Title: DeQuervain’s Tenosynovitis: Trends in Treatment
Authors: Kimberton Nguyen BS OMS3, Marc Nicholes DO, Kyle Klahs DO, John Dunn MD
Introduction
DeQuervain’s Tenosynovitis (DQ) has a prevalence of 0.5% among men and 1.3% among women (Walker-Bone). A heavy burden is placed upon the healthcare system by these upper extremity pathologies. The operating room cost alone per case has been estimated at $8,275 for DQ. Traditionally, mild to moderate DQ have been treated with nonoperative splinting or corticosteroid injections. Surgical release has typically been reserved for severe or resistant cases. Our study examines changes in usage of corticosteroid injections over the last five years. We hypothesize surgeons are quicker to treat DQ with surgical release and use less injections prior to surgery.
Methods
A Truven database review of patients with the diagnosis of De Quervain’s Tenosynovitis from 2015 to 2020 was queried for treatments, patient age, gender, and comorbidities. ICD 9 and 10 codes were identified, patients were then screened for comorbidities. Timing of injections and release was determined the time CPT codes were added. A Chi-Square test was utilized to evaluate significance for the number of injections prior to surgery. A Mann-Whitney U-test was conducted to determine significant differences among time between injection/surgery as well as for number of injections prior to operation stratified between year groups.
Results
In 55,062 patients with DQ, 25,078 treated with injections/surgery. 37 % 55-64 year olds, 24%. 45-54 year olds, 18% males. Most patients received: neither injections nor surgery at 54.5%, injections: 31.6%, :Operation only 8.4%; injection preceding operation:5.5%. The time interval between injections and another injection or operation decreased from 156 days after the first injection, to 143 days after the second injection, down to 113 days after the third injection. Again, a statistically significant decreasing trend was observed with 1.5 injections prior to operation in 2015 down to an average of 1.2 injections in 2020.
Discussion
Our study demonstrated that surgeons are administering fewer injections prior to surgery which confirmed our hypothesis. This practice trend may have been influenced by the literature which demonstrates that while effective, the benefit of corticosteroid injections has proven to be transient in most cases.
In conclusion, corticosteroid injections continue to provide relief for patients with De Quervain’s tenosynovitis
A question from a judge: You seem to imply that the WALANT procedure has changed the management of De Quervain’s tenosynovitis, particularly with your last comment of why you only examined data from the most recent 5-year period. Do you have any direct information about how many people had the newer procedure, perhaps looking at what it cost? Then your hypothesis would be more directly tested. Also, in your blue box, you should indicate what the last 3 arguments are for each year; the yellow box (which shows up later) suggests that these numbers (separated by commas) reflect the mean, median, and mode for each year.
Hello Dr Elliot,
thank you for your question. We hypothesis that the WALANT procedure has changed orthopedic upper limb surgery in general, not just 1st compartment release for QTS. We unfortunately did not pull that information to add into our study, but this would be a great follow up for our particular study. We did however, did literature reviews of WALANT procedures and found that they were more cost effective vs traditional anesthesia related procedures.
Thank you for your suggestions, I greatly appreciate the feedback
Hello and thank you for your work. I am NOT an official judge for your project, but I do have a question. I did not really hear or see you describe the symptoms that patients with this condition experience. Can you tell us about those, and about what criteria are used to move forward with surgical intervention? Thanks so much.
Hi Dr. Briggs Early,
thank you for your question.
Patients tend to have pain/swelling near the base of the thumb and may or may not have restrictive range of motion including but not limiting to thumb abduction/aduction/opposition, ect. We see this in patients who use their hands a lot for their profession or new mothers who are often times lifting their babies a lot.
For the most part, the decision to move forward with surgery is dependent on the surgeon and patient. Most commonly, it is due to refractory pain, worsening pain, or poor quality of life/interference with work or activities. We have seen over the past 5 years a trend towards giving patients less injections and moving faster toward surgical procedures. We hypothesize that a part of this reason may be due to the WALANT procedure, which is a more cost effective, simpler, and less painful procedure that has a quicker recovery time (literature review on WALANT was conducted).
Thank you for this. As a judge, can you clarify the following, you note a statistically significant change 1.5 to 1.2, but how does that relate to a clinically significant difference given that in real life we don’t provide partial injections. Thanks!
Hi Dr. Fritz,
thank you for your question.
I agree with you that partial injections do not/would not correlate with clinical practice. I believe that those stats signify an overall trend, in general, about the decreasing number of injections given prior to making the decision of doing a surgical procedure. I think a good follow up research question to this study is: does a surgical procedure for QTS a definitive procedure to rectify patients symptoms for good/ how long are patients pain free after a surgical procedure vs an injection. I know we did some literature reviews that came to the conclusion that surgical procedures for QTS was more definitive than injections. But a follow up on this with concrete, quantitative data such as days of symptomatic relieve or a number of days after the procedure vs injections until patient presents for recurrence of pain. Clinically, providers can take a look at our data and see the overall decreasing trend of injections prior to surgery and decide for themself what the most cost effective procedure is and what would be best for their patients long term.
Thank you for your presentation. As a judge I am wondering about the trends since the WALANT in percentage of people getting an operation and percentage of people receiving no injection/operation in the last 5 years. Reflecting on Dr. Brigg Early’s question, are the same % people moving to surgery, just with fewer injections, or are more people being considered for surgery?
Hi Dr. Salido,
thank you for your question
I believe the standard of care for QTS is to begin with non-surgical treatment such as physical therapy, anti-inflammatories, ect. The next step would be corticosteroid injections. From then, the refractory cases are either treated with subsequent steroid injections or a surgical release. What we are seeing with our study is that providers are quicker to perform a surgical release, i.e less injections between 1st injection to surgery time. However, there may be some providers who opt to just go to surgery for a definitive treatment, and I cannot say for sure if more patients are being considered for surgery, or, if they are moving with fewer injections. Our study revealed that out of 25,078 patients treated or QTS, 8.4% of those were treated with surgery only (meaning no injections prior), which is actually more than those who had injection followed by surgery at 5.5%. So there may be a shift in providers considering patients for surgery only vs injection then surgery, and this could possibly be due to the rising popularity of the WALANT procedure.