Trapeziometacarpal total joint arthroplasty,with or without supervised hand rehabilitation: A quasi-experimental trial

Abstract

Introduction

Aim of this study was to determine whether postoperative supervised rehabilitation improves functional outcomes after trapeziometacarpal (TMC) total joint arthroplasty (TJA), compared to education alone.

Method

A quasi-experimental before-after trial included 31 women (≥40 years) per group diagnosed with trapeziometacarpal osteoarthritis who underwent TJA. A cohort (n = 31) who was given education alone was compared to a cohort (n = 31) who were subjected to supervised rehabilitation. Primary outcome was the difference in hand function 3 months postoperatively, measured by the Michigan Hand Outcomes Questionnaire (MHOQ). Other outcomes were the MHOQ subscale scores, the active range of motion, strength, time to return to work, satisfaction and complications.

Results

Patients in the education group had a significantly higher median delta MHOQ score when compared to the rehabilitation group at 3 months; 28.5 (20.5-31.3) versus 15.8 (1.9-21.1), (p = <0.01) and at 12 months 36.6 (26.8 - 47.2) versus 27.4 (14.5 - 33.0), (p = 0.01). Only the secondary outcomes the MHOQ subscales hand function, ADL and satisfaction revealed significant differences in favor of the education group. The education method reduced the median number of hand therapy sessions with eight visits.

Conclusion

The present study does not show a significant or clinically relevant benefit from supervised rehabilitation in terms of functional outcomes following TJA compared to education alone. Based on this, it seems safe to leave patients unsupervised in their recovery following TJA and to suffice with just education, however further exploration of effectiveness and safety of this intervention is recommend in larger trials.

Keywords

“Carpometacarpal Joints”“Trapezium Bone/surgery”“Arthroplasty Replacement”Rehabilitation Hand therapy

Introduction

The trapeziometacarpal (TMC) joint is a common location of osteoarthritis (OA). The prevalence of radiologic TMC OA is approximately 35% in people of 55 years or older.¹ Pain and loss of hand function may be present, causing limitations in daily activities and a substantial reduction in quality of life.² When conservative treatment is no longer effective, trapeziectomy with or without ligamentous suspension, or total joint arthroplasty (TJA) with a prosthesis is commonly performed.Effective postoperative care is essential to achieve optimal outcomes.^3–7 However, there is a lack of evidence for the use of a specific rehabilitation protocol, resulting in a wide practice variation regarding the content of rehabilitation protocols after TMC arthroplasty in general, depending on surgical technique, availability of hand therapists and clinical expertise.^8,9 Specifically following TJA, comparative studies assessing the effectiveness of supervised rehabilitation on the outcome are lacking, leaving the effectiveness of rehabilitation unknown.^3,10,11 Besides, the latest generation of prosthesis, does not come with a guideline for supervised rehabilitation.^12,13 The supporting evidence for this recommendation was obtained from retrospective case series in which patients were instructed to gradually resume their daily activities without doing prescribed exercises.^14,15 Higher quality studies are needed to obtain stronger evidence of the optimal care following TMC TJA. As such, the aim of this study is to determine whether supervised postoperative rehabilitation leads to better functional outcomes 3 months after TMC TJA compared to education alone.

Materials and methods

Trial design

This quasi-experimental before-after trial compares a cohort of patients originating from a randomized controlled trial (RCT) (2014-2018) in which all participants received supervised hand therapy¹⁶ to a prospectively enrolled cohort, which was formed from the same source population immediately following the trial, between September 2018 and November 2019. In the latter cohort, patients received education only, by a certified hand therapist.

