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Comparative Evaluation of Surgical Procedures with Clinical Equipoise: A Unique Perspective From Our Hand Therapist Colleagues
Joseph J Schreiber, MD; Susan Clark, OTR/L, CHT; Jeffrey Yao, MD
Stanford University Medical Center, Redwood City, CA
Introduction: There are several accepted surgical treatment options available for carpal tunnel syndrome, thumb carpometacarpal joint (CMC) osteoarthritis (OA), and wrist OA. With no procedure conclusively supported by the literature, a multitude of surgeon and patient specific factors interplay into dictating an individual surgeon's treatment preferences for each of these pathologies. We sought to obtain the unique views and preferences from a cohort of certified hand therapists (CHT) – a group that intimately interacts with patients in the acute post-operative period. We hypothesized that this source of information may identify some differences in procedures that are otherwise widely believed to have clinical equipoise.
Methods: 512 CHTs from around the United States were surveyed regarding their clinical experience, volume, and referral base along with their subjective assessments of patients following open versus endoscopic carpal tunnel release (CTR), various surgical procedures for CMC OA, and proximal row carpectomy (PRC) versus 4-corner fusion (4-CF). Respondents were also queried regarding what procedure they would elect to have performed on themselves if clinically necessary.
Results: The average CHT surveyed had 15.2 years experience and had a referral base of 7.7 different hand surgeons. Only 27% of CHT respondents perceived superior pain control and incisional tenderness following open CTR, however, 68% of CHTs would elect to undergo an open CTR over an endoscopic CTR (Figure 1). Preferences for CMC OA surgical procedures tended to mirror the frequency of which they are performed, with ligament reconstruction and tendon interposition being most frequently performed (45%) and the preferred surgical technique in terms of best pain control (55%), motion (56%), and thumb position (60%) (Figure 2). As compared to 4-CF, PRC was thought to result in superior pain control (34% versus 22%), motion (43% versus 18%), and earlier discharge (32% versus 19%). 53% of respondents would prefer a 4-CF for themselves in a hypothetical situation as compared to 47% preferring a PRC (Figure 3).
Conclusion: Despite subjectively superior pain control following endoscopic CTR, few CHTs would have their own carpal tunnel released endoscopically. PRC was deemed superior to 4-CF for pain control, range of motion and time to discharge, but rates were similar for the preferred treatment among CHTs in a hypothetical situation. Hand therapists are intimately involved in the care of surgical patients, and provide an educated and unique source for evaluating post-operative course and differences between various techniques of treating common hand surgery problems.
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