The influence of evidence in the surgical treatment of thumb basilar joint arthritis

Abstract

Background: For surgical treatment of thumb carpometacarpal joint arthritis, current evidence suggests that simple trapeziectomy is as effective as and may be safer than trapeziectomy and ligament reconstruction with or without tendon interposition. The authors examined whether current practice patterns in the surgical treatment of thumb carpometacarpal joint arthritis reflect adoption of simple trapeziectomy as best practice, and investigated whether surgeon preferences and third-party payer patterns are associated with use of simple trapeziectomy.

Methods: The authors performed a retrospective cross-sectional study of 6776 surgical treatments for thumb carpometacarpal joint arthritis using the all-payer State Ambulatory Surgery Database for Florida, from 2006 to 2009. Multinomial regression analysis was applied to examine associations between covariates, describing surgeon and third-party payer factors and type of procedure performed. An intraclass correlation coefficient was calculated to determine how much of the difference in patient outcome (procedure type) is attributable to differences between surgeons.

Results: Across surgeon characteristics included in the analysis, patients' outcome probabilities were over 90 percent in favor of treatment with trapeziectomy and ligament reconstruction with or without tendon interposition. The level of intraclass correlation among patients clustered within a surgeon showed that individual surgeons contribute substantially to determining what procedure type a patient undergoes.

Conclusions: In this multiyear, one-state study, current evidence demonstrating the equivalent effectiveness of simple trapeziectomy compared with 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.

Figure 1

Specification of the study cohort and covariates using CPT (Current Procedure Terminology) codes, ICD-9 CM (International Classification of Diseases, 9^th Revision, Clinical Modification) codes and variables provided by the database. CMC; carpometacarpal, AVN; avascular necrosis.

Figure 2

Algorithm for defining study cohort using the Florida State Ambulatory Surgery Database (SASD). CPT; current procedure terminology, CMC; carpometacarpal, ICD-9 CM; international classification of disease, 9^th revision, clinical modification.

Figure 3

Figure 3a: Association between the number of procedure types a surgeon performs and a patient’s likelihood of undergoing partial/complete trapeziectomy with soft-tissue arthroplasty for thumb CMC arthritis. The numbers highlighted in red (top left) represent the most common probabilities of treatment with partial/complete trapeziectomy with soft-tissue arthroplasty given that surgeons that performed 1 or 2 procedures treated > 70% of patients. Figure 3b: Association between number of procedures types a surgeon performs and a patient’s likelihood of undergoing simple complete trapeziectomy. The numbers highlighted in red (bottom left) represent the most common probabilities of treatment with simple complete trapeziectomy, given that surgeons that performed 1 or 2 procedures treated > 70% of patients.

Figure 3

Figure 3a: Association between the number of procedure types a surgeon performs and a patient’s likelihood of undergoing partial/complete trapeziectomy with soft-tissue arthroplasty for thumb CMC arthritis. The numbers highlighted in red (top left) represent the most common probabilities of treatment with partial/complete trapeziectomy with soft-tissue arthroplasty given that surgeons that performed 1 or 2 procedures treated > 70% of patients. Figure 3b: Association between number of procedures types a surgeon performs and a patient’s likelihood of undergoing simple complete trapeziectomy. The numbers highlighted in red (bottom left) represent the most common probabilities of treatment with simple complete trapeziectomy, given that surgeons that performed 1 or 2 procedures treated > 70% of patients.

Figure 4

Timeline of procedures devised to treat thumb carpometarcarpal arthritis. CMC; carpometacarpal, FCR; flexor carpi radialis.