The local medical ethical review board approved this study (number 180713). The trial was registered at the Netherlands Trial register, https://www.trialregister.nl (NL7654). This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.¹⁷

Participants

The study was conducted at the Hand and Wrist Center in the Isala hospital. Patients were referred from the outpatient clinic of the department of plastic surgery, after which TMC OA was diagnosed by level 4 certified hand surgeons.¹⁸ Once surgical treatment with TJA was scheduled, the patient was referred to the hand therapy department. Women of 40 years and older, with symptomatic TMC OA (Eaton and Glickel stage II or III), were included if a TJA was done.¹⁹ Exclusion criteria were surgery for TMC OA on the same hand in the past, secondary TMC OA following trauma, rheumatoid arthritis, systemic lupus erythematosus or gout. Patients with De Quervain’s tenosynovitis, symptomatic carpal tunnel syndrome (CTS), or neurological disorders on the affected side that could influence postoperative recovery, and patients with insufficient knowledge of the Dutch language were excluded also. An additional exclusion criterium for the education cohort was a previous contralateral TMC TJA, since experience with the procedure could reduce the need for coaching or rehabilitation. Participants provided written informed consent before participating in the study.

Interventions

The surgical procedure consisted of implantation of an uncemented semi-constrained single mobility prosthesis (MAIA, Groupe Lepine, Genay, France).¹⁶ Postoperatively, the thumb was immobilized in a forearm plaster cast with the TMC joint in slight extension, palmar abduction and opposition, slight flexion of the first metacarpophalangeal (MCP) joint and slight wrist extension (Figure 1). After 1 week the cast was removed and a circular plaster cast for another 3 weeks was applied. Immediately after cast removal, 4 weeks postoperatively, patients attended the hand therapist.

Figure 1.

Cast immobilization.

Education group

Education group patients received one education session preoperatively and one session 4 weeks postoperatively. Education consisted of oral information about the surgery, the expected recovery process and advice when and how to gradually resume daily activities. The standardized content in writing of the education session was handed over to the patients at the end of the first instruction. (Appendix 1). After removal of the cast the hand therapist checked whether the patient remembered and understood the preoperatively provided education and gave additional information if necessary. This check was done according to the ‘repeat-back’ method.²⁰ Patients were urged to contact the hand therapist in case of excessive pain or swelling which persisted despite taking rest. At the 3 months postoperative assessment time point, patients were asked for experienced problems and whether they had sought treatment elsewhere. In case of delayed or obstructed recovery, patients were offered the opportunity to undergo a customized treatment program depending on the patient’s needs.

Supervised rehabilitation group

Patients in the supervised rehabilitation group received supervised rehabilitation for a period of approximately 2 months after cast removal. They attended the hand therapy department once a week from week 4 to 7 and once every 2 weeks in week 8 to 12. Treatment was carried out by experienced hand therapists following the local treatment guideline (Appendix 2). The educational content provided to both groups was identical. Advice about when to resume activities is primary based on perceived pain during activity and related to the osseointegration process in the first 6 to 8 weeks. Patients are progressively resuming their daily activities, with full activity permitted after 12 weeks.

Outcomes

At baseline, sociodemographic characteristics were recorded. The primary outcome was daily hand function 3 months postoperatively, measured by the total score of the Michigan Hand Outcomes Questionnaire (MHOQ; 0-100).^21,22 The Minimal Clinically Important Difference (MCID) for MHOQ total score examined at 1 year follow up is 17 points and the Smallest Detectable Change (SDC) 11 points.²³ Secondary outcomes were the MHOQ subscale scores, the active range of motion of the thumb joints, and grip- and (key) pinch strength of the involved hand. Range of motion was measured using a Devore™ goniometer (North-Coast Medical Inc, Morgan Hill, USA) by the dorsal measurement method in degrees. Flexion was noted as a positive angle and hyperextension as a negative angle.²⁴ The palmar abduction of the thumb was measured in degrees with the Pollexograph (Ipsen Pharmaceuticals, Hoofddorp) using the pollexograph-metacarpal active measurement method. Maximum opposition of the thumb was determined with the Kapandji score (0-10).²⁵

