”Dr. O’Connell’s patient Debra “Nikki” Roman is a case in point. She’s been a successful aesthetician for nearly 22 years (she owns the spa at Salon 119 Beauty & Spa in Palm Springs, a five-time winner of Palm Springs Life magazine’s “Best of the Best” awards). But arthritis in her hands threatened to derail the career she loves. “It started over 10 years ago when I began feeling weakness in the joint at the base of my right thumb,” she explains. “It got worse and worse — and more painful. So I went to see Dr. O’Connell, who did some imaging that revealed signs of osteoarthritis. I was only 50 at the time.
“My line of work is hard on certain joints, like the base of the thumb,” Roman notes. “Plus, I have arthritis on both sides of my family.”
Basal thumb arthritis affects women more
“Basal thumb arthritis is the most common form of arthritis that requires treatment in the hand,” says Dr. O’Connell. “We usually see it after age 40, and it’s 10 times more common in women than men.
“Between the ages of 50 and 60, women and men experience basal thumb osteoarthritis at rates of 15 and seven percent, respectively,” he adds. “By age 75, 25 percent of men and 40 percent of women have X-ray findings of this type of arthritis involving the thumb.”
Despite its prevalence, basal thumb osteoarthritis doesn’t always cause symptoms, which can range from occasional discomfort to intolerable pain that limits the ability to function. Symptoms usually occur with activities that require gripping or pinching, which often is perceived as decreased strength in the thumb or hand, as in Roman’s case.
“While Debra does a lot of loading and pushing of the thumb in her work, most things you do with the hand involve pinching,” Dr. O’Connell explains. “If you exert 20 pounds per square inch (PSI) pinching the tip of the thumb and the index finger together, that translates to 240 PSI at the base of the thumb — 12 times the pinch strength at the base.
“Because of this load, the joint at the base of the thumb can wear down like a hip or knee joint,” he continues. “But a hip joint is a ball in a socket, so it’s very stable by virtue of its bony confines. “The thumb, however, is a saddle joint that gets its stability from ligaments that attach the base of the thumb to the trapezium,” he says, referring to a bone in the wrist. “When there’s inflammation from arthritis, those ligaments stretch out and the joint becomes unstable and loose.
“So when you pinch and load 200 or 300 pounds across that joint, it starts to dislocate, and you get sharp, stabbing pain,” Dr. O’Connell says. “That makes it tough to load your thumb and grab anything, or perform repetitive motions, even simple things like zipping up your pants or opening a jar.
“Patients will frequently come in with weakness, but also because it hurts,” he adds. “The weakness occurs because the brain protects you and signals you to loosen your grip when you feel pain.”
Conservative treatments first
The first line of treatment for basal thumb arthritis involves conservative (non-surgical) measures, including cortisone injections to calm inflammation and reduce pain, oral or topical antiinflammatory medications, splinting to rest the joint, and activity modification (golfers, for example, can adjust their grip once they understand the mechanics involved).
“I wore a brace at night and got by with cortisone injections for several years,” Roman says. “The relief from the shots was instantaneous, and would last seven or eight months at first. Then I was having them every three to four months; finally, they just stopped working.”
She gives kudos to Dr. O’Connell’s physician assistant Andrew Allen, PA, who administered the injections.
“He’s brilliant,” she says. “It’s a big needle going into a tiny joint, but he’s so good at it, I could just sit there while he did it. “I waited as long as I could to have surgery because I knew I’d be out of work for a while after the operation and I’m self-employed,” she says. “But it got to the point where it was either have the surgery or I wouldn’t work any more, period.”
That point came in July of 2015, and Roman underwent a procedure to remove the painful joint in the base of her right thumb and recreate the stability of the joint through ligament reconstruction. This procedure is called ligament reconstruction with tendon interposition (LRTI) arthroplasty.
What surgery involves
“While there are multiple versions of surgery that we can do, I like this procedure because it not only addresses the arthritis but also ligament instability, providing better motion and stability,” Dr. O’Connell says. He has performed nearly 1,500 LRTI arthroplasties to date — an average of 60 per year — more than any other hand surgeon in the desert.
LRTI is performed on an outpatient basis under regional or general anesthesia, and takes about 60 minutes. It involves removing the trapezium, one of the bones that make up the joint at the base of the thumb, called the carpometacarpal joint, eliminating the painful contact between the bones. This is done through a small incision over the base of the thumb.
To address ligament instability, Dr. O’Connell uses a tendon graft to stabilize the remaining bone of the joint. He obtains a tendon graft through two small incisions in the wrist and forearm. This part of the procedure not only restores stability to the joint but also recreates the thumb’s normal functional position.
“Recovery usually takes about three months, and four to six months altogether to regain full strength and function after surgery,” Dr. O’Connell says, noting that patients wear a cast for about six weeks post-surgery, then a splint for another month while undergoing occupational therapy.
“Because this procedure requires some downtime, we usually don’t perform it until the patient is experiencing function-limiting pain,” he adds.
“The surgery went really well,” Roman relates. “Dr. O’Connell and his office staff explained everything so I knew what to expect and what I needed to do. I did everything they told me, and had 100 percent success. I was out of work for four months from beginning to end, most of it over the summer. And when I returned to work, it was like nothing had ever been wrong. After so many years of pain, that was pretty amazing.”
On the other hand
In the meantime, however, Roman started having problems with her left thumb. Up until early 2018, cortisone injections were keeping the pain under control. Then, once again, they stopped providing relief — and it was time to consider surgery again.
“I had such faith in Dr. O’Connell that I had no doubt I’d have a good result,” Roman says. “So, I had my second procedure last July. “I knew first-hand what to expect,” she continues, “and this time, I was back to work in just two months, doing waxing and lash extensions — nothing that put pressure on the joint.
“I went to occupational therapy again but by the fourth visit, ten weeks after surgery, I was able to press 50 pounds of pressure and they said I didn’t need them anymore,” she adds. “And I was off pain medication in no time at all.
“There’s nothing I can’t do”
“I have gotten all my strength back in both hands,” Roman says. “My clients tell me there’s nothing wrong with these hands. There’s nothing I can’t do, and my life has gone back to doing everything I want — but with no pain.
“At one point, people I knew were saying to me that maybe I should consider another career,” she continues. “But I love what I do, and look forward to going to work. For me, there was no other option but surgery. And if anyone I know has hand issues, I tell them with 100 percent confidence to see Dr. O’Connell. He’s a great doctor, with a great team.
“Today, it’s as if there was never anything wrong with my hands,” she adds. “They’re as strong and healthy as they ever were.” “It’s very satisfying to be able to give that back to my patients,” says Dr. O’Connell.
To make an appointment with a physician at Eisenhower Desert Orthopedic Center, call 760.773.4545, or to learn more, or listen to a podcast, visit EisenhowerHealth.org/Hand