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

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.