Grip strength was measured in kilograms using a calibrated Baseline Jamar® handheld dynamometer (Fabrication Enterprises, White Plains, NY) in the second position. The pinch- and key pinch strength were measured in kilograms by a calibrated mechanical pinch gauge (Baseline, Fabrication Enterprises, White Plains, NY). Patients received standardized instructions for each grip and pinch test measurement and the average out of three maximum contractions was taken. Return to work was assessed with a questionnaire containing questions regarding type of employment, weekly working hours and the number of weeks until resuming original or modified work. Satisfaction with the outcome was assessed with one question scored on a 11 point (0-10) numeric rating scale. The number of extra contact moments with hand therapist or surgeon were also recorded. ‘Extra’ was defined as all the contact moments initiated by the patient except for the scheduled appointments according to the study protocol. The study of Bricout et al. was used to detect all possible complications related to the TJA.¹⁵ All complications were registered and tabulated using the modified Clavien-Dindo Classification for hand surgery.²⁶ Data were collected at baseline, 3 and 12 months after surgery by three certified hand therapists with more than 10 years of clinical experience.

Blinding

As this study compares two consecutive cohorts, it was not possible to make patients and hand therapists unaware of the intervention. Participants were not able to see outcomes of previous assessments. To avoid measurement bias in the rehabilitation group, hand therapists involved in the pre-and postoperative assessments were not involved in the postoperative rehabilitation.

Sample size calculation

A previous study on CMC1 osteoarthritis showed patients who underwent surgery had a mean baseline MHOQ total score of 46 points (SD 15).²⁷ Three months postoperatively the total MHOQ score for the education only group is estimated at 64 (SD 17) and for the hand therapy group 81 points (SD17). The MCID of 17 points²⁷ is used as a significant difference between the groups. An a priori sample size calculation showed that, with 28 patients in each group, a difference of 17 points on MHOQ could be detected with 1 primary endpoint, an alfa of 5% and a power of 80%, based on a two-sided unpaired t-test. Including 10% extra patients for taking potential loss into account, the calculation counts 31 patients in each group.

Statistical methods

The data were checked for errors, outliers and missing data. All variables were analyzed for normal distribution. Continuous variables are presented as means with standard deviation (SD) in a normal distribution or as median with first and third quartiles (Q1-Q3) when non-normality of data is present. Dichotomous and categorical data are described as frequencies with percentages. Missing value analysis was conducted using non-responder analysis and matrix plot inspection to explore missing value patterns, aiming to assess whether the data were missing completely at random (MCAR), confirmed by Little’s MCAR test.

To adjust for baseline differences, delta scores, representing the difference between a follow-up score minus the baseline score, are reported for MHOQ scores and Cochran-Mantel-Haenszel (CMH) analysis for confounding variables. Groups were analyzed according to complete cases using an intention to treat analysis. Unpaired t-tests with Bonferroni correction or Mann Whitney U test in case of non-parametric distribution were used to detect between-group differences for continuous variables. Fisher exact test was used for categorial variables. A p-value of <0.05 was considered significant.

Results

A flowchart of the study is presented in Figure 2. Table 1 presents baseline characteristics.

Figure 2.

Participant flow.

Table 1.

Baseline characteristics.

Baseline characteristics	Supervised rehabilitation n = 31	Education alone n = 31	p-value
Age, mean years (SD)	58.6 ± 6.5	61.0 ± 8.5	0.21^a
Smoking, yes, n	7	1	0.05^b
Diabetes mellitus present, n	2	3	>0.999^b
Dominant hand is surgery side, n	13	15	0.79^b
Eaton & Glickel stage OA, n II/III	13/18	13/18	>0.999^b
MHOQ total score, mean (SD)	49.9 ± 13.1	42.5 ± 14.2	0.05^a

MHOQ scores 0-100, a higher score represents a better hand function.

^aUnpaired t-test

^bFisher exact test.

