Dr. Hubert Klauser is a renowned specialist in foot surgery, ankle surgery, sports traumatology and hand surgery, who combines his expertise at the HAND AND FOOT CENTRE BERLIN. As medical director of the facility, Dr. Klauser not only has extensive experience in the diagnosis and treatment of diseases of the hands and feet, but has also made significant contributions to the further development of orthopaedics through the development of innovative implants. Dr. Klauser has made a name for himself in particular through his pioneering work in the field of forefoot surgery and hallux valgus treatment. He uses advanced, magnesium-based and bioresorbable implants, which he himself helped to develop. The advantage of these implants is that they promote the natural formation of new bone and do not require subsequent operations to remove metal. The positive effectiveness of this technology is proven by scientific studies and numerous successful applications.
Dr. Klauser is also a recognized author of numerous specialist publications and is actively involved as an orthopaedic expert and trainer. His experience and knowledge benefit not only his patients, but also the professional community as he shares his findings at national and international conferences. Dr. Klauser offers comprehensive treatment options for patients of all ages, including athletes and people with complex orthopaedic needs. His expertise in functional orthopaedics and sports orthopaedics complements his broad range of treatments and is reflected in his patient-centered practice. Dr. Klauser stands for sound and modern orthopaedic care based on both innovative techniques and proven treatment methods.
Rhizarthrosis is the most common form of osteoarthritis of the hand, and the editors of the Leading Medicine Guide were able to talk to Dr. Klauser about this in particular.
Osteoarthritis is a widespread joint disease characterized by the progressive breakdown of cartilage tissue in the joints. This process leads to a variety of symptoms, including pain, stiffness and limited mobility. The disease can affect all joints, but is particularly common in the knees, hips and hands. The symptoms usually develop gradually and worsen over time, which can lead to a significant reduction in quality of life. The causes of osteoarthritis are varied and range from age-related changes and genetic predispositions to injuries and overloading of the joints. While there is no cure for osteoarthritis, various therapeutic approaches, such as drug treatment, physical therapy and surgery, can help to alleviate the symptoms and maintain the function of the affected joints.
Rhizarthrosis is a special form of osteoarthritis that affects the so-called thumb saddle joint (thumb root joint), i.e. the joint at the base of the thumb. This disease leads to gradual destruction of the cartilage tissue in the joint, resulting in pain, stiffness and limited mobility of the thumb. Rhizarthrosis is common in older adults, but can also occur in younger people due to overuse or injury. Symptoms typically manifest as pain when moving the thumb, especially when gripping, and increasing weakness of the thumb.
The thumb saddle joint plays a central role in the mobility and function of the thumb.
It is located at the base of the thumb, where the first metacarpal bone articulates with the trapezoid bone (os trapezium) of the wrist. This joint enables a variety of movements that are essential for everyday tasks. “If you translate the word rhizarthrosis, which comes from the Greek, rhizon means root. Of particular note is the thumb's ability to oppose, in which the thumb moves towards the palm of the hand and enables objects to be grasped and held. Repositioning, in which the thumb is moved back to the starting position, is also an important function. Flexion and extension, the bending and stretching of the thumb, as well as abduction and adduction, the movements away from and back to the palm, are also crucial for precise hand movements. These movements are essential for numerous everyday activities such as writing, gripping objects and crafts. The thumb saddle joint therefore contributes significantly to the functionality and dexterity of the hand and enables a variety of complex hand movements, which makes the thumb and therefore the hand unique. And if the thumb-saddle joint does not work, the gripping function of the hand is also considerably restricted. What is also important to know is that the thumb joint is not a ball-and-socket joint, but an egg-and-dart joint. This means that there is no joint position where the joint partners slide congruently in relation to each other, as is the case with the hip, for example, and therefore the wear and tear on the joint surface partners also varies,” explains Dr. Klauser at the beginning of our conversation.
The first symptoms of rhizarthrosis are usually pain and limited mobility of the thumb.
