Evidence-based medicine in hand surgery: clinical applications and future direction

Surgeon preferences in the treatment of thumb carpometacarpal osteoarthritis

BACKGROUND

Primary thumb carpometacarpal (CMC) osteoarthritis is one of the most common conditions encountered by hand surgeons. Of the vast number of operations that have been proposed, none have demonstrated results significantly superior to trapeziectomy alone.

AIM

The purpose of our study was to determine why surgeons opt for their technique in treating CMC arthritis.

METHODS

A cross-sectional survey of active members of the American Society for Surgery of the Hand was conducted to evaluate the reasons behind their preferred technique in the treatment of isolated thumb CMC arthritis. Surgeons were contacted by e-mail once and provided with a link to a de-identified survey consisting of 5 treatment questions and 5 demographic questions.

RESULTS

Of 950 responses were received. 40.5% of surgeons preferred trapeziectomy + ligament reconstruction tendon interposition (LRTI), followed by trapeziectomy + suspensionplasty (28.2%), suture button suspension (5.9 %), trapeziectomy alone (4.6%), prosthetic arthroplasty (3.2%), arthrodesis (1.1%), and other (6.6%). Proponents of trapeziectomy + LRTI cited familiarity (73.2%), exposure during fellowship (48.8%) and less proximal migration (60%) to be the main reasons affecting their decision. Surgeons who preferred trapeziectomy + suspensionplasty most reported simplicity (74.9%), fewer complications (45.3%), less proximal migration (43.8%), and avoidance of autogenous tissue harvest (42.7%). Advocates of suture button suspension cited avoidance of autogenous tissue harvest (80.4%), shorter immobilization (76.8%), and quicker recovery (73.2%) with their technique. Advocates of trapeziectomy alone cited simplicity (97.7%), fewer complications (86.4%), and avoidance of autogenous tissue harvest (59.1%). In their comments, 45% of surgeons choosing trapeziectomy alone cited evidence as an additional rationale. Advocates of prosthetic arthroplasty cited improved pinch strength (83.3%) and improved range of motion (63.3%), while those preferring arthrodesis cited better pinch strength (90%) and frequently in their comments, durability. Of the surgeons who preferred a technique other than LRTI, 41.8% reported they had tried LRTI in the past, citing complexity of the procedure, flexor carpi radialis harvest, and longer operative time as reasons for moving on.

CONCLUSION

Our study provides an update on current treatment trends and offers new insight into the reasons behind surgeons' decision making in the management of thumb carpometacarpal osteoarthritis. Despite strong Level 1 evidence supporting the use of trapeziectomy alone, our findings demonstrate that most surgeons continue to supplement trapeziectomy with other techniques such as LRTI or suspensionplasty. Several factors including familiarity, personal experience (Level 4 evidence), and comfort may be more influential than Level 1 evidence in determining the techniques in a surgeon's armamentarium. Further prospective studies are needed to determine the optimal technique for surgical management of Eaton stages II-IV CMC arthritis and how these studies will affect surgeons' choice.

Differences between trapeziometacarpal arthrodesis and trapeziectomy with ligament reconstruction for the treatment of trapeziometacarpal osteoarthritis: a systematic review and meta-analysis

The optimal management of trapeziometacarpal (TMC) osteoarthritis remains controversial. This meta-analysis assessed the subjective and objective outcomes of trapeziometacarpal arthrodesis (TMA) versus trapeziec-tomy with ligament reconstruction (LRTI). The PubMed, Cochrane Library, Embase, Web of science data-bases were searched from inception to June 30, 2022. Keywords included "trapeziometacarpal osteoarthrosis", "trapeziometacarpal arthrodesis" and "trapeziectomy with ligament reconstruction". Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) including patients treated for TMC osteoarthritis were included. The subjective outcomes visual analogue scale (VAS) , Patient-Rated Wrist and Hand Evaluation (PRWHE), Disabilities of arm, shoulder and hand (DASH) scores, Kapanji scores, objective outcomes total interphalangeal (IP) and metacarpophalangeal (MCP) joint motion, palmar abduction, grip strength, tip, key pinch strength and complications were extracted. The methodological quality of each was assessed in- dependently. Meta-analysis was performed for comparative trials. From the 5 included studies (2 RCTs, 3 CCTs), 208 cases were divided into TMA group (n = 107) and LRTI group (n =101) groups. Compared with the TMA group, PRWHE, tip pinch strength and palmar abduction was better in the LRTI group. There was no statistical difference in DASH score, VAS, kapandji score, grip strength, key pinch strength, total IP joint motion, total MCP joint motion and complications. The LRTI group had more obvious advantages in term of PRWHE, tip pinch strength and palmar abduction. Moreover, there was no statistical difference in DASH score, VAS, kapandji score, grip strength, key pinch strength, total IP joint and total MCP joint motion and complications. Therefore, we concluded LRTI was more recommendable for more management of TMC osteoarthritis. Certainly, high-quality studies are required in long-term follow-up.

