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Hand Surgeons Surveyed About Treatment for Thumb Arthritis

n this study, outcomes of various treatments for basal thumb arthritis are investigated and compared with current trends in the treatment of this condition. Basal thumb arthritis refers to pain, stiffness, and decreased pinch strength associated with degenerative changes of the trapeziometacarpal (TM) joint.

The trapeziometacarpal (TM) joint is at the base of the thumb where the metacarpal bone of the thumb connects to the trapezium of the wrist. This joint is also referred to as the CMC joint (an abbreviation for carpometacarpal joint) of the thumb. This is the joint that allows you to move your thumb into your palm, a motion called opposition. The TM or CMC joint is sometimes referred to as a universal joint because of the wide range of movements possible.

Treatment usually begins with conservative (nonoperative) care. This could include splinting, exercise, antiinflammatory medications, and steroid or hyaluronate injections. Patients who fail conservative care may benefit from surgery. The simplest procedure is a trapeziectomy (removal of the trapezium bone). More advanced procedures include trapeziectomy with ligament reconstruction, arthrodesis (fusion), or arthroplasty (joint replacement).

In order to find out how hand surgeons are currently treating this condition, the authors sent an on-line survey to active members of the American Society for Surgery of the Hand. They asked questions about conservative care, preferred methods of treatment for patients who failed conservative care, and most common surgical procedures used. Demographic information about the surgeon was also collected (e.g., geographical location, number of years in practice).

They received a response rate of 50 per cent. Surgeons from all regions of the United States participated with a wide range of experience. Half had been practicing less than 15 years; half had been practicing more than 15 years.

Younger surgeons were more likely to recommend conservative care while the more experienced surgeons opted for trapeziectomy or trapeziectomy with ligament reconstruction. Steroid injection was favored by most (89 per cent) of the group.

Only a small number of surgeons (four per cent) used the more recent treatment of hyaluronate injections, which have not yet received approval from the FDA for the trapeziometacarpal joint. Insurance doesn't always cover this procedure and it costs more than steroid injection. Studies haven't really shown a benefit of hyaluronate injection over steroid injection. These factors may explain why this treatment is not more popular.

In general, surgery (and more involved procedures) was reserved for patients with more advanced cases of arthritis. There appears to be a trend toward returning to the simpler trapeziectomy procedure by many hand surgeons. Studies seem to show similar good results for all types of surgery. However, there is evidence that more advanced surgeries do not yield better outcomes than simple trapeziectomy. And those procedures involving ligament reconstruction have higher rates of complications.

The use of trapeziectomy with ligament reconstruction instead of a simple trapeziectomy is not supported by the evidence. The authors suggest the need for more research with larger studies to compare outcomes for the surgical treatment of trapeziometacarpal arthritis. Such data would give hand surgeons better direction when choosing treatment for their patients.

Reference: Jennifer Moriatis Wolf, MD, and Steven Delaronde, MPH, MSW. Current Trends in Nonoperative and Operative Treatment of Trapeziometacarpal Osteoarthritis: A Survey of US Hand Surgeons. In The Journal of Hand Surgery. January 2012. Vol. 37A. No. 1. Pp. 77-82.

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