Michael Anderson, MD (Host): Hello, everyone. And welcome to this episode of The FortCast, the official vodcast of Fort HealthCare. I'm your host, Dr. Michael Anderson, ear, nose and throat, physician and president and CEO of Fort HealthCare. And with me today is a very special guest. We have Dr. Matthew Bliss with us. Dr. Bliss is one of our exceptional orthopedic surgeons. And I want to welcome Dr. Bliss to the program. Thank you, Dr. Bliss, for joining us today.

Matthew Bliss, MD: Thanks for having me, Mike. This is great.

Host: And I know we're going to talk about arthritis in our hands and wrists, a very common topic. But before we get into that, Dr. Bliss, can you just give us a little bit of background on, say, maybe how long you've been with Fort HealthCare and a little bit of your education?

Matthew Bliss, MD: Sure. I joined Fort HealthCare here in 2018, so about eight years now. It seems like it was yesterday, but it's been eight great years, and looking forward to more. So, education-wise, I attended a undergraduate at the US Naval Academy in Annapolis. And then, after five years in the US Navy, I then went to medical school back home at the University of New Mexico in Albuquerque. I then attended residency in orthopedic surgery at Wake Forest University in North Carolina.

And after that, I did a year-long hand and upper extremity specialty fellowship at the University of Cincinnati, then made my way to Wisconsin. Now, here I am.

Host: Well, Dr. Bliss, first of all, thank you for your service. And we are very thankful that you made your way to Wisconsin. I mean, you do such an amazing job taking care of our patients and our community. Truly, thank you for being part of our medical staff here at Fort HealthCare, and it is just wonderful to have somebody with your level of expertise being fellowship-trained in hand and upper extremity is a huge, huge treat for our patients and families. So, thank you.

Matthew Bliss, MD: Well, you're very kind. And thank you.

Host: Well, let's just dive in. So, Dr. Bliss, arthritis of the hand and of the wrist, you must see a lot of patients that come in for this issue. So, why don't we just level set, and can you explain to us like what is arthritis and what are the typical presenting symptoms of that?

Matthew Bliss, MD: Of course. Arthritis is definitely the bread and butter of our hand and upper extremity clinic here. We see all sorts of patients suffering from different types of arthritis and offer an array of different treatments, conservative and surgical, for various arthritis conditions. So, it is something that I think everybody experiences at some time in their life, aching hands, aching fingers, aching wrist.

We'll start off with one of the most common types that we see. A typical patient will come in and say, "Hey, you know, Doc, my thumb is killing me." And I'll say, "How long that's been going on?" And they'll say, "You know, probably about a year, two years now. And every time I grab the jar to the mayonnaise or the pickle jar, oh, it hurts—or when I'm ringing out a washcloth, it hurts right there at the base of my thumb. So, this is a very common ailment that we see. And what this oftentimes turns out to be an entity known as basal joint arthritis.

The basal joint is the joint at the base of your thumb, and it's a pretty complex joint. It's saddle-shaped and it sees a lot of pressure when we pinch and grip up to about a hundred PSI. So with time and life, that joint tends to wear out. And so, when we talk about arthritis, what we're really talking about is injury to the cartilage, which is the smooth, rubbery surface that lines the joints. And when people develop significant arthritis, they have lost that cartilage and instead have bone-on-bone contact. And that bone-on-bone contact hurts. Our bones are very well-innervated. We know that every time you smack your shin against the coffee table, that's what gives people this dull toothache pain in the base of their thumbs. So, very common.

Host: So, Dr. Bliss, is this something that normally people come in to see somebody with your level of expertise right away, or do they typically go to their primary care provider? And if they do go to the primary care provider, what sort of entry level treatments do patients try before they would see somebody with your expertise?

Matthew Bliss, MD: Sure. I would say that the vast majority of the patients that we see get to us via the primary care provider. They will mention the thumb pain when they're in for their annual exam or in for a blood pressure check. And the doctor asks, "Anything else going on?" And they'll mention this. So oftentimes, our family practice physicians, our internal medicine physicians will then get them started in treatment. And that usually involves a visit with our hand therapist, our occupational therapists and/or some splinting, as well as some over-the-counter medications, usually Tylenol and ibuprofen.

Host: So when that fails and they end up seeing you, what goes into the diagnostic workup for somebody when you're suspicious that this is what they have?

Matthew Bliss, MD: Sure. Once they get to us, really there's three levels of diagnosis here. Really, the first is listening to the patient's story. And the pain that they described with very specific things is very classic for this type of arthritis. As I mentioned earlier, pain with pinching and gripping is a hallmark of this issue.

Second modality we use is x-ray, plain old x-ray. And an x-ray done correctly will definitely demonstrate those arthritic changes at the joint where we see the joint being narrowed. We'll see bone spurs growing. And oftentimes, we'll even see loose pieces of bone within the joint, all indicating that that cartilage has been severely damaged and the patients living with a bone-on-bone type situation in the thumb.

And then, lastly, physical exam, there are some very specific physical exam maneuvers that definitely tell you that's where the pain is coming from, and you do them right and you will know exactly what the problem is.

