joint when it becomes painful. It's about
1:02:41
equipping them for a lifetime of joint health
1:02:44
awareness. A primary recommendation is to adopt
1:02:47
a proactive approach, starting with activity
1:02:50
modification even before symptoms become severe,
1:02:53
if possible. This includes being mindful of and
1:02:56
consistently avoiding or adapting activities
1:02:58
that place excessive, repetitive strain or cause
1:03:01
pain in the thumb joint. Listen to your body.
1:03:03
Regular physical activity, particularly specific
1:03:06
exercises that strengthen the muscles surrounding
1:03:08
the CMC joint, like the venar muscles, and improve
1:03:11
pain -free range of motion, is essential. This
1:03:14
isn't about working through sharp pain, but building
1:03:16
robust dynamic support around the joint to potentially
1:03:18
stabilize it and offload the stress cartilage.
1:03:20
Strengthening the supporting muscles. Yes, dynamic
1:03:23
stability is key. Ergonomic adjustments are another
1:03:26
really important area. We strongly advise patients
1:03:29
on the judicious use of assistive devices and
1:03:31
ergonomic tools. Simple items like specialized
1:03:34
jar openers, key turners, ergonomic pens with
1:03:37
wider grips, or even large handled utensils can
1:03:40
significantly alleviate stress on the joint during
1:03:42
daily tasks. Education on joint protection techniques
1:03:46
and proper hand positioning is vital for maintaining
1:03:48
functionality while minimizing pain. For example,
1:03:52
instead of using a tight pinch grip with just
1:03:54
the thumb and index finger to lift something,
1:03:56
we encourage patients to use the whole hand or
1:03:58
both hands to grasp, distributing forces more
1:04:00
broadly across stronger joints. Smart techniques
1:04:03
to reduce the load. Precisely. For individuals
1:04:06
experiencing early symptoms, early intervention
1:04:09
strategies are highly effective and can potentially
1:04:11
alter the disease trajectory or at least manage
1:04:14
symptoms effectively for longer. Prompt conservative
1:04:17
treatments, such as custom -made splints for
1:04:20
support during activities and judicious use of
1:04:23
analgesic and anti -inflammatory medications,
1:04:25
oral or topical, to manage pain and inflammation
1:04:28
can make a significant difference. Early engagement
1:04:31
in manual therapy with a hand therapist and the
1:04:34
consistent use of therapeutic taping, like kinesiotape,
1:04:37
can also contribute to joint stability and provide
1:04:39
pain relief, potentially delaying or even preventing
1:04:41
the need for surgical intervention for years
1:04:44
in some individuals. So, acting early with conservative
1:04:46
measures is beneficial. Definitely. Finally,
1:04:49
we need to empower patients with comprehensive
1:04:51
long -term management strategies that go beyond
1:04:53
just the physical. This includes ongoing education
1:04:56
about lifestyle modifications, such as maintaining
1:04:59
a healthy weight to reduce overall systemic inflammation
1:05:01
and joint stress, and advising on workplace ergonomics
1:05:05
tailored to their specific roles. Crucially,
1:05:08
it involves fostering self -management techniques
1:05:10
and developing effective coping strategies for
1:05:12
dealing with chronic pain flares when they occur.
1:05:15
This could mean incorporating stress reduction
1:05:17
techniques like mindfulness, meditation, or Tai
1:05:20
Chi. Practicing deep breathing exercises can
1:05:23
help manage acute pain episodes. Seeking support
1:05:26
from counseling services or arthritis specific
1:05:28
support groups like those run by visor arthritis
1:05:31
can be invaluable, allowing patients to connect
1:05:34
with others facing similar challenges and sheer
1:05:36
coping strategies. Focusing on the whole person
1:05:38
again. Absolutely. What's truly fascinating and
1:05:41
powerful here is the positive impact of encouraging
1:05:44
patients to focus on enjoyable aspects of life,
1:05:47
maintaining strong social connections, and continuing
1:05:49
to engage in hobbies and activities that bring
1:05:51
them joy, even if those activities need to be
1:05:54
adapted slightly. These elements, while seemingly
1:05:57
separate from orthopedics, are fundamental to
1:05:59
enhancing overall quality of life, reducing the
1:06:02
perceived burden of the condition and allowing
1:06:04
patients to thrive despite living with chronic
1:06:06
pain. This has been an incredibly insightful
1:06:09
deep dive into basal thumb arthritis, covering
1:06:12
everything from the intricate anatomy and pathophysiology
1:06:15
right through the diverse range of conservative
1:06:18
and surgical treatments, and critically, finishing
1:06:21
on that holistic journey of recovery and well
1:06:23
-being for our patients. As we consider the significant
1:06:27
forces at play in such a small but vital joint,
1:06:30
it truly underscores the remarkable resilience
1:06:33
of the human hand and perhaps the often underestimated
1:06:36
mental fortitude required to navigate chronic
1:06:39
conditions like basal thumb arthritis. It leaves
1:06:42
me wondering, what more could we as medical professionals
1:06:44
perhaps do to better support our patients not
1:06:46
just surgically or pharmacologically, but truly
1:06:50
holistically in their long -term journey with
1:06:52
chronic conditions like this? That is a profound
1:06:54
question and it really speaks to the evolving
1:06:56
nature of medicine, doesn't it? Perhaps our greatest
1:06:58
future challenge and indeed opportunity is not
1:07:01
just to fix the specific anatomical part, but
1:07:03
to truly care for the whole person, integrating
1:07:06
all aspects of their fixable emotional and social
1:07:08
well -being into every single treatment plan
1:07:10
we devise. Thank you for such an enlightening
1:07:13
discussion today. If you found this deep dive
1:07:15
valuable, please do consider rating and sharing
1:07:18
this with your colleagues. It really helps us
1:07:19
reach more professionals. Thank you for tuning
1:07:22
in to the deep dive.