#JHSJC

October #JHSJC Transcript

We’ll be posting all #JHSJC transcripts from here on out (including past conversations!), so be sure to check back in case you miss a discussion! You can read the transcripts for June #JHSJC here,  July #JHSJC here and September #JHSJC here!

October’s #JHSJC was a spirited discussion addressing two articles from Volume 44, Issue 10 of The Journal of Hand Surgery: The Effect of Intraoperative Corticosteroid Injections on the Risk of Surgical Site Infections for Hand Procedures and Early Practice Patterns of Hand Surgeons: An American Board of Orthopaedic Surgery Database Study.

Feel free to continue the conversation below in the comments!

J Hand Surg Am- ASSH @JHandSurg:
JHSJC starts now! Let’s get the discussion going.

Brent Graham @BgTalkinman:
Welcome to the October chat! #jhsjc

Brent Graham @BgTalkinman
Let’s start with the article about #corticosteroid #injections and #SSI #jhsjc The visual abstract is on the jhsfocus.org/jhsjc page received over 1800 impressions yesterday. Lots of interest in this. #jhsjc

Steven Haase @schaase:
Not sure of the possible mechanism here. Don’t we have other studies that show no diff in infection rates for patients on steroids? #jhsjc

Brent Graham @BgTalkinman:
That was my first question – biologic plausibility? #jhsjc

The method used by the authors – matched cohorts – is good so the observations are valid. #jhsjc

Steven Haase @schaase:
If I’m not going to hold my RA patient’s steroids for surgery, why should I be concerned about giving an injection? #jhsjc

David Ring @DrDavidRing:
Similar evidence for total knee replacement after steroid injection in larger cohorts. Perhaps time dependent. #jhsjc

Brent Graham @BgTalkinman:
The rate of #SSI in both groups was low – consistent with previous studies. #jhsjc

Steven Haase @schaase:
I agree the observations seem valid but just wonder if the numbers they saw are clinically significant infections. #jhsjc

Andrew D. Sobel, MD @AndrewSobelMD:
What about preop injections? Are we then waiting a set amount of time for surgery? Do the effects of steroid last for weeks? #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
What do you mean by “time dependent”? Do you mean concomitant with the surgery? #jhsjc

David Ring @DrDavidRing:
In the hand, there was only one deep infection. Not sure how steroids would result in superficial injections #jhsjc

Brent Graham @BgTalkinman to @AndrewSobelMD:
It’s a good point because the expected therapeutic effect is for weeks. It wasn’t studied so that isn’t clear. #jhsjc

David Ring @DrDavidRing:
Time dependent = the longer after surgery, the lower the risk. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Agreed. The biologic link doesn’t seem clear and yet this is what was shown. #jhsjc

David Ring @DrDavidRing:
The rate of superficial infection / suture infection is higher if you track people closely. See: ncbi.nlm.nih.gov/pubmed/26359272 #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Right! So concomitant with the surgery would be the highest risk – if in fact it is real. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I agree that most of the published estimates of #SSI are probably spuriously low. #jhsjc

Brent Graham @BgTalkinman:
Given the very low rate of #SSI in hand surgery the risk of spurious association is always present even with good study designs. #jhsjc

The fact that this aroused such large interest in my Twitter feed suggests that this resonates with surgeons. #jhsjc

Would anyone out there stop doing these intraoperative injections for dx other than the one leading to the surgery? #jhsjc

Warren @whammert to @BgTalkinman:
Do you think this will make surgeons not inject steroids? or change practice habits? #jhsjc

Brent Graham @BgTalkinman to @whammert:
That’s my question! I have never done it anyway but it is commonly done by many surgeons. #jhsjc

Warren @whammert to @BgTalkinman:
I give about 6 weeks following an injection before making an incision in the area, but will still use them #jhsjc

Brent Graham @BgTalkinman to @whammert:
This is an important question because it represents level III evidence. #jhsjc

Jeffrey Stepan MD, MSc @JeffStepanMD to @BgTalkinman:
This may magnify the limitation of a retrospective nature of chart review and quality of documentation in diagnosing patients – where only a few patients among almost 800 patients determines a “meaningful” difference. #jhsjc

David Ring @DrDavidRing:
Corticosteroid injection is a short term plan for everything but trigger finger #jhsjc

Brent Graham @BgTalkinman to @whammert:
Meaning that you will do an intra-operative injection? #jhsjc

