Beneficial Effects of Nonsurgical Treatment for Symptomatic Thumb Carpometacarpal Instability in Clinical Practice: A Cohort Study

Publication date: March 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 3

Author(s): Robbert M. Wouters, Harm P. Slijper, Lisa Esteban Lopez, Steven E.R. Hovius, Ruud W. Selles, R.A.M. Blomme, B.J.R. Sluijter, D.J.J.C. van der Avoort, A. Kroeze, J. Smit, J. Debeij, E.T. Walbeehm, G.M. van Couwelaar, G.M. Vermeulen, J.P. de Schipper, J.F.M. Temming, J.H. van Uchelen, H.L. de Boer, K.P. de Haas, O.T. Zöphel

Abstract

Objective

To describe outcomes of nonsurgical treatment for symptomatic thumb carpometacarpal joint (CMC-1) instability. Secondary, to evaluate the conversion rate to surgical treatment.

Design

Prospective cohort study.

Setting

A total of 20 outpatient clinics for hand surgery and hand therapy in the Netherlands.

Participants

A consecutive sample of patients with symptomatic CMC-1 instability (N=431).

Intervention

Nonsurgical treatment including exercise therapy and an orthosis.

Main Outcome Measures

Pain (visual analog scale [VAS], 0-100) and hand function (Michigan Hand Outcomes Questionnaire [MHQ], 0-100) at baseline, 6 weeks, and 3 months. Conversion to surgery was recorded for all patients with a median follow-up of 2.8 years (range, 0.8-6.7y).

Results

VAS scores for pain during the last week, at rest, and during physical load improved with a mean difference at 3 months of 17 (97.5% CI, 9-25), 13 (97.5% CI, 9-18), and 19 (97.5% CI, 12-27), respectively (P<.001). No difference was present at 3 months for MHQ total score, but the subscales activities of daily living, work, pain, and satisfaction improved by 7 (97.5% CI, 1-14), 10 (97.5% CI, 4-16), 5 (97.5% CI, 2-9), and 12 (97.5% CI, 2-22) points, respectively (P<.001-.007). After median follow-up of 2.8 years, only 59 participants (14%) were surgically treated. Both in the subgroups that did and did not convert to surgery, VAS pain scores decreased at 3 months compared with baseline (P<.001-.010), whereas MHQ total score did not improve in both subgroups. However, VAS and MHQ scores remained worse for patients who eventually converted to surgery (P<.001).

Conclusions

In this large sample of patients with symptomatic CMC-1 instability, nonsurgical treatment demonstrated clinically relevant improvements in pain and aspects of hand function. Furthermore, after 2.8 years, only 14% of all patients were surgically treated, indicating that nonsurgical treatment is a successful treatment of choice.

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