Variation in Treatment for Trapeziometacarpal Arthrosis

Abstract

Background: Treatment recommendations for trapeziometacarpal (TMC) arthrosis are highly variable from surgeon to surgeon. This study addressed the influence of viewing radiographs on a decision to offer surgery for TMC arthrosis.

Methods: In an online survey, 92 hand surgeons viewed clinical scenarios and were asked if they would offer surgery to 30 patients with TMC arthrosis. Forty-two observers were randomly assigned to review clinical information alone and 50 to review clinical information as well as radiographs. The degree of limitation of daily activities, time since diagnosis, prior treatment, pain with grind, crepitation with grind, and metacarpal adduction with metacarpophalangeal hyperextension were randomized for each patient scenario to determine the influence of these factors on offers of surgery. A cross-classified binary logistic multilevel regression analysis identified factors associated with surgeon offer of surgery.

Results: Surgeons were more likely to offer surgery when they viewed radiographs (42% vs. 32%, P = 0.01). Other factors associated variation in offer of surgery included greater limitation of daily activities, symptoms for a year, prior splint or injection, deformity of the metacarpophalangeal joint. Factors not associated included limb dominance, prominence of the TMC joint, crepitation with the grind test, and pinch and grip strength.

Conclusion: Surgeons that view radiographs are more likely to offer surgery to people with TMC arthrosis. urgeons are also more likely to offer surgery when people do not adapt with time and nonoperative treatment. Given the notable influence of surgeon bias, and the potential for surgeon and patient impatience with the adaptation process, methods for increasing patient participation in the decision-making process merit additional attention and study.

Keywords: Decision-making; Interobserver variation; Osteoarthritis; Surgery; Trapeziometacarpal arthrosis; Treatment.

Figure 1

The scenario prior to randomization of the elements for the lateral (A), oblique (B), and Robert (C) radiographs depicted in the figure: A 62 year-old man has pain at the base of her (dominant/nondominant) thumb. The pain (does not limit/slightly limits/moderately limits/severely limits/makes impossible) daily activities. The patient was diagnosed with trapeziometacarpal arthrosis (now/ 3 months ago/ 1 year ago). The patient has (not treated it/ tried a splint/ tried a cortisone injection). On physical exam there (is / is not) fullness at the base of the thumb (so called “shoulder sign”), and (no/ mild/ moderate, severe/ extreme) pain and (no/ mild/ moderate/ substantial/ severe) crepitation with grind test. There is no adduction contracture and no MCP hyperextension. There (is / is not) an adduction contracture and MCP hyperextension. Pinch and grip strength are (good / poor)