Commentary and Perspective
Hutchinson et al. have designed a carefully done, Level-II study that compares 2 different postoperative immobilization protocols following ligament reconstruction and tendon interposition. They found that 4 weeks of thumb-spica splint immobilization followed by 4 weeks of intermittent splinting (early mobilization group) provided outcomes that were virtually comparable with those provided by 6 weeks of immobilization with use of a forearm-based thumb-spica splint followed by 6 weeks of intermittent splinting (immobilization group).
Much of what is taught and done in musculoskeletal medicine is based on what we have learned from our mentors or what we have gleaned from the literature. Unfortunately, the literature frequently falls short and therapeutic decisions are based on Level-IV or Level-V evidence. As Hageman et al. pointed out, when evidence is inconclusive, surgeons default to “works in my hands,” “familiarity with treatment,” and “what my mentor taught me.”1 To address this situation and better serve our patients, the American Academy of Orthopaedic Surgeons and many specialty societies have worked diligently to publish Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria (AUC). The CPGs are based on the studies with the highest levels of evidence available in the peer-reviewed literature; unfortunately, much of the evidence is inconclusive, and hence there is the need for more Level-I and Level-II studies. AUC combine expert opinion with the findings of studies with the best levels of evidence in order to guide practitioners on when it is appropriate to perform a procedure under a specific set of circumstances. Regrettably, there are no CPGs or AUC for many of the procedures that surgeons commonly perform or for those that have, to date, not gained a great deal of traction.
In one of the earliest articles about basal joint arthroplasty, Gervis reported on 15 patients who underwent trapeziectomy alone2. Only 2 patients had “inferior” results. The postoperative recommendations in the study were brief: initiate an active range of motion “at once” and use “supervision” as necessary to achieve a full range of motion. Since then, in a systematic review, Wolfe et al. pointed out that rehabilitation protocols have become more detailed but recommendations are all over the map3. The focus of most of the literature on basal joint arthritis is on surgical technique.
When developing a rehabilitation program following basal joint arthroplasty, it is key to consider the length of time for complete thumb immobilization, when to initiate an active range of motion, and the total time that the splint should be worn because these factors affect cost, quality of life while recuperating, and return to full activity. In the study by Hutchinson et al., 2 secondary considerations were noted. The type of splint (forearm-based versus hand-based) did not seem to matter. The treatment in the immobilization group was supplemented by 6 weeks with a forearm-based splint whereas the early mobilization group utilized a less restrictive hand-based splint for 4 weeks. On a similar note, wrist and thumb strengthening was initiated at 8 weeks in the early mobilization group and 12 weeks in the immobilization group. Again, outcome was not affected. I was surprised to learn that simultaneous procedures—particularly those on the metacarpophalangeal joint—had no effect on outcome when comparing the 2 groups.
Finally, an aspect not addressed in this study is the role of supervised hand therapy and how it affects outcome. In their systematic review, Wolfe et al. noted that some authors recommended no formal therapy whereas others endorsed a very structured rehabilitation program3.
Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/E822).
1. Hageman MGJS, Guitton TG, Ring D; Science of Variation Group. How surgeons make decisions when the evidence is inconclusive. J Hand Surg Am. 2013 Jun;38(6):1202-8. Epub 2013 May 4.
2. Gervis WH. Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg Br. 1949 Nov;31B(4):537-9, illust.
3. Wolfe T, Chu JY, Woods T, Lubahn JD. A systematic review of postoperative hand therapy management of basal joint arthritis. Clin Orthop Relat Res. 2014 Apr;472(4):1190-7.