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 all of the #JHSJC transcripts here!
November’s #JHSJC was a spirited conversation addressing two articles from Volume 44, Issue 11 of The Journal of Hand Surgery: Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture and Complications of Corrective Osteotomies for Extra-Articular Distal Radius Malunion.
Feel free to continue the conversation below in the comments!
J Hand Surg Am- ASSH @JHandSurg:
November’s #JHSJC
starts now! Let’s get the discussion going!
Brent
Graham @BgTalkinman:
Let’s start with the article on #DRFx #osteotomy; https://www.jhandsurg.org/article/S0363-5023(17)31618-0/fulltext #jhsjc
Please use the #jhsjc hashtag to let us know you are here!
Steve Lee
@kichmd:
#jhsjc Hi all! Steve Lee here
RyanC
@RPCalfeeSTL:
#jhsjc eye opening incidence of complications
Erika
Sears @ErikaDSears:
#jhsjc Hi everyone, Erika Sears here
Brent
Graham @BgTalkinman:
Sample size of this study an average of about 10 cases/year among a few
surgeons; impact on the observations? #jhsjc
There were a lot of complications. Does that reflect inexperience? #jhsjc
In other words, should these findings be considered generalizable? #jhsjc
Warren
@whammert to @BgTalkinman:
not a really common procedure for most, but hard to be confident with that
small of a cohort #jhsjc
RyanC
@RPCalfeeSTL:
#jhsjc I would be surprised if many surgeons have large numbers of these cases
Warren
@whammert to @BgTalkinman:
I think this as more of a pilot study to set hypothesis and form a question
rather than generalizable #jhsjc
Brent
Graham @BgTalkinman:
Our practice sees a lot of these cases – I prob do about 20/yr myself. I
haven’t had this rate of complications. #jhsjc
Steve Lee
@kichmd:
#jhsjc I agree. I don’t do a lot, but I they report a very high rate of
complications
Warren
@whammert to @BgTalkinman:
That is a big number – write it up:) #jhsjc
Avi
Giladi @theaviram to @whammert:
agree, but it would seem likely that for many they are generalizable because
most don’t have high volume…their experience reflects the challenges of these
procedures #jhsjc
Brent
Graham @BgTalkinman:
There were a lot of non-unions which is especially concerning. #jhsjc
What about the technique – bone grafting, probably volar approach. How does that relate to the findings? #jhsjc
Erika
Sears @ErikaDSears to @BgTalkinman:
do you prefer autograft versus allograft? would that explain some of the
differences you see in complications? #jhsjc
Steve Lee
@kichmd:
#jhsjc The authors at the end question volar plating and do say iliac crest is
the “gold standard”
RyanC
@RPCalfeeSTL:
#jhsjc I do autograft first nonunion but don’t see as necessary for malunion
Warren
@whammert:
Who defines the “Gold Standard”? #jhsjc
Brent
Graham @BgTalkinman:
I’ve ALWAYS done this dorsally bc it’s easier. Does a volar approach possibly
lead to a risk of non-unions? #jhsjc
Warren
@whammert to @BgTalkinman:
I almost always go volar – autograft if volar cortex not in continuity and
otherwise allograft or nothing #jhsjc
Joe
Rosenbaum, MD @JRHandSurg:
It’s been my impression that a volar approach is the more common way to do
these, but that’s just what I’ve seen. Would others agree? #jhsjc
Steve Lee
@kichmd:
#jhsjc call me old fashioned but I have tried all types of bone graft and have
settled on iliac crest autograft. Dorsal approach with low profile radial and
column separate dorsal plates. I have been happy with the results.
John
Seiler @jgseiler:
#jhsjc- Iliac crest has the advantage of being able to be sculpted to fit the
defect and have good structural support- still my graft of choice here-
Brent
Graham @BgTalkinman to @ErikaDSears:
I have only ever used autograft, iliac crest only; at least 250 cases without
nonunion – all dorsal. #jhsjc
Warren
@whammert to @jgseiler:
But do you need the structural support or are VLP strong enough #jhsjc
Brent
Graham @BgTalkinman to @jgseiler and @kichmd:
Totally agree with that. #jhsjc
John
Seiler @jgseiler to @whammert:
#jhsjc Usually if you can get the
carpentry right and get a stable fixation construct union is reliable – agree
with Brent
Brent
Graham @BgTalkinman to @whammert and @jgseiler:
Don’t understand how graft goes in dorsally with a volar approach. That is why
I have always done this dorsally #jhsjc
Neal Chen
@NealChen18:
If I go volar will secure distal first and then clamp to shaft then back fill
#jhsjc I’ve done both volar and dorsal and I like autograft
Warren
@whammert to @jgseiler:
Iliac crest can be in a deep hole in Rochester – proximal tiba cancellous graft
is my first choice #jhsjc
Brent
Graham @BgTalkinman to @whammert and @jgseiler:
My concern is that these are the reasons why there are cx especially with small
experience. #jhsjc
Steve Lee
@kichmd:
#jhsjc I totally agree with Brent. Iliac crest autograft placed dorsally
easier, heals very fast.
Brent
Graham @BgTalkinman:
My general point is that I think this article has meaning for surgeons who use
approaches like volar plating/allograft #jhsjc
Warren
@whammert to @kichmd:
DO you use a dorsal plate? Remove
later? or K-wires? #jhsjc
Brent
Graham @BgTalkinman:
One reason this article was published is because I suspect it IS generalizable.
