Trapezium Surgery: Indications, Types, Recovery, and Risks

What is a Trapezium Surgery?

Trapezium surgery refers to surgical procedures primarily performed on the trapezium bone, one of the carpal bones located at the base of the thumb in the wrist. The most common indication for such surgery is severe osteoarthritis affecting the carpometacarpal (CMC) joint, often referred to as basal joint arthritis of the thumb.

Understanding the Trapezium Bone and Its Role

The trapezium bone is a small, irregularly shaped carpal bone situated at the radial (thumb side) aspect of the wrist. It forms the critical carpometacarpal (CMC) joint with the first metacarpal bone of the thumb. This unique saddle-shaped joint allows for the thumb's extensive range of motion, including opposition (touching the fingertips), flexion, extension, abduction, and adduction. These movements are fundamental to fine motor skills, grasping, pinching, and overall hand dexterity. Due to its constant use and the forces it withstands, the CMC joint is highly susceptible to degenerative wear and tear, leading to osteoarthritis.

Why is Trapezium Surgery Performed? (Indications)

Trapezium surgery is typically considered when conservative treatments fail to alleviate significant pain, stiffness, weakness, or loss of function caused by conditions affecting the trapezium bone and its associated joints. The overwhelming majority of these surgeries are performed for basal joint (CMC joint) osteoarthritis of the thumb.

Key indicators for surgery include:

• Severe, persistent pain at the base of the thumb that interferes with daily activities, even at rest.
• Significant weakness in grip and pinch strength.
• Loss of thumb motion and difficulty with tasks requiring dexterity (e.g., opening jars, turning keys, writing).
• Failure of conservative treatments, such as splinting, anti-inflammatory medications, corticosteroid injections, and physical therapy.
• Radiographic evidence of advanced CMC joint degeneration.

Less common indications might include certain fractures or other degenerative conditions affecting the trapezium.

Types of Trapezium Surgery

Several surgical techniques exist, tailored to the individual's specific condition, severity of arthritis, and the surgeon's preference. The goal of most procedures is to alleviate pain by removing or replacing the damaged joint surfaces and restoring stability and function.

• Trapeziectomy: This is the most common procedure and involves the complete surgical removal of the trapezium bone. By removing the arthritic bone, the painful bone-on-bone grinding is eliminated. While effective for pain relief, simply removing the bone can lead to instability or shortening of the thumb.
• Ligament Reconstruction Tendon Interposition (LRTI): This is often performed in conjunction with a trapeziectomy. After the trapezium is removed, a portion of a local tendon (e.g., flexor carpi radialis or abductor pollicis longus) is harvested. This tendon is then used to:
  • Reconstruct the damaged ligaments to stabilize the thumb metacarpal.
  • Coil or interpose the remaining tendon into the space left by the removed trapezium, creating a "cushion" or "spacer" to prevent the thumb metacarpal from sinking and rubbing against the scaphoid bone.
• Suspension Arthroplasty: A broader term that describes various techniques used to suspend or stabilize the thumb metacarpal after trapeziectomy, often using a tendon graft, to maintain the joint space and prevent collapse. LRTI is a form of suspension arthroplasty.
• Arthrodesis (Fusion): In select cases, particularly for younger, heavy laborers where maximum stability is prioritized over full range of motion, the CMC joint may be surgically fused. This eliminates pain by preventing movement at the joint but results in a permanent loss of thumb mobility at that specific joint.
• Implant Arthroplasty: Less common for the CMC joint compared to other joints, this involves replacing the damaged joint surfaces with an artificial implant (prosthesis). This option aims to preserve motion while relieving pain, but implants can have issues with wear, loosening, or dislocation.

The Surgical Procedure: What to Expect

Trapezium surgery is typically performed on an outpatient basis, meaning the patient can go home the same day.

• Anesthesia: Local, regional (arm block), or general anesthesia may be used.
• Incision: A small incision is made on the back or side of the wrist at the base of the thumb.
• Bone Removal/Reconstruction: The surgeon carefully removes the trapezium bone. If an LRTI or suspension arthroplasty is performed, the necessary tendon graft is harvested, and the remaining steps of reconstruction and interposition are completed.
• Closure: The incision is closed with sutures, and a sterile dressing is applied. The hand and wrist are then typically immobilized in a cast or splint.

Recovery and Rehabilitation

Recovery from trapezium surgery is a multi-phase process requiring patience and adherence to a prescribed rehabilitation program.

• Immediate Post-Op (0-6 weeks): The hand will be immobilized in a cast or splint to protect the healing tissues. Pain management is crucial, often involving oral pain medications. Swelling reduction through elevation and ice is also important.
• Early Rehabilitation (6-12 weeks): Once the initial healing phase is complete and the cast is removed, a structured hand therapy program begins. This involves gentle range-of-motion exercises to prevent stiffness, scar massage, and light strengthening exercises. The hand therapist guides the progression based on healing and pain levels.
• Advanced Rehabilitation (3-6 months+): As strength and mobility improve, the exercises become more challenging, focusing on restoring grip strength, pinch strength, and fine motor control. Gradual return to light daily activities and eventually more demanding tasks or sports is permitted under the guidance of the therapist and surgeon.
• Full Recovery: While significant improvement is seen within 3-6 months, full recovery and maximal strength gains can take up to a year or more. Some residual stiffness or mild discomfort with very heavy activities may persist.

Potential Risks and Complications

While generally safe and effective, trapezium surgery, like any surgical procedure, carries potential risks:

• Infection: Though rare, infection at the surgical site can occur.
• Nerve Damage: Injury to sensory nerves can lead to numbness, tingling, or hypersensitivity in parts of the hand or thumb.
• Persistent Pain: While the goal is pain relief, some individuals may experience ongoing discomfort.
• Stiffness: Adhesions or scar tissue can limit thumb or wrist motion.
• Instability or Weakness: Despite reconstruction, some degree of instability or reduced strength may remain.
• Complex Regional Pain Syndrome (CRPS): A rare but serious complication involving chronic pain, swelling, and changes in skin temperature/color.
• Scar Sensitivity: The surgical scar may remain tender or sensitive to touch for an extended period.
• Tendon Rupture (for LRTI): Although uncommon, the reconstructed tendon could potentially rupture.

Alternatives to Surgery

Before considering surgery, a comprehensive course of non-surgical (conservative) treatments is almost always recommended. These include:

• Activity Modification: Avoiding activities that exacerbate pain.
• Rest and Ice: Reducing inflammation and pain.
• Splinting or Bracing: Providing support and immobilization to rest the joint.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Oral medications like ibuprofen or naproxen to reduce pain and inflammation.
• Corticosteroid Injections: Injections directly into the CMC joint to reduce inflammation and provide temporary pain relief.
• Physical or Occupational Therapy: Exercises to improve range of motion, strength, and technique for daily tasks.

When to Consider Surgery

Trapezium surgery is typically reserved for individuals who have exhausted conservative management strategies and continue to experience significant pain, functional limitations, and a reduced quality of life due to basal joint arthritis. A thorough evaluation by a hand surgeon is crucial to determine if surgery is the most appropriate course of action, weighing the potential benefits against the risks for each individual.

Conclusion

Trapezium surgery, most commonly a trapeziectomy with or without tendon interposition, is a well-established and effective procedure for alleviating the debilitating pain and functional impairment caused by severe basal joint osteoarthritis of the thumb. While demanding a dedicated rehabilitation period, the procedure often leads to significant pain relief, improved thumb function, and an enhanced ability to perform daily activities, ultimately improving the patient's quality of life.