One patient from the rehabilitation group was not referred to hand therapy due to a satisfactory natural recovery within 6 weeks. In two patients in this group the surgery had to be converted to trapeziectomy due to a trapezium fracture occurring during reaming for cup implantation. Six patients in the education group reached out to the hand therapist once, while three patients made contact two or three times before the scheduled assessment at 3 months. Reasons for contacting were feelings of insecurity and fear (n = 4) for which advice and reassurance was given and check-up for one patient after a fall on operated hand. Other reasons for contacting included signs and symptoms of De Quervain’s tenosynovitis or CTS, for which advice and splinting was provided (n = 2), as well as advice and self-rehabilitation exercises for MCP pain associated with thumb collapse deformity and finger stiffness (n = 2), clinically diagnosed by the hand therapist. None of the patients sought advice or treatment elsewhere or switched to the supervised rehabilitation program.

In each group ten questionnaires were missing. The total percentage missing questionnaires for the primary outcome was 10.7%. Little’s MCAR test was non-significant (p = 0.63), showing no relation between missing questionnaires and other variables. Table 2 shows no differences in other prognostic variables in responders versus non-responders. This findings confirm missing values were completely at random.

Table 2.

Non responder analysis for primary outcome on MHOQ total score at 3 months.

Baseline characteristics	Responder	Non responder	p-value
Baseline characteristics	N = 55	N = 7	p-value
Age, mean years (SD)	60 (7.28)	58 (8.89)	0.4 (95% CI -8.63 – 3.59)*
Smoking, yes, n (%)	7 (12.73)	1 (14.29)	>0.99 (OR 0.87, 95% CI 0.08 - 45.93)
Diabetes mellitus present, n	4 (7.27)	1 (14.29)	0.46 (OR 0.48, 95% CI 0.04 - 26.99)
Dominant hand is surgery side, n	26 (47.27)	2 (28.57)	0.44 (OR 0.58, 95% CI 0.18 - 1.83)
Eaton & Glickel stage II/III, n (%)	25/30 (45.5/54.5)	1/6 (14.3/85.7)	0.22 (OR 0.20, 95% CI 0.004 - 1.86)
Group rehabilitation/education, n (%)	27/28 (49.0/50.9)	4/3 (57.1/42.9)	>0.99 (OR 0.71, 95% CI 0.10 - 4.74)
MHOQ total score baseline, mean (SD)	46.9 (14.0)	39.2 (10.1)	0.29 (95%CI -25.38 - 10.05)*
MHOQ baseline present, yes (%)	53 (96.4%)	4 (57.1%)	0.008 (OR 17.84, 95% CI 1.59 – 273.63)
AROM/strength present at 3 months, yes, n (%)	54 (98.2)	6 (85.7)	0.21 (OR 8.41, 95% CI 0.10 – 713.92)
Complications present at 3 months	9 (16.36%)	1 (14.28%)	>0.99 (OR 1.17, 95% CI 0.12 – 59.0)
MHOQ 1 year present, yes (%)	51 (92.7%)	3 (42.9%)	0.004 (OR 15.50, 95% CI 1.93 – 149.06)
AROM/strength present at 1 year, yes (%)	52 (94.5%)	5 (71.4%)	0.09 (OR 6.57, 95% CI 0.45 – 73.82)
Number of hand therapy visits, median (Q1-Q3)	3 (0-8)	2 (0-11)	0.92**

Responders are defined as patients with completed questionnaires at 3 months.

p-value derived from Fisher exact test unless specified with * for Unpaired t-test or ** for Mann-Whitney U test.

Patients in the education group had a significantly higher median delta score when compared to the rehabilitation group at 3 months (28.5 versus 15.8, p = <0.01) and at 12 months (36.6 versus 27.4, p = .01) (Table 3). The MHOQ subscales hand function, ADL and satisfaction showed significant differences in favor of the education group. The CMH test showed patients in both groups improved at MHOQ total score independent of smoking (3 months p = 0.62, 12 months p = 0.64). Figure 3 shows the individual changes of MHOQ total score and whether patients reached the MCID at 3 months. Raw MHOQ scores are available in the supplementary table (Appendix 3). Between group differences were not found at 3 and 12 months for range of motion and strength (Table 4).

