Journal Article Review, August 2018

The best way to rehab a thumb after ligament reconstruction and tendon interposition (LRTI) for basal joint osteoarthritis.

Hutchinson DT et al: A Prospective, Randomized Trial of Mobilization Protocols Following Ligament Reconstruction and Tendon Interposition. J Bone Joint Surg 2018 Aug 1;100(15):1275-1280
Investigators at the University of Utah last week published a randomized, prospective trial comparing two methods of postoperative rehabilitation for patients undergoing ligament reconstruction and tendon interposition (LRTI) for osteoarthritis (OA) at the thumb carpometacarpal (CMC) joint.
LRTI is the most commonly performed procedure for CMC OA, yet prior evidence has been weak in ascertaining the postoperative rehabilitation protocol. Recommendations have varied from 8 to 13 weeks of immobilization, a considerable difference when patients need to plan their return to vocational and avocational activities. The investigators hypothesized that the immobilization protocol would yield better results.
At 2 institutions, the investigators recruited 223 patients (238 thumbs) undergoing LRTI to receive 1 of 2 postoperative rehab protocols. The thumbs were prospectively randomized. Patients under 40, and those with either rheumatoid arthritis or previous CMC joint surgery were excluded. Patients that had concomitant thumb MP joint stabilization or carpal tunnel or trigger finger release were included.
The early rehab protocol consisted of a forearm (FA) based thumb spica splint (TSS) for a week followed by a FA based thermoplastic TSS for 3 weeks, then a hand-based TSS for 4 weeks. Active range of motion exercises were started 4 weeks post-op.
The immobilization protocol consisted of the same splint for the first week followed by a FA based TSS for 11 weeks. Active ROM exercises were started 6 weeks post-op.
Outcome measures included DASH score, pinch and grip measurements, 9-hole peg test, visual analog scale (VAS) scores for pain and patient satisfaction, and wrist/thumb ranges of motion. All measures were obtained preoperatively and at 6, 12, 26, 52, and 104 weeks postoperatively.
Follow-up was at least 1 year (average 1.7 years) for 74 patients (80 thumbs) treated with the immobilization protocol and for 83 patients (89 thumbs) with the early rehab protocol.
RESULTS: DASH scores, grip and pinch strengths, and VAS scores for pain and satisfaction improved in both groups and without any significant between-group differences at any time point. Wrist and thumb movements and peg tests were better at 6 weeks for the early rehab group, but thereafter both groups showed only statistically insignificant differences.
Concomitant surgery did not affect outcome. For the early rehab group, DASH scores and patient satisfaction VAS scores maximized at 12 weeks and at 6 weeks, respectively. These scores maximized at 26 and 12 weeks for the immobilization group.
COMMENT: I love to read and review prospective, randomized trials—high level evidence! Blinding of the patients was impossible, as it was for the examiner during the early postoperative visits when an orthosis was still in place. Whether or not the examiner remembered at the late follow-up visits which group the patient was in is not known. Although this could be a source of observer bias, is would likely be negligible. The authors also caution that the conclusions here may not apply to other rehab protocols for LRTI or for other surgical procedures, such as simple trapezial excision.
The immobilization protocol did not produce better results for the measures tested; and although the study did not assess the overall patient experience with the two protocols, I have my guess which group was happier. I am going with early rehab.