Trapeziectomy and suspension arthroplasty with the flexor carpi radialis tendon for treatment of trapeziometacarpal osteoarthritis

Excision of the trapezium is the common step in most arthroplasties for treating trapeziometacarpal arthritis. Trapeziectomy can be supplemented by several techniques intended to stabilize the first metacarpal but none of these has been proven superior. The aim of this study was to verify if a simplified suspension arthroplasty with the flexor carpi radialis (FCR) tendon, requiring only a single short surgical incision, no intraosseous tunnels and no interposition of prosthetic material, yields equal clinical outcomes to more complex techniques and if the clinical outcomes remain stable over the long term. A cohort of 299 patients was reviewed retrospectively at a follow-up ranging from 3 to 12 years (mean follow-up time 6 years) following total trapeziectomy and suspension arthroplasty using a half-tendon strip of FCR. At this long-term follow-up, the mean DASH score improved from 52 preoperatively to 20 postoperatively. Pain at follow-up was subjectively rated by patients as absent or improved in 92% cases. Thumb opposition assessed on the Kapandji scale was rated 9 or 10 in 144 (76%) hands, 7 or 8 in 30 (16%) hands and <7 in 15 hands (8%). Mean palmar flexion and radial abduction were 45° and 42°, respectively. Mean key pinch and grip strength were 4.7 Kg and 23.5 kg, respectively. When treating trapeziometacarpal osteoarthritis, surgical techniques that do not require complex procedures, bone tunnels, K wire stabilization or interposition of prosthetic materials can be considered and maybe preferred. Our technique of trapeziectomy and suspension arthroplasty with the FCR tendon produces good long-term results.

Translating Hand Surgery Evidence to Policy and Practice

Hand surgery researchers should focus on developing high-quality evidence to support the development of health policies affecting surgical care. Policy-makers and leaders of national hand societies can help reduce the variation of care for patients receiving hand surgery by incorporating evidence into guidelines and policies. Comprehensive guidelines for perioperative care help encourage the translation of evidence into practice. Moreover, the identification of institutional-level barriers and facilitators of integration ensures the successful implementation of hand surgery-specific programs. The development of robust metrics to evaluate the effect of policy on practice helps examine the feasibility of clinical guidelines.

Comparing National Inpatient Sample and National Surgical Quality Improvement Program: An Independent Risk Factor Analysis for Risk Stratification in Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To explore interdatabase reliability between National Inpatient Sample (NIS) and National Surgical Quality Improvement Program (NSQIP) for anterior cervical discectomy and fusion (ACDF) in data collection and its impact on subsequent statistical analyses.

SUMMARY OF BACKGROUND DATA

Clinical studies in orthopedics using national databases are ubiquitous, but analytical differences across databases are largely unexplored.

METHODS

A retrospective cohort study of patients undergoing ACDF surgery was performed in NIS and NSQIP. Key demographic variables, comorbidities, intraoperative characteristics, and postoperative complications were analyzed via bivariate and multivariate analyses.

RESULTS

A total of 112,162 patients were identified from NIS and 10,617 from NSQIP. Bivariate analysis revealed small, but significant, differences between patient demographics, whereas patient comorbidities and ACDF intraoperative variables were largely much more distinct across the two databases. Multivariate analysis identified independent risk factors between NIS and NSQIP for mortality, cardiac complications, and postoperative sepsis, some of which were identified in both but most of which were unique to one database. Identification of independent risk factors from both databases specifically highlights their greater validity and importance in stratifying patient risks. In addition, NSQIP was found to be a more accurate predictor for complications based on the average areas under the receiver-operating curve (CNSQIP = 0.83 vs. CNIS = 0.81) across the multivariate models. Complication rate analysis between inpatient and outpatient settings in NSQIP showed the importance of at least 30-day patient follow up, which was devoid in NIS data tabulation and further marked its weakness compared with NSQIP.

CONCLUSION

Despite having largely similar patient demographics, this study highlights critical risk factors for ACDF and demonstrates how different patient profiles can be across NIS and NSQIP, the impact of such differences on identification of independent risk factors, and how NSQIP is ultimately better suited for adverse-event studies.

LEVEL OF EVIDENCE

3.