Table 3.

Primary outcome MHOQ and subscales.

MHOQ	Supervised rehabilitation		Education alone		Difference between groups at 3 months^a p-value	Difference between groups at 12 months^a p-value
MHOQ	∆ 3 months - baseline n = 27	∆ 12 months - baseline n = 25	∆ 3 months - baseline n = 26	∆ 12 months - baseline n = 25	Difference between groups at 3 months^a p-value	Difference between groups at 12 months^a p-value
Total score	15.8 (1.9 - 21.1)	27.4 (14.5 - 33.0)	28.5 (20.5 - 31.3)	36.6 (26.8 - 47.2)	<0.01	0.01
Pain	25.0 (17.5 - 42.5)	35.0 (21.3 - 53.8)	25.0 (15.0 - 40.0)	40.0 (20.0 - 50.0)	0.79	0.83
Hand function	10.0 (0.0 - 12.5)	20.0 (1.3 - 28.8)	25.0 (12.5 - 35.0)	35.0 (20.0 - 45.0)	<0.01	<0.01
ADL	11.0 (4.1 - 25.0)	22.0 (13.8 - 33.3)	34.8 (22.8 - 52.5)	41.4 (22.9 - 60.7)	<0.01	<0.01
Work	5.0 (−2.5 - 25.0)	30.0 (6.3 - 45.0)	12.5 (0.0 - 28.8)	40.0 (20.0 - 75.0)	0.25	0.08
Aesthetics	0.1 (-6.3 - 18.7)	9.4 (−4.7 - 18.7)	6.2 (0.0 - 28.1)	6.3 (0.0 - 37.5)	0.16	0.31
Satisfaction	25.0 (0.0 - 45.8)	43.8 (20.8 - 58.3)	41.7 (22.9 - 57.1)	45.8 (25.0 - 67.0)	0.03	0.43

MHOQ scores 0-100, a higher score presents a better hand function Data are presented as delta scores (∆) with median (Q1-Q3). Statistically significant values shown in bold font.

^aMann-Whitney U test.

Figure 3.

Change plot of individual MHOQ scores over time per group.

Table 4.

Secondary outcomes.

Outcome measure	Supervised rehabilitation		Education alone		Difference between groups at 3 months p-value*	Difference between groups at 12 months p-value*
Outcome measure	∆ 3 months – baseline n = 29	∆ 12 months – baseline n = 29	∆ 3 months – baseline n = 31	∆ 12 months – baseline n = 28	Difference between groups at 3 months p-value*	Difference between groups at 12 months p-value*
Extension MCP joint (dgr)	0.0 (−6.0 -16.0)	0.0 (−2.0 – 15.0)	0.0 (−8.0 -5.0)	1.0 (−6.3 – 10.0)	0.41	0.59
Flexion MCP joint (dgr)	−9.0 (−14.0 - -4.0)	−2.0 (−15.0 -3.0)	−5.0 (−11.5 - -2.5)	−1.5 (−5.3 – 5.0)	0.25	0.28
Kapandji score (0-10)	0.0 (−1.0 – 0.0)	0.0 (0.0 - 1.0)	0.0 (−1.0 – 0.0)	0.0 (−1.0 – 0.0)	0.79	0.74
Palmar abduction (dgr)	−4.0 (−6.0 – 2.0)	0.0 (−4.0 – 4.0)	0.0 (−2.0 – 4.0)	4.0 (−2.5 – 6.0)	0.08	0.14
Grip strength (kgs)	−1.6 (−5.0 – 2.0)	3.4 (1.0 – 7.8)	5.4 (1.7 – 10.0)	5.4 (1.7 – 10.0)	0.67	0.43
Pinch strength (kgs)	0.0 (−1.0 – 1.2)	0.9 (0.1 – 1.6)	0.2 (−0.3 – 0.8)	0.8 (0.0 – 1.2)	0.67	0.37
Key pinch strength (kgs)	0.0 (−1.4 – 0.7)	1.0 (1.2 – 1.9)	0.0 (−0.6 – 0.7)	1.3 (−0.2 – 2.0)	0.85	0.73
Extra visits handtherapist^a	8.0 (6.0 - 10.0)		1.0 (0.0 -1.0)		<0.001
Extra visits surgeon†	2.0 (0.5 - 4.0)		0.0 (0.0 – 1.0)		<0.001