Warren @whammert to @BgTalkinman:
no – inject before and will operate if symptoms persist. #jhsjc

Brent Graham @BgTalkinman:
We are talking very small numbers but the risk was just that much higher for an ipsilateral injection. Is there any meaning to that? #jhsjc

Warren @whammert to @BgTalkinman:
I will inject another area during surgery -ie trigger when doing CTR #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I agree and trigger finger is the only condition for which I ever perform a steroid injection. #jhsjc

Warren @whammert to @BgTalkinman & @DrDavidRing:
deQuervains? no injections? #jhsjc

Brent Graham @BgTalkinman to @whammert:
That is what most of the injections likely were. Will you tell pts that the risk is 4X higher than if done in clinic? #jhsjc

David Ring @DrDavidRing:
The numbers are too small for a safety study. And the absolute risk is very small. #jhsjc

Brent Graham @BgTalkinman to @whammert, @BgTalkinman & @DrDavidRing:
no – splint only #jhsjc

Steven Haase @schaase to @whammert & @BgTalkinman:
I sometimes will inject a basal joint or a contralateral trigger during surgery on the other side. #jhsjc

David Ring @DrDavidRing:
No evidence that steroids are disease modifying for de Quervain #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
So do you think this could be spurious? #jhsjc

Warren @whammert to @BgTalkinman, @whammert & @DrDavidRing:
hmm. I offer injection and splint – more people want the injection than splint #jhsjc

Warren @whammert to @DrDavidRing:
Is there evidence they are not disease modifying? #jhsjc

Warren @whammert to @DrDavidRing:
interested to hear how you would design the study to test this? #jhsjc

Brent Graham @BgTalkinman:
I did an editorial last month of admin data research. This question is well-suited to that. Better than single institution study. #jhsjc

Steven Haase @schaase to @whammert, @BgTalkinman & @DrDavidRing:
I also inject and splint before going to surgery. #jhsjc

Brent Graham @BgTalkinman to to @whammert @DrDavidRing:
An admin database study would be ideal. I hope someone does that. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
That isn’t my reason. I fear depigmentation especially in a city with a lot of non-Caucasian pts. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I decided long ago to not have a white person and a black person treatment. Splints for all. #jhsjc

David Ring @DrDavidRing:
We used a EMR database to track prescription of antibiotics. ncbi.nlm.nih.gov/pubmed/26359272 #jhsjc

Even that doesn’t catch all suture abscesses, since they get better with suture removal alone. #jhsjc

Warren @whammert to @BgTalkinman & @DrDavidRing:
water soluble steroid rather than fat soluble? #jhsjc

David Ring @DrDavidRing to @whammert:
There is evidence that de Quervain is self-limited. So, yes there is some evidence. #jhsjc

Brent Graham @BgTalkinman to @schaase:
We will have a paper soon showing that continuing biologics has no effect on complications. #jhsjc

Brent Graham @BgTalkinman:
For those who do intra-op injections, does this data change your discussions with pts? #jhsjc

Steven Haase @schaase to @BgTalkinman:
I guess I would disclose that there is some evidence of slight increased chance of infection. But risk is still low. #jhsjc

Brent Graham @BgTalkinman to @schaase:
I think that is very reasonable. 4X risk is still very low. #jhsjc

Brent Graham @BgTalkinman:
Let’s move on to readiness for the #SCOSH. #jhsjc

This is a topic that interests a lot of people including #ASSH i.e. pathway to membership which presently requires #SCOSH #jhsjc

The question seems to be: Is the bar too high or is preparation/early practice somehow inadequate? #jhsjc
Brent Graham @BgTalkinman

Andrew D. Sobel, MD @AndrewSobelMD:
Very interesting to a young hand surgeon… Are these categories representative of most/all CAQ hand surgeons’ practices years in? #jhsjc

Brent Graham @BgTalkinman:
In the podcast Dr Kaplan reflected on what should define a hand surgeon. Views? #jhsjc

I’ve been practicing more than 25 years and I have done 0 congenital cases – not a single 1. I still think I am a “hand surgeon”. #jhsjc

How can the categories be changed to make them more accessible or should there just be fewer categories required? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
I remember having to squeeze things into categories to make it work. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
One suggestion made in the paper was change “microvascular” to “microsurgical” — that makes a lot of sense to me? #jhsjc
Replying

