Original Research

Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011

Am J Orthop. 2015 August;44(8):363-368

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Chi-squared linear-by-linear association analysis was used to determine statistical significance with regard to trends over time in procedure volumes, sex, age group, and region. For all statistical comparisons, P < .05 was considered significant.

Results

In the database, we identified 41,171 unique patients who underwent CMC interposition arthroplasty between 2005 and 2011. Over the 7-year study period, number of patients who had CMC interposition arthroplasty increased 46.2%, from 4761 in 2005 to 6960 in 2011 (P < .0001) (Table 1, Figure 1). Throughout this period, females underwent CMC interposition arthroplasty more frequently than males at all time points (P < .0001). Overall ratio of female to male patients, however, changed significantly. In 2005, 18.1% of all CMC interposition arthroplasties were performed on male patients; this increased to 23.9% of all procedures by 2011 (P < .0001) (Figure 2). Table 1 presents an age-group analysis. There were no significant differences in relative percentage of patients in any given age group who underwent CMC interposition arthroplasty over the study period.

Analysis of overall procedure incidence by region revealed significant increases in all regions (P < .0001), ranging from 18.5% (West) to 54.5% (Northeast) (Figure 3). At all time points, the incidence of CMC interposition arthroplasty was significantly lower in the Northeast than in any other region and compared with the overall average.

Between 2005 and 2011, there were significant increases in both per-patient charges and reimbursements for CMC interposition arthroplasty (Figure 4). Mean per-patient charge increased from $2676 in 2005 to $4181 in 2011 (P < .0001), and mean per-patient reimbursement increased from $1445 in 2005 to $2061 in 2011 (P < .0001). The discrepancy between charge and reimbursement increased throughout the study period: Reimbursement in 2005 was 54.0% of the charge; this decreased to 49.3% by 2011 but was not statistically significant (P = .08).

Overall, 40.9% of patients who underwent CMC interposition arthroplasty also had a CTS diagnosis. Between 15.5% and 17.3% of these patients had concomitant open or endoscopic CTR at time of CMC interposition arthroplasty (Table 2). Percentage of patients who underwent concomitant CTR did not change significantly from 2005 to 2011 (P = .139). Use of postoperative occupational and/or physical therapy increased significantly over the study period, from 33.5% of patients in 2005 to 50.7% of patients in 2010 (P < .0001). Use of postoperative thumb, hand, and/or wrist radiography also increased throughout the study period, from 7.4% of patients in 2005 to 18.7% of patients in 2010 (P < .0001).

We identified 1916 unique patients who underwent thumb CMC arthrodesis between 2005 and 2011. Over the 7-year study period, there was a 19.1% decrease in number of patients who underwent CMC arthrodesis, from 309 in 2005 to 250 in 2011 (P < .0001) (Figure 5). Significantly fewer patients had CMC arthrodesis compared with CMC interposition arthroplasty at all time points, ranging from 6.5% (thumb CMC arthrodesis:CMC interposition arthroplasty) in 2005 to 3.6% in 2011 (P < .0001).

Discussion

Our results demonstrated a significant increase in use of thumb CMC interposition arthroplasty in a US Medicare population, with an increase of more than 46% from 2005 to 2011. This finding supports the findings of a recent cross-sectional survey-based study in which 719 (62%) of 1156 surveyed US hand surgeons reported performing trapeziectomy with LRTI for advanced thumb CMC-OA.²¹ A prior study had similar findings, with 692 (68%) of 1024 American Society for Surgery of the Hand (ASSH) members performing LRTI and 766 (75%) of 1024 performing some type of CMC interposition with trapeziectomy for advanced CMC-OA.²³ This preference for CMC interposition arthroplasty prevails despite the fact that numerous studies have shown no superiority of any surgical procedure to another for CMC-OA in terms of pain, function, satisfaction, range of motion, and strength.^{7,15,18,19,24-34} Our data demonstrated that, not only does CMC interposition arthroplasty remain the most frequently used procedure for thumb CMC-OA, the incidence of CMC interposition arthroplasty continues to increase yearly.

The incidence of thumb CMC-OA is higher in women than in men, with more joint laxity a known contributor and subtle sex differences in trapezium geometry and congruence postulated as additional factors.^3,35,36This trend was confirmed in the present study, as females underwent significantly more CMC interposition arthroplasties at all time points. It is interesting that the overall ratio of female to male patients changed significantly over the study period, with the percentage of patients who were male increasing from 18.1% in 2005 to 23.9% in 2011. No previous studies have captured such a large cross section of the population to establish this trend. Although this trend is not necessarily intuitive, potential theories include increased acceptance of CMC interposition arthroplasty as a surgical option for male patients, and potentially a larger number of male patients seeking medical care for thumb CMC-OA in recent years.