OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.
Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.
It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.
The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”
However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.
For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.
But perhaps the most compelling question is — why do we need an AUC app in the first place? Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories? And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.
However, there is another, critically important theme to the AUC story. Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide. As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.” If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.
With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome. More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.
Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.
Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 16, 2016 Specialty Update on hand surgery, to select the five most clinically compelling findings from among the more than 30 he cited in his article.
–In the treatment of distal radius fractures, is volar plating superior to closed reduction and pin fixation? A prospective randomized trial of 461 adults with acute dorsally displaced distal radial fractures that were amenable to closed reduction found no clinically significant differences in Patient-Rated Wrist Evaluation (PRWE) scores among those who underwent percutaneous wire fixation and those who underwent locking-plate fixation. The findings led the authors to conclude that when looking at functional outcomes, treatments other than plate fixation may suffice.1
–Authors of a cost and utility analysis of 268 patients with a surgically treated distal radial fracture concluded that the routine use of radiographs made at two weeks postoperatively is of little clinical benefit, except in cases of patients with high-energy intra-articular fractures or those who sustain an injury after surgery.2
–To challenge conventional dogma that the contralateral wrist of rheumatoid arthritis patients who undergo wrist arthrodesis must maintain motion in order for them to perform activities of daily living, a long-term study followed 13 bilateral wrist arthrodesis patients for an average of 14 years. The major functional limitations noted were turning a door knob and opening a tight jar lid. Increasing age, preoperative corticosteroid use, and concomitant shoulder or elbow disorders were associated with worse outcomes. Ninety-three percent of the patients expressed satisfaction and said they would repeat the bilateral procedure.3
Carpal Tunnel Syndrome
–Should one perform staged or simultaneous carpal tunnel surgery? A cost-effectiveness study of simultaneous versus staged bilateral carpal tunnel release in 198 patients found that those who underwent simultaneous surgery had significantly fewer days off work and fewer postoperative follow-up visits, and they also incurred significantly lower costs in terms of mean amounts billed and fees collected.4
Trapeziometacarpal Joint Arthritis
–Is there an optimal suspension arthroplasty for the treatment of basilar thumb arthritis? A randomized controlled trial of 79 patients with trapeziometacarpal arthritis found that functional/clinical outcomes at 12 months were essentially the same between a group that underwent ligament reconstruction and tendon interposition (LRTI) and a group that underwent trapeziectomy and flexor carpi radialis weave around the abductor pollicis longus tendon. The notable exception was an improvement in PRWE scores at three months among those who underwent the LRTI procedure.5
- Costa ML, Achten J, Parsons NR, Rangan A, Griffin D, Tubeuf S, Lamb SE;DRAFFT Study Group. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807. Epub 2014 Aug 5
- Stone JD, Vaccaro LM, Brabender RC, Hess AV. Utility and cost analysis of radiographs taken 2 weeks following plate fixation of distal radius fractures. J Hand Surg Am. 2015 Jun;40(6):1106-9. Epub 2015 Mar 31.
- Wagner ER, Elhassan BT, Kakar S. Long-term functional outcomes after bilateral total wrist arthrodesis. J Hand Surg Am. 2015 Feb;40(2):224-228.e1. Epub 2014 Dec 13.
- Phillips P, Kennedy J, Lee T. Cost effective analysis of simultaneous versus staged bilateral carpal tunnel release. Read at the American Association for Hand Surgery Annual Meeting; 2015 Jan 21-24; Paradise Island, Bahamas. Paper no. 104.
- VermeulenGM, Spekreijse KR, Slijper H, Feitz R, Hovius SE, Selles RW.Comparison of arthroplasties with or without bone tunnel creation for thumb basal joint arthritis: a randomized controlled trial. J Hand Surg Am. 2014 Sep;39(9):1692-8. Epub 2014 Jun 10.
Among a prospectively enrolled group of 49 patients (54 wrists) with mild or moderate carpal tunnel syndrome (CTS) who received a single corticosteroid injection, 79% experienced symptom relief at six weeks. Reporting in the October 7, 2015 edition of The Journal of Bone & Joint Surgery, Blazar et al. found that the rate of freedom from symptom recurrence in this cohort was 53% at six months and 31% at one year after injection. During the study period, 19 wrists underwent surgical carpal tunnel release at a median time of 181 days post-injection.
Diabetic patients in the study (13% of the wrists enrolled) were at a 2.6-fold greater risk of reporting recurring symptoms within one year of follow-up. In a univariable analysis, a 1-point increase in the baseline Boston Carpal Tunnel Questionnaire symptom score increased the risk of patients reporting post-injection symptoms by 5%, but that association became nonsignificant during multivariable analysis. Pre-injection symptom duration, patient age, and pre-injection electrophysiologic grade did not predict either symptom recurrence or subsequent intervention.
