LRT Surgery: Understanding the Procedure, Recovery, and Risks

What is LRT Surgery?

LRT surgery, or Ligament Reconstruction and Tendon Interposition arthroplasty, is a surgical procedure commonly performed to alleviate pain and restore function in the thumb's carpometacarpal (CMC) joint, primarily due to severe osteoarthritis.

Understanding the Acronym: What Does LRT Stand For?

LRT stands for Ligament Reconstruction and Tendon Interposition. Each part of this name describes a critical component of the surgical technique:

• Ligament Reconstruction: Refers to the creation of a new stabilizing ligament at the base of the thumb. This is often achieved by using a portion of a local tendon, such as the flexor carpi radialis (FCR) tendon.
• Tendon Interposition: Involves removing the arthritic trapezium bone (one of the carpal bones at the base of the thumb) and then filling the created space with a rolled-up portion of the patient's own tendon (often the remaining part of the FCR tendon or another local tendon). This "interposition" acts as a cushion or spacer, preventing the thumb metacarpal bone from grinding directly against the scaphoid bone, which would otherwise occur after the trapezium's removal.

Purpose of LRT Surgery: Why is it Performed?

LRT surgery is primarily indicated for individuals experiencing significant pain and functional limitations due to advanced osteoarthritis of the thumb carpometacarpal (CMC) joint, also known as basilar joint arthritis.

• Indications:
  • Severe, persistent pain at the base of the thumb that is not relieved by conservative treatments (e.g., splinting, anti-inflammatory medications, corticosteroid injections).
  • Loss of pinch strength and grip strength.
  • Difficulty with daily activities requiring thumb use, such as opening jars, turning keys, or writing.
  • Imaging (X-rays) confirming significant degeneration of the CMC joint.
• Goals of the Surgery:
  • Eliminate or significantly reduce pain.
  • Restore strength and stability to the thumb.
  • Improve overall function and range of motion, allowing for a return to activities of daily living and recreational pursuits.

The Surgical Procedure: How is LRT Performed?

LRT surgery is typically performed on an outpatient basis under regional or general anesthesia. The procedure focuses on the thumb's CMC joint, which connects the metacarpal bone of the thumb to the trapezium bone of the wrist.

• Anatomical Focus: The thumb CMC joint is a saddle joint, allowing a wide range of motion crucial for pinch and grasp. However, its mobility also makes it susceptible to degenerative changes over time.
• Surgical Steps (General Overview):
  1. Incision: An incision is made at the base of the thumb.
  2. Trapezium Excision: The arthritic trapezium bone is carefully removed. This step is known as a trapeziectomy.
  3. Tendon Harvest: A small portion of a nearby tendon, most commonly the Flexor Carpi Radialis (FCR) tendon, is harvested.
  4. Ligament Reconstruction: One part of the harvested tendon is used to create a new ligament, often by drilling a tunnel through the thumb metacarpal and weaving the tendon through it, anchoring it to provide stability.
  5. Tendon Interposition: The remaining portion of the harvested tendon is rolled up or folded and placed into the space where the trapezium was removed. This acts as a biological spacer to prevent bone-on-bone grinding.
  6. Closure: The incision is closed, and a bulky dressing or cast is applied.
• Variations: While the FCR tendon is common, other tendons (e.g., extensor carpi radialis longus/brevis, palmaris longus) may be used depending on surgeon preference and patient anatomy. Some surgeons may also use an anchor or suture suspension to further stabilize the thumb metacarpal.

Recovery and Rehabilitation: What to Expect Post-Surgery?

Recovery from LRT surgery is a gradual process that requires patience and adherence to a structured rehabilitation program.

• Immediate Post-Op (0-2 weeks):
  • The hand will be immobilized in a cast or splint to protect the surgical site and allow initial healing.
  • Pain management is crucial, often involving prescribed medication.
  • Elevation of the hand is recommended to reduce swelling.
• Early Rehabilitation (2-6 weeks):
  • The cast is typically replaced with a removable splint.
  • Gentle, supervised physical or occupational therapy begins, focusing on passive and then active range of motion exercises for the wrist and fingers, avoiding the thumb initially.
  • Edema control and scar management are important.
• Intermediate Rehabilitation (6-12 weeks):
  • Gradual introduction of gentle active thumb range of motion exercises.
  • Light strengthening exercises for the thumb and hand begin, focusing on isometric contractions and then light resistance.
  • Activities of daily living are slowly reintroduced.
• Advanced Rehabilitation (3-6 months and beyond):
  • Progressive strengthening exercises are advanced, including grip and pinch strengthening.
  • Return to more demanding activities and sport-specific training, under the guidance of a therapist.
  • Full recovery and maximal strength can take 6 months to a year.

Potential Risks and Complications

While generally successful, LRT surgery, like any surgical procedure, carries potential risks:

• Infection: Though uncommon, it's a possibility with any incision.
• Nerve Injury: Temporary or permanent numbness, tingling, or weakness due to nerve irritation or damage.
• Tendon Rupture: Although rare, the reconstructed ligament or interposition tendon could rupture.
• Persistent Pain: Some individuals may still experience residual discomfort.
• Stiffness: Limited range of motion in the thumb or wrist.
• Complex Regional Pain Syndrome (CRPS): A rare, chronic pain condition that can develop after injury or surgery.
• Scar Sensitivity: Tenderness or hypersensitivity around the incision site.

Implications for Fitness and Movement

For fitness enthusiasts, understanding the long-term implications of LRT surgery is vital for a safe and effective return to activity.

• Return to Activity: A gradual, phased return is critical. High-impact activities or those requiring significant thumb stress should be avoided until full clearance from the surgeon and therapist. This often means modifying exercises or using adaptive equipment.
• Modifications and Precautions:
  • Grip-intensive exercises: Activities like heavy lifting, pull-ups, or gripping sports equipment may require modifications (e.g., using straps, changing grip width, reducing weight) initially and potentially long-term.
  • Weight-bearing on hands: Exercises like push-ups, planks, or yoga poses that put direct pressure through the palm and thumb may need to be modified or avoided depending on individual recovery and comfort.
  • Impact activities: Sports involving catching or throwing may require a longer return-to-play protocol.
  • Listen to your body: Any new or increased pain should be a signal to stop and reassess.
• Long-Term Function: Most patients experience significant pain relief and improved function, allowing them to return to many, if not all, of their pre-surgical activities with greater comfort. However, some minor limitations in extreme range of motion or maximum grip strength compared to the unoperated hand may persist. Regular hand exercises and maintenance of strength are often recommended indefinitely.

Who is a Candidate for LRT Surgery?

Candidacy for LRT surgery is determined by an orthopedic surgeon, typically a hand specialist. It's usually reserved for individuals with:

• Advanced CMC joint arthritis.
• Significant pain and functional impairment.
• Failure of conservative (non-surgical) treatments.
• Good overall health and realistic expectations regarding recovery and outcomes.

Conclusion

LRT surgery is a well-established and effective treatment for severe thumb CMC joint osteoarthritis, offering substantial relief from pain and improved hand function. While the recovery process is extensive, adherence to a structured rehabilitation program is key to optimizing outcomes. For individuals whose daily lives and fitness pursuits are significantly impacted by thumb base pain, LRT surgery can be a transformative intervention, allowing for a return to a more active and pain-free lifestyle. Always consult with a qualified hand surgeon to determine if LRT surgery is the right option for your specific condition.