Data are presented as median (Q1-Q3). The delta (∆) scores represents the difference between follow-up and baseline. Statistically significant values shown in bold font.

* Difference in delta scores between groups using Mann-Whitney U test.

^aMedian (Q1-Q3) visits in each group at 3 months post-surgery.

Less than 50% of the patients were employed at the time of surgery. Prior to surgery, 15 patients in the rehabilitation group worked a median of 20.5 h (19 - 26.5) per week versus 13 patients in the education only group, working 24 (16-25) hours per week. The rehabilitation group started working after a median of 6 (1.0-10.0) weeks postoperatively, and the education group after 8.0 (2.5-8.0) weeks. After 3 months five patients in the rehabilitation group returned to their original work and six were doing modified work compared to eight and four in the education group. Complications occurred in both groups, involving the dominant hand in 5 patients from the rehabilitation group versus 10 in the education group. Median time to complications was 2 months (range 1-12) in the rehabilitation group compared to 3.5 (range 1-10) in the education group. No significant differences were found regarding the total number of complications between both groups 3 months (OR 3.15, 95% CI 0.77 - 15.77, p = .13), 12 months (OR 0.55, 95% CI 0.15 - 1.94, p = 0.40). Revision surgery was required in one patient in the rehabilitation group and two patients in the education group at 12 months (Table 5). Surgery for associated complications, among which CTS, TVS or De Quervain’s tenosynovitis was necessary in 3 rehabilitation patients and 7 patients from the education group, with a median time to surgery of respectively 4 (range 2-6) versus 8 (4-15) months. At 3 months, the education group scored a median satisfaction (NRS 0-10) of 8.0 (7.0-9.25), while the rehabilitation group scored 7.0 (6.0-8.0) (p = 0.08). After 1 year, this was 7.5 (6.3-8.0) points for the rehabilitation group and 8.0 (8.0-10.0) points for the education group (p = 0.03). At 3 months 21 patients in the rehabilitation group and 27 in the education group would consider having the surgery again under the same circumstances. There was no significant difference between the groups at 3 months (OR 0.16, 95% CI 0.003 - 1.59, p = 0.09), nor at 12 months (p = >0.99). The education method reduced the number of hand therapy sessions and surgeon consults with a median of respectively eight visits (p = <0.001) and two (p = <0.001), saving approximately 4 hours of health care professional time.

Table 5.

Complications.

