We reviewed the charts of 191 patients (218 trapezia) who underwent
trapezial excision and ligament reconstruction with tendon interposition
for the treatment of primary osteoarthritis. Data were collected
from medical history questionnaires, physical examination notes,
operative reports, and pathology reports. Patients were included
if they had presented with clinical symptoms of osteoarthritis of
the thumb carpometacarpal joint without a history of trauma, conservative
treatment had failed, trapezial excision had been performed between
1990 and 2000 by one of three senior surgeons, and the excised trapezium
had been submitted for routine pathologic examination. Of the 191 patients,
160 (182 trapezia) met the inclusion criteria. The thirty-one excluded
patients had missing or incomplete pathology reports and/or
charts.
From Current Procedural Terminology (CPT) codes for pathologic
examination of an excised trapezium (88305 and 88311) used at the
University of Cincinnati Medical Center, The Christ Hospital, and The
Good Samaritan Hospital in Cincinnati, Ohio, pathology charges were
calculated with use of relative value units (RVU) and current Medicare
fees with a $36.61/RVU conversion rate5.
Also, 300 members of the American Society for Surgery of the
Hand were asked whether they routinely send excised trapezia to
the pathology department for examination.
To verify rules and regulations for the handling of specimens,
the operating-room policy-and-procedures manuals for specimens removed
from patients during an operative/invasive procedure were
obtained from the three hospitals involved in this study.
The pathology reports for the 182 excised trapezia were reviewed,
and 157 (86%) of the reports confirmed the preoperative
diagnosis of degeneration and osteoarthritis of the thumb carpometacarpal joint.
Twenty-five pathologic diagnoses (14%) were ambiguous and
inconclusive. In all cases, the pathologic findings failed to reveal
any unsuspected results. Furthermore, in the surgeon’s
postoperative notes, there was never a discussion or comment regarding
the pathology reports. Consequently, none of the pathology findings
affected the outcome of the case or altered the treatment course. According
to our calculations, the average pathology charge for examination
of the trapezium would have been $98.85 (Table I).
We received responses from 246 (82%) of the 300 members
of the American Society for Surgery of the Hand. Eighty-six (35%)
of the respondents said that they routinely submit excised trapezia
to the pathology department for examination, 154 (63%) said
that they do not submit excised trapezia to the pathology department,
and six (2%) said that they do not perform trapezial excisions
to treat osteoarthritis of the thumb carpometacarpal joint.
Hospital policies and procedures regarding the removal of specimens
during surgery and submission to the pathology department were variable.
At the University of Cincinnati Medical Center, all specimens removed
from patients during an operative or other invasive procedure must
be sent to the laboratory. The Christ Hospital policy-and-procedure
manual states that all specimens removed during an operation are
the property of the hospital and must be sent to the pathology laboratory
for examination, with a short list of exceptions (Table II). The Good
Samaritan Hospital manual states that all tissues and specimens,
with the exception of those listed as exempt from pathologic examination and
those that are to be sent at the surgeon’s discretion (Table II), should be
sent for a pathologic diagnosis.
Several authors have described radiographic staging of osteoarthritis
of the thumb carpometacarpal joint4,6-8.
North and Eaton stated that the treatment of this condition should
be based on the disability produced by the symptoms and not on the
presence of radiographic degenerative joint changes alone9. In our practice, we consider pain
that is refractory to conservative treatment as well as the preoperative
radiographic stage to be the indicators for surgical intervention,
and our surgical procedure of choice is trapezial excision and ligament
reconstruction with tendon interposition as described by Burton
and Pellegrini4. To our knowledge,
the literature on trapezial excision never mentions submission of
the excised trapezium to the pathology department to confirm the diagnosis
of primary osteoarthritis4,10-15.
Until recently, we submitted excised trapezia to the pathology department
for routine examination simply because we were taught "to
send everything to pathology."
Specimens should be sent to the pathology department only if
new or potentially useful information may be obtained. In this study,
we found that routine pathologic examination of excised trapezia from
patients with osteoarthritis of the thumb carpometacarpal joint
is not justified because the findings never changed the diagnosis
or altered the course of treatment. Using the current Medicare RVU
conversion factor of $36.61, we found that $98.85
in pathology charges can be eliminated each time this operation
is performed.
The majority (63%) of the hand surgeons in our survey
agreed that an excised trapezium should not be sent to pathology
for routine examination, stating that doing so is "too
costly to the patient" and "a totally unnecessary
utilization of resources." One surgeon commented that "there
must be some benefit from the pathology report to warrant sending
any tissue."
The eighty-six respondents who did submit excised trapezia
to the pathology department often cited "hospital policy" as
their rationale for the costly and (we believe) unnecessary test.
We found that local hospital policies can be highly variable, even among
hospitals in the same health-care system.
If hospital policies mandate the submission of all specimens
to the pathology department, these policies should be considered
outdated and in need of revision. There are several guidelines for
revising hospital policies (and thus controlling costs): policies
should be revised frequently, a detailed list of exempt types of
specimens should be established, the decision regarding whether
to submit a specimen should be left to the surgeon and/or
pathologist, and "gross only" examinations of
certain specimens should be permitted.
We hope that this study will serve as a stimulus to orthopaedic
surgeons who routinely submit all specimens for pathologic evaluation
to question whether the evaluation will change or influence the course
of treatment. Furthermore, if hospital policies mandate submission
of all specimens, appropriate steps to amend the policies should
be considered.