At the beginning, the pain can occur particularly during certain activities such as gripping objects or opening jars. Pain can also be felt during everyday tasks such as holding a pen or lifting bags. This pain often occurs during exertion and can also become noticeable during periods of rest as the disease progresses. “Those affected notice the symptoms, for example, when they try to open a bottle and it falls out of their hand. Or the thumb hurts when you try to turn the key in a door. Some patients are unable to grasp objects at all. There is also discomfort in the ball of the thumb. This is caused by an inflammation that develops in the thumb saddle joint if you have osteoarthritis. In addition to the pain, there are also real restrictions in movement in advanced stages. My personal experience with patients is very different. In some cases, I am often surprised that despite stage IV of IV osteoarthritis, the pain is not yet so pronounced, whereas other patients with stage II have considerable pain and then have to undergo surgery. So it's very different. You can't deduce a pain stage from the X-ray imaging,” explains Dr. Klauser.
The process of cartilage degeneration often begins with tiny cracks and irregularities in the cartilage, which gradually expand. Over time, the cartilage becomes thinner and loses its smooth, elastic structure. As the cartilage continues to deteriorate, the protective layer between the bone ends becomes thinner and thinner until eventually bone can rub against bone. This direct rubbing of the bone ends causes severe pain and inflammation. The loss of cartilage reduces the space that normally forms the joint space. The joint space, which is visible on x-rays as the space between the bones, becomes increasingly narrow. This narrowed joint space is a typical radiological sign of osteoarthritis. The more the cartilage degrades, the less space remains between the bones and the joint space becomes correspondingly narrower. In addition to the narrowing of the joint space, bone spurs (osteophytes) can form at the edges of the joint, further restricting the range of movement and causing pain. Chronic inflammation can lead to swelling and further damage to the joint structures. Ultimately, this process results in a significant restriction in the mobility and function of the thumb saddle joint, making everyday activities such as gripping and holding more difficult.
“At the first symptoms, patients are given a so-called rhizoring orthosis, which surrounds the thumb saddle joint with a silicone ring. The thumb remains completely free and can be moved fully, while the joint itself is stabilized without immobilizing it. Laser and magnetic field therapy are also available, and if the pain is more intense and you want to take a more aggressive approach, radial shock wave therapy can also be used, although this is relatively painful. I recommend magnetic field therapy first, because if patients, usually women, also have osteoarthritis of the finger joints, both hands can be treated completely. However, this is only suitable in the early stages. Injections of cortisone can also be administered. However, the joint space must not be too narrow for this. In this case, injections are not effective. Injections with hyaluronic acid or autologous blood can also help, although it is often difficult to reach the joint with the injection. Physiotherapy and occupational therapy can also help. What is also offered is X-ray irradiation, which I personally do not approve of due to the radiation exposure and the effectiveness of the therapy is also too short,” explains Dr. Klauser.
Total thumb saddle joint endoprosthesis (TEP) offers several specific advantages compared to traditional treatment methods for rhizarthrosis, especially when conservative measures are no longer sufficient to control symptoms and improve the functionality of the joint.