Grade	Definition	Supervised rehabilitation (n = 12)	Education (n = 15)
I	Any deviation from the normal treatment course without the need for surgical, endoscopic and radiological interventions	Sensibility disturbance (n = 2)	Sensibility disturbance (n = 1)
	Acceptable therapeutic regimens are: extra analgesics and additional hand therapy/splinting/cast	Pain (n = 2)	Carpal tunnel syndrome (n = 1)
	This grade incudes e.g.: tendinitis, scar tenderness, temporary sensory disturbances, etc.
II	Any deviation from the normal treatment course requiring antibiotics, steroid injections or other pharmacological treatment not listed in grade I. Also included are wound infections and hematoma’s not needing anesthesia	Superficial wound infection requiring antibiotics (n = 1)	Corticosteroid injection required for:
II		Tendinitis EPB or FPL requiring corticosteroid injection (n = 2)	Tenosynovitis first extensor compartment requiring (n = 2) for which n = 1 combined with splintCarpal tunnel syndrome (n = 1)Pain combined with splint (n = 1)
III	Any deviation from the normal treatment course requiring surgical, endoscopic or radiological intervention. Also, this includes tendinitis, scar tenderness, persistent pain, etc. not responding to conservative therapy, drugs or injections
A	Minor surgical intervention under local anesthesia (e.g. irritating K wire, suture removal subcutaneously)
B	Major surgical intervention under regional or general anesthesia (e.g. repeat surgery, tenolysis, neurolysis, nerve repair or surgery for tendon rupture, breaking of plate, non-union, initial prosthesis failure)	CTR (n = 1)TFR dig 1 + MCP1 artrodesis (n = 1)TFR dig 1 + release first extensor compartment (n = 1)LRTI (after perioperative trapezium fracture > trapeziectomy) (n = 1)	CTR (n = 4) of which n = 1 combined with UNE releaseMCP1 artrodesis (n = 1)Release 1st ext comp (n = 2) of which n = 1 combined with RSN neurolysisCup loosening and luxation > trapeziectomy (n = 2)
C	Complex regional pain syndrome, diagnosed using Budapest* criteria, independent of the initiated treatment	Mild CRPS, symptoms resolved within 1 year (n = 1)

ICHOM Complications in Hand and Wrist conditions (ICHAW), modified and derived from Clavien-Dindo 2009.

Discussion

The main objective was to determine whether postoperative supervised rehabilitation improves functional outcomes after TMC TJA, compared to education alone. We could not find clinical and statistical evidence that supervised rehabilitation is beneficial in improving functional outcomes at 3 and 12 months. Supervised rehabilitation aims to improve hand function by, amongst other reasons, coaching, AROM and strength exercises. Although the rehabilitation program is usually completed by 3 months, the natural course of total recovery often takes approximately 1 year^7,27–31 Reduction of pain is usually achieved within 3 months when pain caused by the surgery itself has subsided.³² When pain diminishes, functional hand use during daily activities may be adequate for increasing AROM and strength, potentially explaining why no between group differences were found on these variables. In recent years, early active motion protocols have become more common, leading to reduced immobilization time, less rigid immobilization and early initiation of active range of motion.^33,34 However, there remains a wide practice variation with on one hand publications reporting TJA aftercare with self-rehabilitation or functional use without prescription of supervised rehabilitation ^35–41 while other studies still prescribe supervised rehabilitation.^42–44 Comparative studies concerning type and duration of postoperative rehabilitation after TMC TJA are lacking.^3,10,11 One study described two different types of postoperative care where patients with trapeziectomy with tendon interposition were referred to hand therapy and patients with TJA were allowed to unlimited use.²⁹ Since this study did not control for selection bias and compared two different surgical interventions as well, the effectiveness of supervised rehabilitation cannot be determined. The evidence to gradually resume daily activities without supervised rehabilitation was obtained mostly from retrospective cohort studies.^{14,15,32,45,46} However, outcomes for AROM and strength ^{14,15,30,32,45} as well as MHOQ scores^43,47 are consistent with our findings.

It remains unclear whether a causal relationship exists between the number of grade 3 complications and the lack of formal hand therapy in the education group. TVS, CTS and De Quervain’s tenosynovitis are common associated complications after TJA.³⁸ The number of patients as well as the median time to complications and the time to surgery for associated complications is larger compared to the rehabilitation group, however there is an overlap between the ranges in both groups. Notably, CTS was more prevalent in the education group (n = 6). Except for one patient, these symptoms developed within 2 to 3 months postoperatively, a period during which patients increase their physical activity. As the development of complications is multifactorial, the number of reoperations could be attributable to the intervention but also under influence of persistent swelling, disuse or overuse or even a psychological or social context.⁴⁸ CTS occurred in one frailty elderly patient, bilaterally in one case and in another patient CTS was atypically and combined with ulnar neuropathy symptoms. The patient who underwent MCP arthrodesis was already symptomatic with an unstable MCP joint before TJA. As a preventative measure, the provision of comprehensive patient education on the symptoms of possible complications and the appropriate responses, firstly by adjustments of activity level and secondly by consultation of the hand therapist may help to prevent such complications.^10,49,50

Study strengths and limitations

This study is a first attempt to compare postoperative protocols after TMC TJA surgery. A non-randomized design was used because the supervised rehabilitation cohort from the RCT had already been enrolled, so high quality data were available for comparison with the education group.

