What's the Best Treatment for Painful and Severely Limiting Wrist Arthritis?Imagine you have a severely painful wrist from arthritis that limits your everyday life.
Would you trade a few extra years of living in order to live your remaining years pain free? If you said, yes, how many years would equal the value of living pain free?
These are the questions given to hand surgeons comparing the results of one procedure over another.
Surgical treatment for severe and painful wrist arthritis includes arthrodesis (wrist fusion) and arthroplasty (wrist replacement). Without clear and direct evidence of the benefit of one procedure versus another, as patients, we rely on surgeon's opinions and judgments to guide us.
The literature shows that from the limited studies done so far, surgeons believe the value added from wrist arthroplasty (replacement) is not worth it. The potential complications and risks that come with that procedure outweigh the benefit to the patient. The consensus is that you might as well have a wrist arthrodesis (fusion). You'll get the same (or better) pain relief, still get the same overall function, and with fewer problems.
In this study, the authors surveyed 73 experienced hand surgeons who had been in practice for 11 to 20 or more years. The survey was a utility survey. This means it was designed to measure the value placed on living with a painful, poorly functioning arthritic wrist compared to living a shorter, but pain free, life.
They calculated the expected quality adjusted life years (QALY) for three patient cases: 1) living with a painful wrist, 2) wrist arthrodesis (fusion), and 3) wrist arthroplasty (replacement). Utility values for each one were compared. The tool they used was designed to place a value on gains in quality and quantity of life from treatment.
The benefit of this type of measurement is that it allows researchers to compare how a surgeon values one surgical procedure over another. Then the cost of each gain in quality adjusted life years (QALY) can be calculated. This helps put the value into economic terms when making decisions about health care policies and spending. In other words, how much value is gained for procedure A versus procedure B? And how much does it cost?
What they found was that from a surgeon's point-of-view, it would be worth it to trade 14 years of life to avoid having a painful, arthritic wrist. This result suggests that surgeons believe that a painful, functionally limited wrist would severely alter and limit life. As has been reported in other studies, the surgeons in this study also agreed that the value of arthroplasty over arthrodesis is very small.
The authors questioned whether this preference for fusion over replacement may be based on a lack of experience with the benefits of arthroplasty. Most of the surgeons surveyed did not do wrist replacements. It is true that of the studies done so far, the rates of re-operation and revision are higher with wrist replacement. They suggested that maybe if as much time and money is spent improving the wrist implant as has been invested in hip and knee implants, the results would improve dramatically.
In a study of this type, it's important to know that patients may not judge things the same way surgeons would. The loss of the use of a hand would be quite devastating for a surgeon.
Most patients adjust their thinking and expectations, along with their activities to fit their physical abilities. It may be that it's one thing to imagine poor health, it's another to experience it. And the human ability to adapt and cope results in higher quality of life than might be predicted or expected.
Until more and larger studies on wrist arthroplasty are available, patients must rely on surgeons' opinions and preferences. Given this information, patients may want to review their own goals, needs, and values. It may turn out that patients will adopt a different attitude and approach. Their choices may differ from surgeons' choices.
Data from decision analysis like in this study provides helpful information. The cost effectiveness of one treatment approach can be compared to another. For many patients, choosing the best treatment may come down to dollars and cents over quality and quantity of life.
Using quality adjusted life years, researchers may be able to help patients calculate their own utility values. Taking into account quality and quantity of life with and without a painful wrist may help with the decision-making process. The same approach could be used with other health care decisions (not just arthritis). More study is needed to evaluate this model with other common conditions for which there is more than one possible treatment choice.
Christi M. Cavaliere, MD, and Kevin C. Chung, MD. Total Wrist Arthroplasty and Total Wrist Arthrodesis in Rheumatoid Arthritis: A Decision Analysis From the Hand Surgeons' Perspective. In The Journal of Hand Surgery. December 2008. Vol. 33-A. No. 10. Pp. 1744-1755.
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