A major advantage of the thumb saddle joint TEP is the significant pain relief it can offer patients. Compared to conservative methods, which often only provide temporary relief or are aimed at symptomatic improvement, arthroplasty can provide a permanent solution to pain with an unrestricted range of motion. “The HEMI prosthesis, a partial arthroplasty, has not proved successful for the thumb saddle joint. I have been using the TEP for 20 years, always the same model with certain modifications, which has proved its worth. Resection arthroplasty, also known as Epping plastic surgery, has also been around for 40 years. This involves removing the large polygonal bone (the joint partner to the first metacarpal bone) in order to eliminate the painful contact between the joint surfaces. The disadvantage of this outdated surgical method is that, over time, the first metacarpal bone slips onto the next carpal bone, namely the scaphoid. After the bone has been removed, an interposition arthoplasty is therefore performed, usually with a tendon, to ensure the stability of the joint. However, a tendon is not vital and can break or thin out. To improve this, the idea of taking part of the tendon and attaching it to the first and second metacarpal bones - a suspension arthroplasty - came about. To do this, a hole is drilled at the base of the second metacarpal and a tendon is looped from the thumb through the hole in the second metacarpal and through the first metacarpal, preventing the first metacarpal from slipping onto the scaphoid. This principle also works well, but it is a laborious operation and the results have not been very satisfactory. There is also the option of stiffening the thumb saddle joint with screws and plates. The restriction of movement is then of course limited. But you can stiffen it in such a way that you can manage quite well,” explains Dr. Klauser and then returns to the subject of TEP:
“The TEP, which is usually made of titanium (hydroxyapatite-coated to optimize healing) and has a polyethylene inlay, is experiencing a boom and great acceptance today. The main advantage of a TEP is strength, excellent mobility and a short rehabilitation period. A TEP is conceivable for almost every patient, except if the subsequent joint, the scaphoid-trapezium-trapezoid joint (STT joint between the scaphoid, large polygonal bone and small polygonal bone), is also osteoarthritic. This is because the patient would not benefit from a TEP in this case, as pain is not only caused by the thumb saddle joint, but also by the STT joint. In this case, resection arthroplasty makes more sense. The average operation time for a TEP is 35-45 minutes. For this, the base of the first metacarpal bone is finely sawed off, the stem of the endoprosthesis is milled and implanted in the first metacarpal bone, and the socket bearing for the socket of the TEP is milled in the polygonal bone. The whole thing then looks like a miniature hip endoprosthesis. The head-neck component can then be inserted between the cup and stem in the appropriate length and flexion. As far as durability is concerned, no long-term studies are yet available. In one of my patients, whom I fitted with a TEP in 2004, the prosthesis is still holding up. Around 15 years is the rule. I have not yet had to revise, i.e. “remove”, a TEP."
Depending on the material and load, the prosthesis can last for many years, ensuring long-term stability and functionality. Finally, the thumb saddle joint TEP reduces the need for repeated surgical procedures or ongoing conservative treatments that may become necessary as the disease progresses. By implanting a TEP, the risk of ongoing inflammation and degradation of adjacent tissue is minimized, resulting in a more stable and sustainable solution.
As with any surgical intervention, there are risks and potential complications associated with the implantation of a thumb saddle joint total endoprosthesis (TEP) that patients should be aware of.
“A high level of expertise in the use of TEP is important, and the learning curve for this is high. You need around 100 operations to have a sufficient level of experience. The difficult part of the operation is inserting the cup. You have to be careful when rasping the metacarpal bone to insert the stem of the TEP, as this can break. And if you mill the cup bearing for the 'press-fit' procedure, you cannot correct it as often as you like, otherwise the polygonal bone may burst. After all, the bone material is no longer of this youthful elasticity. However, this happens extremely rarely. In the last 20 years, I have successfully implanted over 1000 DSG TEPs, so I am well placed to assess the challenges involved,” states Dr. Klauser.
Post-operative rehabilitation after implantation of a total thumb endoprosthesis (TEP) plays a decisive role in the success of the procedure and the return to normal activities.
“The patient usually stays in hospital for two nights. 10-15 years ago, I performed the operations on an outpatient basis and am now doing them on an inpatient basis again because the hygiene in outpatient surgery centers is not designed for such endoprosthetic procedures. Rehabilitation for a TEP is very quick. A plastic longgette is placed over the thumb for two weeks and the patient is then given an orthosis, but the fingers can be moved. Then the physiotherapy, occupational therapy or hand therapy starts, and after six weeks at the latest, the patient is fully fit for everyday life again,” Dr. Klauser makes clear and expresses another personal wish: ”The status quo is very good, and I am satisfied with the quality of the TEPs. We also have what is known as 'double mobility' here, which means that the head swings flexibly in the socket during the TEP, which also offers increased protection against dislocation. This has been copied from the hip endoprosthesis. Personally, I would like to see even greater acceptance among hand surgery colleagues for the installation of a DSG TEP”. And that concludes our conversation.
Thank you very much, Dr. Klauser, for giving us such a good insight into the complexity of the hand!
