Two Thumbs Up

Nikki Roman's thumbs are essential to her work as an aesthetician
The eyes may be the window to the soul, according to “The Bard,” William Shakespeare, but Board Certified Orthopedic and Hand Surgeon Stephen O’Connell, MD, says it’s the hands that are essential to what we do and who we are. 

“A hand injury can be devastating to our ability to function in virtually every area of life — work, play, communication, maintaining our appearance, everyday activities like driving, or feeding and dressing ourselves,” says Dr. O’Connell. “The hands are part of our personality — who we are.

”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 this procedure requires some downtime, we usually don't perform it until the patient is experiencing function-limiting pain."- Stephen O'Connell, MD
“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