David Ring @DrDavidRing to @BgTalkinman:
Hand surgery is far and away the common stuff. And puzzling pain is far more common than uncommon pathology. #jhsjc

Warren @whammert:
I was surprised the tumor category was not often filled- ganglions, GCT of tendon sheath. I do wonder about coding. #jhsjc

Brent Graham @BgTalkinman:
The other thing is the time period for collecting the cases. I agree the spectrum of cases might be less at the beginning of practice #jhsjc

Warren @whammert to @BgTalkinman & @DrDavidRing:
there is a nerve section, but probably used more for compressions than nerve injuries #jhsjc

Brent Graham @BgTalkinman to @whammert & @DrDavidRing:
Plastic surgeons – do the same challenges exist in different categories? #jhsjc

Steven Haase @schaase:
Do we change the categories to make it easier? Or were they chosen because once we thought that is what a hand surgeon should be? #jhsjc

Steven Haase @schaase to @BgTalkinman, @whammert & @DrDavidRing:
have to be honest—I don’t recall categories at all. Either they were not there or I forgot. #jhsjc

Warren @whammert to @BgTalkinman & @DrDavidRing:
I read a paper previously indicating PS are more likely to do congenital, soft tissue than bone #jhsjc

Brent Graham @BgTalkinman to @schaase:
That is the central question. Their data showed that by the previous criteria only 26% were on track to qualify. #jhsjc

Warren @whammert to @schaase @BgTalkinman and 2 others:
categories have been around at least since early 2000 #jhsjc

Brent Graham @BgTalkinman to @whammert & @DrDavidRing:
That would be my expectation- that they don’t fill up the fracture category #jhsjc

Brent Graham @BgTalkinman:
The data also showed that most candidates could make 3 of categories so even lowering to 4/8 wouldn’t be enough. #jhsjc

Do these findings suggest that changes are required for fellowship training? #jhsjc

The assumption seems to be that the candidates know how to do the cases but they don’t see them. is that likely true? #jhsjc

Warren @whammert to @BgTalkinman:
I think these are two different issues – training does not equate to early practice #jhsjc

Warren @whammert:
what they do is likely dependent on what comes into the office early on #jhsjc

Brent Graham @BgTalkinman to @whammert:
Does that change a lot over the first few years? #jhsjc

Should they qualify after 5 years? #jhsjc

Warren @whammert to @BgTalkinman:
depends on your practice and partners – difficult to generalize I think, but probably does as a practice grows #jhsjc

Brent Graham @BgTalkinman:
What can be done to make this more feasible while not lowering the status of “hand surgeon”? There are implications for re-cert too. #jhsjc

Warren @whammert:
You can qualify at any time, but to use ABOS case list, you have to do it within a specific time period – I think 18 mos #jhsjc

Steven Haase @schaase:
I would have thought taking a reasonable amount of ER Hand call should cover at least five categories. #jhsjc

Warren @whammert to @BgTalkinman:
With all the chances in MOC, I don’t think the recertifications will be an issue for many wanting to do it. #jhsjc

Brent Graham @BgTalkinman:
Is this likely a problem that is equivalent for academic and private practice? #jhsjc

Warren @whammert to @BgTalkinman:
I think more private practice and plastic academic who don’t have much elective surgery #jhsjc

Brent Graham @BgTalkinman to @schaase:
That is interesting bc covering ER call seems to be another issue altogether i.e. getting people to do it. #jhsjc
Replying

Steven Haase @schaase to @BgTalkinman:
As an academic surgeon covering hand call, I would have had no problems with any categories except congenital #jhsjc

Warren @whammert to @schaase & @BgTalkinman:
being at a busy level i hospital gives you micro and others – most of the are sent to UM #jhsjc

Brent Graham @BgTalkinman to @schaase:
That would certainly have been my personal experience too but evidently that is not generalizable. #jhsjc

Brent Graham @BgTalkinman:
Given the linkage to #ASSH membership there is a risk of a widening gap btw private practitioners and academics. That isn’t healthy. #jhsjc

Warren @whammert to @BgTalkinman & @schaase:
But most hand surgeons are not at academic medical centers. #jhsjc

Brent Graham @BgTalkinman to @whammert & @schaase:
Exactly! That should be a concern for #ASSH. #jhsjc

Steven Haase @schaase:
Great discussion! Thanks, friends! #jhsjc

Brent Graham @BgTalkinman:
Thanks for the insights! Keep the discussion going. See you next month. #jhsjc

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