Blazar et al. add that their exclusion of people with normal electromyography results and those with severe carpal tunnel syndrome created a rather homogenous study population. Thus, they say, “these results may not be generalizable to all patients who present with clinical signs or symptoms of carpal tunnel syndrome.” Still, the findings should help orthopaedists counsel patients with CTS about the results they might expect from a single corticosteroid injection.
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
George Phalen’s article, “The Carpal-Tunnel Syndrome,” was published in The Journal of Bone and Joint Surgery in 1966. I feel some kinship with Phalen because he and I both grew up in Illinois, and we both obtained medical degrees from Northwestern University. (Phalen graduated from Northwestern in 1937, 48 years before me, which makes me feel young.) Dr. Phalen finished his residency at the Mayo Clinic and was a founding member (and later a president) of the American Society for Surgery of the Hand.
Several characteristics make “The Carpal-Tunnel Syndrome” a classic. First, Phalen’s article stands out as the definitive description of a common condition that, while previously noted by others, had never been studied so thoroughly or documented so completely. Phalen’s paper, which reviewed a 17-year experience of diagnosing and treating 654 hands at the Cleveland Clinic, was the pivotal scientific text that identified carpal tunnel syndrome as the most common peripheral compression neuropathy and a highly treatable orthopaedic condition. Moreover, no other article written about carpal tunnel syndrome in the past 50 years has matched Phalen’s paper with respect to both breadth and depth of knowledge.
Phalen’s article is also a classic when considered as medical literature. It is written in a way that makes critical points of anatomy, diagnostic evaluation, treatment options, and surgical management easy to remember. Although the article is 17 pages long, the content and organization are so well presented that the information flows naturally and is not burdensome to absorb. Packed with clinical and anatomical pearls, this paper is like an antique chair built by an old-school craftsman. It retains its comfort and rock-solid function even after decades of use because of the master-carpenter’s skill. This 1966 article makes me think, “They don’t often build ‘em like this anymore.”
But perhaps the most compelling “classic” feature of Phalen’s article is its lasting insights. Everything Phalen presented about carpal tunnel syndrome holds true 50 years later. This includes his descriptions of the anatomical, epidemiologic, histologic, and clinical features of carpal tunnel syndrome and his emphasis that careful history-taking and physical examination are by the far the most efficient ways to evaluate patients. He also notes the limitations of electrical testing (see related OrthoBuzz item) and presents a variety of surgical-technique tips that are still relevant today.
What is also amazing is Phalen’s observation that carpal tunnel syndrome is not truly caused by any occupation, but may be only temporarily worsened by repetitive movements. Despite subsequent decades of controversy on this subject, it is becoming clearer that, even on this point, Phalen had it right all along.
“The Carpal-Tunnel Syndrome” is a brilliant contribution to orthopaedic and hand surgery. Its detailed comprehensiveness and bulls-eye accuracy are complemented by the artful way the article is constructed and worded. Anyone treating carpal tunnel syndrome today should read this article, because a half-century later, it is still the best source of information on the subject.
Leon S. Benson, MD
JBJS Associate Editor
In the Sept. 3, 2014 issue of The Journal Fowler et al. elegantly compare the accuracy of ultrasound for confirming the clinical diagnosis of carpal tunnel syndrome with the current standard of electrodiagnostic testing. In a very well-designed trial using the validated CTS-6 patient-reported outcome tool as the reference standard, they determined 90% diagnostic specificity and 89% sensitivity for ultrasound, with a corresponding 80% specificity and 89% sensitivity for electrodiagnostic testing. In this experimental design, high-volume practitioners administered the diagnostic tests so there is a caveat: the reliability of both ultrasound and electrodiagnostic testing is probably dependent on practitioner experience.
The study clearly shows that in patients with positive CTS-6 results and no signs of radiculopathy or polyneuropathy, ultrasound is as good as electrodiagnostic testing at confirming the diagnosis–and more comfortable for the patient. But the findings also beg a question: Do we really need any adjunctive testing for this group of patients, who I think represent the majority of those presenting with carpal tunnel syndrome symptoms? Wouldn’t the patient-reported symptoms and physical-exam results that are captured in the CTS-6 be sufficient?
I believe most of us agree that a careful history and physical exam should always form the basis for most diagnoses in orthopaedics. Carpal tunnel syndrome has a well-clarified anatomic basis and a very effective surgical treatment. There may occasionally be a role for conservative care but it is often ineffective, and patients should be counseled carefully about the limited efficacy of splints and corticosteroid injections. For most patients in whom this diagnosis is strongly suggested by history and exam, advanced testing is not needed and only adds to patient and system costs. By ordering these tests only for complex cases in which the diagnosis or severity of impairment is unclear, we will be improving patient outcomes while lowering the overall cost of care. That in turn will help us achieve the “triple aim” of access, good outcomes, and lower cost.