Surgeon preferences in the treatment of thumb carpometacarpal osteoarthritis

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.

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

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.

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.

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.