The thumb is a key feature in the function of the human hand. Its evolutionary adaptations predispose it to degenerative change and thumb base osteoarthritis is a common presentation to primary and secondary care. Radiographic changes are recognized as a normal part of ageing, and it is important to distinguish radiographic from symptomatic thumb base osteoarthritis. The majority of patients can be managed non-operatively with a combination of oral and topical analgesia, physiotherapy, splintage, activity modification and injections. For failed non-operative management, the trapeziectomy (excision arthroplasty) is the commonest procedure and rates are rising, but a number of surgical options exist, and one must consider the patient's requirements and the involvement of the whole ‘thumb column’.