Original Research

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

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We conducted a study to investigate current trends in carpometacarpal (CMC) interposition arthroplasty across time, sex, age, and region of the United States; per-patient charges and reimbursements; and the association between this procedure and concomitantly performed carpal tunnel syndrome (CTS) and carpal tunnel release (CTR).

Patients who underwent CMC interposition arthroplasty (N = 41,171) were identified in a national database. Between 2005 and 2011, the number of patients who had CMC interposition arthroplasty increased 46.2%. Females had the procedure more frequently than males at all time points, though the percentage of patients who were male increased throughout the study period. Of the patients who had CMC interposition arthroplasty, 40.9% also had a diagnosis of CTS. Between 15.5% and 17.3% of these patients had CTR performed concomitantly.

Despite a lack of evidence that thumb CMC interposition arthroplasty is superior to other surgical treatment options, the number of patients who are having this procedure has increased significantly. The impetus for these trends requires additional investigation.


 

References

A common entity, osteoarthritis (OA) at the base of the thumb is largely caused by the unique anatomy and biomechanics of the thumb carpometacarpal (CMC) joint.1 Radiographically evident CMC degeneration occurs in 40% of women and 25% of men over age 75 years, making the thumb CMC joint the most common site of surgical reconstruction for upper extremity OA.2,3

Over the past 40 years, numerous surgical techniques for managing thumb CMC-OA have been described. These include volar ligament reconstruction, first metacarpal osteotomy, CMC arthrodesis, CMC joint replacement, and trapeziectomy. Trapeziectomy can be performed in isolation or in combination with tendon interposition, ligament reconstruction, or ligament reconstruction and tendon interposition (LRTI).4-20 The authors of a recent systematic review concluded there is no evidence that any one surgical procedure for CMC-OA is superior to another in terms of pain, function, satisfaction, range of motion, or strength.4 Nevertheless, a recent survey found that 719 (62%) of 1156 US hand surgeons used LRTI as the treatment of choice for advanced CMC-OA.21

Our detailed literature search yielded no other database studies characterizing current trends in the practice patterns of US orthopedic surgeons who perform interposition arthroplasty for CMC arthritis. Analysis of these trends is important not only to patients but also to the broader orthopedic and health care community.22

We conducted a study to investigate current trends in CMC interposition arthroplasty across time, sex, age, and region of the United States; per-patient charges and reimbursements; and the association between this procedure and concomitantly performed carpal tunnel syndrome (CTS) and carpal tunnel release (CTR). In addition, we compared incidence of CMC interposition arthroplasty with that of CMC arthrodesis.

Patients and Methods

All data were derived from the PearlDiver Patient Records Database (PearlDiver Technologies), a publicly available database of patients. The database stores procedure volumes, demographics, and average charge information for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and procedures or Current Procedural Terminology (CPT) codes. Data for the present study were drawn from the Medicare database within the PearlDiver records, which has a total of 179,094,296 patient records covering the period 2005–2011. This study did not require institutional review board approval, as it used existing, publicly available data without identifiers linked to subjects.

PearlDiver Technologies granted us database access for academic research. The database was stored on a password-protected server maintained by PearlDiver. ICD-9 and CPT codes can be searched in isolation or in combination. Search results yield number of patients with a searched code (or combination of codes) in each year, age group, or region of the United States, as well as mean charge and mean reimbursement for the code or combination of codes.

We used CPT code 25447 (arthroplasty, interposition, intercarpal, or CMC joints) to search the database for patients who underwent thumb CMC interposition arthroplasty. Although this code does not specify thumb, we are unaware of any procedure (other than thumb CMC interposition arthroplasty) typically given this code. Our search yielded procedure volumes, sex distribution, age distribution, region volumes, and mean per-patient charges and reimbursements for each CPT code. We then searched the resulting cohort for CTS (ICD-9 code 354.0), endoscopic CTR (CPT code 29848), and open CTR (CPT code 64721) to find CTR performed concomitantly with CMC interposition arthroplasty. Last, patients were tracked in the database past their surgery date to evaluate for postoperative physical or occupational therapy evaluations within 6 months (using CPT codes appearing in at least 1% of the cohort: 97001, 97003, 97004, 97110, 97112, 97124, 97140, 97150, 97350, 97535) and postoperative thumb, hand, or wrist radiographs within 6 months (using CPT codes appearing in at least 1% of the cohort: 73140, 73130, 73110). To ensure adequacy of 6-month postoperative data, we included in this portion of the study only those patients with surgery dates between 2005 and 2010.

For comparative purposes, we also searched the database for patients who underwent thumb CMC arthrodesis within the same period—using CPT codes 26841 and 26842 (arthrodesis CMC joint thumb, with or without internal fixation; with or without autograft) and CPT code 26820 (fusion in opposition, thumb, with autogenous graft).

Overall procedure volume data are reported as number of patients with the given CPT code in the database output in a given year. Age-group and sex analyses are reported as number of patients reported in the database output and as percentage of patients who underwent the CPT code of interest that year. Mean charges and reimbursements are reported as results by the database for the code of interest (CPT 25447). Data for the region analysis are presented as an incidence, as there is an uneven distribution of patient volumes among regions. This incidence is calculated as number of patients in a particular region and year normalized to total number of patients in the database for that particular region or year. Regions are defined as Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South (AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV), and West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY).

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