Richard Baker Blog

What is arthritis of the thumb?

Arthritis at the base of the thumb is very common particularly, in women over the age of 40 years old. It’s probably caused by weakening of the ligaments over the years through exposure to estrogen which is the female hormone. Weakening of the ligament means the thumb partially dislocates from its joint on the hand leading to wear and tear of the cartilage which is essentially what arthritis is. It leads to new bone formation, causing spikes of bone which can dig into the surrounding flesh and causing inflammation of the tissues around the joint. This leads to pain but also to deformity of the joint and reduced range of motion, strength and function. In many patients it’s painful for a few years and then burns it’s self out. In other patients, it’s persistently painful and these patients require treatment. The main treatment is avoiding activities that cause pain but also wearing splints at times of exacerbation of pain, taking pain killers, both tablets but also creams and gels which can be applied to the skin, steroid injections where the steroid is injected directly into the joint under a local anaesthetic, sometimes it’s necessary to use ultrasound on an x-ray machine to ensure the needles are in the right place, very often this can be administered in clinic. Often the joint is more painful after a steroid injection for a day or two and it can take several days for the steroid to kick in and can last up to six months. Steroid injections can be repeated over time and tend to last for shorter and shorter periods. We’re not quite sure why steroid injections work but steroids dampen down inflammation and inflamed tissue is painful.

In some patients, steroid injections and other treatments are not sufficient in controlling the pain and we have to consider surgery. The options begin with denervation, which is where the small nerves that go to the joint are cut and this stops the joint transmitting pain to the brain and so the arthritis goes on, the patient can’t feel the pain. I like to perform this operation in patients who are young, still working and whose joints are not particularly damaged on the x-ray. This is because of the recovery is much quicker and leaves open the possibility of doing other operations. The next option is trapeziectomy which means removing the arthritic piece of bone, which is called the trapezium, and in some patients reinforcing it with nearby tendons to stabilise the thumb. This is a good operation for people whose arthritis is quite advanced and who want a definitive solution. The recovery can take several months and it is quite painful afterwards. However, the pain relief is often permanent.

The last option is a joint replacement and I like to use the operation in people whose arthritis is only moderately advanced. It has the advantage in the recovery is quicker than in a trapeziectomy and the length of the thumb is maintained with a good range of motion. However, joint replacements aren’t strong, so I’d be cautious about using this in a man particularly in a manual worker.  All of these operations would require some time off work. For denervation, I’d recommend around two weeks off work, for trapeziectomy, I’d recommend six weeks off work and for a joint replacement something like four weeks.

All of these operations involve a scar about an inch long on the base of the thumb. Other risks include infection, swelling, stiffness and incomplete pain relief or problems with ongoing pain caused by things such as damage to nearby nerves.

Richard Baker Blog

Who are seeking breast uplift and implants?

This week I’ve seen several patients who are seeking breast uplift and implants. Otherwise known as augmentation mastopexy. It strikes me after seeing several different types of patients requesting this surgery, that there are two main groups of patients who request this but actually need slightly different operations. The first type of patient is a woman who’s had children and has breast fed and has lost volume, such that the breasts have then become deflated and droopy. These patients require a small implant to restore lost volume particularly in the upper part of the chest as well as a lift to tighten up the skin and reduce the droopiness. As a small implant is being used and no breast tissue is being removed, this can be safely performed in one procedure.

However, there is a second group of patients who have larger, droopier breasts whom have not necessarily had children or breastfed and these patients often want lifted, firmer breasts and a rounder shape but I don’t believe that they’re expectations can be met with a single procedure. These patients actually would be served better if they had a formal breast reduction, so removal of the breast tissue, lifting of the nipple and tightening of the skin, followed three to six months later by insertion of medium to large breast implants although it’s possible to reverse the order of the procedures. This technique replaces the breast tissue, which is naturally prone to drooping over time, with a breast implant which maintains its shape permanently and because the implant is relatively big, it augments the volume in the upper part of the chest more effectively.

However, this technique does require two operations and that is because removing a significant amount of breast tissue whilst putting in big implants compromises the blood supply to the nipple, which can lead to the nipple not surviving the procedure and also lead to problems in healing. I think it’s very important to distinguish between a patient that is suitable for a breast uplift and implants in one operation and a patient that needs breast reduction, followed by large breast implants in two operations.