To mitigate the limitations of non-randomized studies, we controlled for selection bias and confounding by indication in the education cohort, by enrolling consecutive patients meeting the inclusion criteria and giving the total TJA population this education method.

Assumptions that were made to calculate the sample size could have led to a threat of the internal validity. Firstly, because the MCID for the MHOQ in TMC OA²³ is established for the one-year follow-up and might not be sensitive enough for the primary outcome at 3 months or to detect between group differences. London et al. determined the MCID between eight and thirteen points after 3 months in nontraumatic conditions among which OA.⁵¹ Since the MCID for surgically treated TMC OA was not calculated specifically for 3 months, we used the one-year MCID established for the postsurgical TMC OA population. Secondly, because of high known standard deviations of seventeen points on the MHOQ scores,^23,27 variation between groups were high which could have led to an overestimation of the effect size. These factors influence the power of our study; the effect size remains small, either because no differences exist or because the groups were too small in hindsight, resulting in a greater chance of a type II error. A post-hoc sample size calculation shows that, with the found difference on the primary outcome and a power of 80%, 171 patients had to be included in each group.

It also should be noted that results are not extrapolatable to trapeziectomy with or without soft tissue arthroplasties. Multiple studies suggests that TJA can provide a quicker recovery, thereby demanding less intensive rehabilitation, and improved function in the short term when compared to trapeziectomy with or without soft tissue arthroplasty.^{29,30,47,52–58} Furthermore, in TJA the osseointegration time needs to be taken into account. These differences complicate direct comparison of their rehabilitation protocols.

As recommended in previous studies, different types of postoperative care protocols within the same surgical procedure must be compared in studies.^49,50,59 This trial contributes to structured research into the effectiveness of supervised rehabilitation and the transparency of rehabilitation protocols after TMC TJA and may help to determine the optimal postoperative care and reduce practice variation. As supervised rehabilitation potentially has no benefit to education alone after TMC TJA, the latter can yield a patient benefit and may be an efficient and cost saving alternative. It would be of future interest to reproduce this study in a larger non-inferiority trial and to explore whether the number of complications will reduce when patients are provided with comprehensive education on the symptoms of possible complications and the appropriate responses. Development of a prediction model for postoperative course after TJA will enable individually tailored patient care.

Conclusion

Supplemental Material

Supplemental Material - Trapeziometacarpal total joint arthroplasty, with or without supervised hand rehabilitation: A quasi-experimental trial

Supplemental Material for Trapeziometacarpal total joint arthroplasty, with or without supervised hand rehabilitation: A quasi-experimental trial by Elske EDJ Bonhof-Jansen, Sander M Brink, Tjeerd R de Jong, Jeroen H van Uchelen and Eric WP Bakker in Hand Therapy.

Footnotes

Acknowledgements

Many thanks to all patients for participating in this trial, hand therapists Danielle Hoedemaker, Jacqueline Francoys and Anja Verhoeff for data collection, Mirell Papenhuijzen, clinical librarian, for her accurate contribution to the literature search. And professor Paul Werker for his valuable additions and critical review of the manuscript.

Author’s note

Part of the material in the manuscript was presented at the congress of the International Federation of Societies of Hand Therapists and Surgeons (IFSHT/IFSSH), London, June 2022.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Isala Hospital Innovation and Science fund.

Ethical statement

ORCID iD

Elske EDJ Bonhof-Jansen

Supplemental Material

Supplemental material for this article is available online.

Appendix

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