Host: So, Dr. Bliss, once you've gone through that diagnostic process and these patients aren't necessarily getting the results that they want to get from either pharmaceutical means or by the expertise of the occupational therapy team, what other sort of treatments exist for these patients?

Matthew Bliss, MD: Certainly. I should mention, with the occupational therapy treatments, one of their hallmarks of treatment is to provide a splint for the patient. Now, splinting any joint with arthritis will help with the pain, certainly. The problem is it's hard to splint your thumb, your thumb's important, you use it for a lot of things. And although the splint can help with the pain, it does certainly restrict patients. I find a vast majority of them don't tolerate this for long periods of time.

So once people have passed the conservative therapy point, we move into more interventional therapies. And one of the first-line treatments for any type of arthritis is to consider cortisone injections. Cortisone is a powerful local anti-inflammatory medication that is injected into the joint. We use it in knee arthritis, shoulder arthritis, wrist, et cetera. Now, certainly, cortisone injections for the thumb basilar joint are offered to the patient. The downside is it's a small joint and putting fluid in it is not comfortable. So, it's not an enjoyable injection. And oftentimes, the results are temporary. The relief will wear off eventually.

Host: What percentage of patients would you say, Dr. Bliss, just in your practice, seek out the the cortisone injection?

Matthew Bliss, MD: Honestly, talking to them about it, giving them the pros and cons, I would say maybe 20%. Most people are interested in a more permanent solution to the problem.

Host: Well, it sounds like a small percentage. So, what is that permanent solution, Dr. Bliss?

Matthew Bliss, MD: Permanent solution is then surgical intervention, and numerous types of surgeries have been described for this type of arthritis. But the classic and the standard of care surgery is referred to as a thumb CMC joint arthroplasty. And really what that is is a joint replacement. So, imagine, if you will, you have these two bones rubbing on each other, well, how are we going to solve that problem? One way to solve it is to get rid of one of the bones.

So in this case, we remove the first wrist bone in the wrist called your trapezium, that gets rid of the bone on bone contact, and it gets rid of your pain generator. Problem is it leaves a hole or a space that we have to fill with something. And what we found works the best is your own tissue. So, we use a tendon from the forearm that you don't necessarily need, and we roll that up, anchor it in the space left by that trapezium. And that forms a bumper or a cushion that lets the thumb move without pain.

Host: That's pretty remarkable. How long does that take to do? It seems like a very meticulous process.

Matthew Bliss, MD: It's a pretty specialized type surgery. But in general, for an uncomplicated case, it's about an hour-long outpatient procedure. We do here in the hospital. Come in for the procedure, have it done, leave about half an hour later. We are able to do the vast majority of these surgeries with what's referred to as a peripheral nerve block. Our anesthesia expert will do an injection up in the patients shoulder that makes the arm numb and temporarily paralyzed. And that allows us to give the patient some light sedation during the case and perform the surgery without any pain.

The added benefit is it oftentimes gives patients pain relief for up to three days after this surgery. And most patients find that they don't need any narcotics after surgery and are able to transition strictly to Tylenol and ibuprofen after the procedure.

Host: That's pretty remarkable. So, it's a very time-efficient surgery where patients don't need to be intubated and they go home, it sounds like, pretty quickly after their surgery's been completed and don't need a lot of narcotics postoperatively.

Matthew Bliss, MD: Correct. This surgery was really described by two surgeons named Burton and Pellegrini back in the '70s. We have a lot of data on it. And we know that it's a good long-term solution. People have excellent results out to 15 to 20 years. Oftentimes people state that they would have this done again up to 95-98% of the time

Host: So postoperatively, Dr. Bliss, do they then have therapy with the occupational therapy team? Can you take us through that? And then, what's the timeline for full recovery for something like that?

Matthew Bliss, MD: Yes. That's a excellent question, Mike. Therapy is key after the surgery. We're very upfront with our patients. This is a team approach. After our procedure, we're very aggressive about getting people into therapy. Most people start therapy within two to three days of the surgical procedure. Most people, I would say, are in therapy for about six weeks. Therapy is designed initially to help with the swelling, get the incision to heal, and then we work on range of motion and, finally, strengthening of the hand. So, the patients oftentimes form an excellent relationship with our therapist and can see them off and on in the future.

Host: I tell you, I think your therapy team is excellent, and I know that firsthand, no pun intended, because you took care of my son who broke his hand. So, I know that they're quite a wonderful team to have around to provide that support and healing.

Matthew Bliss, MD: Yes, I refer to them as my professional bad guys. They're the people that enforce the no pain, no gain scenario. And I don't have to. So, they are excellent. They are consummate professionals and, you know, their name is occupational therapy. Their goal is to get you back to your occupation, whether that's homemaker, carpenter, whatever. They are dedicated to getting you back to doing that.

Host: Well, Dr. Bliss, I have learned a lot today. I can't thank you enough for being on this episode of the FortCast. Thank you, my friend.

Matthew Bliss, MD: You're very welcome. Always a pleasure, Mike.

Host: And I hope you enjoyed this episode as well. Please share us on your social media channels and please check out our full library at our Fort HealthCare website of other past podcast episodes. For now, thank you for tuning in. Again, this is Dr. Michael Anderson. Have a great day.