The Influence of Evidence in the Surgical Treatment of Thumb Basilar Joint Arthritis

Abstract

Background For surgical treatment of thumb carpometacarpal (CMC) arthritis, current evidence suggests that simple trapeziectomy is as effective and may be safer than trapeziectomy and ligament reconstruction (LR) with or without tendon interposition (TI). We examined whether current practice patterns in the surgical treatment of thumb CMC arthritis reflect adoption of simple trapeziectomy as best practice. Furthermore, we investigated whether surgeon preferences and third-party payer patterns are associated with use of simple trapeziectomy. Methods We performed a retrospective cross-sectional study of 6776 surgical treatments for thumb CMC arthritis using the all-payer State Ambulatory Surgery Database (SASD) for Florida, during 2006–2009. We applied multinomial regression analysis to examine associations between covariates, describing surgeon and third-party payer factors and the type of procedure performed. We calculated an intra-class correlation coefficient (ICC) to determine how much of the difference in patient outcome (procedure type) is due to differences among surgeons. Results Across surgeon characteristics included in the analysis, patients’ outcome probabilities were over 90% in favor of treatment with trapeziectomy and LR with or without TI. Additionally, the level of intra-class correlation amongst patients clustered within a surgeon showed that individual surgeons contribute substantially to determining what procedure type a patient undergoes. Conclusion In this multi-year one state study, it appears that current evidence demonstrating the equivalent effectiveness of simple trapeziectomy compared to more involved alternatives did not result in wide adoption of the technique. This finding is consistent with studies in many clinical disciplines that highlight the difficulty of influencing clinical practice with available evidence. Level of Evidence III therapeutic

Surgical Treatment of Cubital Tunnel Syndrome: Trends and the Influence of Patient and Surgeon Characteristics

“…This indicates that the procedure a patient undergoes is highly dependent upon the treating surgeon. This finding was also noted in another Florida HCUP study evaluating patterns of treatment for thumb carpometacarpal arthritis (32). In both studies, effect sizes for surgeon-level characteristics greatly outweighed those for patient-level characteristics.…”

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“…Therefore, trapeziectomy and ligament reconstruction with tendon interposition remains the procedure of choice for the majority of hand surgeons. 41,42 Although many surgeons are resistant to change practice patterns on the basis of new information, further development of arthroscopic techniques and research with regard to thumb carpometacarpal joint arthritis may favor arthroscopic treatment in the future.…”

What’s New in Hand Surgery

“…With regard to the performance of surgery, there is fairly strong evidence to support the notion that the simplest procedure, trapeziectomy without further reconstruction, provides results comparable with those of more complicated procedures, but with fewer complications. Nevertheless, a study performed with use of the State Ambulatory Surgery Database of Florida, which includes all surgical cases in the state 15 , showed that 90% of the procedures done in that state included a ligament reconstruction. As with other treatments, current practice and treatments recommended by the evidence base do not always coincide.…”