#jhsjc
John
Seiler @jgseiler:
#jhsjc- I always worry about smokers and
those that Cierny used to call the B hosts- makes healing less
predictable! I usually use a dorsal
plate construct. Having a reference
point around complication rate is a very useful reference
Brent
Graham @BgTalkinman to @whammert and @kichmd:
About 25% implant removals. Cost of doing business there. I don’t apologize for
it. #jhsjc
Yes dorsal plate from the small frag set – from about 25 years ago. #jhsjc
Ray Raven
MD, MBA @RayRavenMD:
anyone using a bone stimulator for corrective #osteotomy for #DistalRadiusFracture
#Malunion? #jhsjc
Steve Lee
@kichmd:
#jhsjc I use 2 radial styloid plates but put 1 over dorsal radial column and 1
over dorsal ulnar column. Remove at 6 months if symptomatic
Warren
@whammert to @BgTalkinman and @kichmd:
do they stay in or do you remove them? #jhsjc
RyanC
@RPCalfeeSTL:
#jhsjc no experience with bone Stim – do others see value?
John
Seiler @jgseiler:
#jhsjc Ray I don’t use a stimulator but occasionally use a BMP sponge (off
label) and cover them with steroids
Brent
Graham @BgTalkinman:
We will get to the other article, but the long term cost, including implant
removal may be less if cx like this are avoided. #jhsjc
Steve Lee
@kichmd:
#jhsjc Haven’t needed bone stim when using iliac crest autograft and dorsal
approach. Baby lamina spreader without teeth nice too to “jack open”
the osteotomy
Brent
Graham @BgTalkinman to @whammert and @kichmd:
25% rate of removal. I don’t
consider that a complication. #jhsjc
Steve Lee
@kichmd:
#jhsjc In current paper they had some volar plates break, so plate not strong
enough in some cases
Brent
Graham @BgTalkinman to @kichmd:
I flex the wrist over a towel, over distract with Senn retractor, wedge in
graft with cortical bone to strut the dorsal frags #jhsjc
a totally different topic but volar plating doesn’t fit the forces with most DRF. That’s why I’ve never done one. #jhsjc
John
Seiler @jgseiler:
#jhsjc Do you think that the method of
volar osteotomy and plate fixation places inordinate stress on the distal plate
screw construct facilitating failure of plate?
Brent
Graham @BgTalkinman:
Conclusions? Suggests to me that experience matters, use autograft and good
construct. #jhsjc
John
Seiler @jgseiler:
#jhsjc I would agree- these are tough
cases!
Steve Lee
@kichmd:
#jhsjc I agree!
Joe
Rosenbaum, MD @JRHandSurg to @BgTalkinman and @kichmd:
Hang on… You’ve never done a single volar locked plate for a distal radius
fracture? That is fascinating. Are you using dorsal plates? Spanning plates? Ex
fix? #jhsjc
Brent
Graham @BgTalkinman:
Let’s move on to the article about costs in #Dupuytren https://www.jhandsurg.org/article/S0363-5023(18)31491-6/fulltext #jhsjc
The #visualabstract I posted on Twitter got >1400 impressions. Hot topic! #jhsjc
This is a link to the podcast I did with Marco Rizzo https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/November_2019.mp3 #jhsjc
Marco
Rizzo @MarcoRizzo001:
Hello everyone Marco Rizzo here. Thanks
for inviting me to participate – my first time at JC.#JHSJC
Ray Raven
MD, MBA @RayRavenMD to @MarcoRizzo001:
welcome and thank you! #jhsjc
Brent
Graham @BgTalkinman:
Most of the lit on #Dupuytren treatment focuses on short term outcomes. We have
2 RCT showing high rate of recurrence within 2 years #jhsjc
Ray Raven
MD, MBA @RayRavenMD to @BgTalkinman:
I think this was a great article and confirms what we already know about
#Dupuytren disease and #collagenase #JHSJC
Brent
Graham @BgTalkinman to @MarcoRizzo001:
Great! Don’t let me misquote you! #jhsjc
Joe
Rosenbaum, MD @JRHandSurg:
As a recent graduate, I watched interest in #collagenase increase sharply, then
fall precipitously. It’s been interesting to see. #jhsjc
Brent
Graham @BgTalkinman to @RayRavenMD:
If this is widely known, why is #CCH in such wide use? #jhsjc
Brent
Graham @BgTalkinman to @JRHandSurg:
The most recent lit suggests that its use is actually increasing. We had a
paper on that in the last 2 years. #jhsjc
Avi
Giladi @theaviram to @BgTalkinman and @RayRavenMD:
convenience, marketing, ease…lots that appeals to patients, many come in with
high expectations for it too #jhsjc
Joe
Rosenbaum, MD @JRHandSurg to @BgTalkinman:
To me, watching my attendings and the listserv, it almost feels like the
enthusiasm travels in waves. #jhsjc
Neal Chen
@NealChen18:
#jhsjc CCH very common in scandinavian countries from what I learned from
visitors. I think they sell for much cheaper than in US
Brent
Graham @BgTalkinman:
A few methodology points – just direct costs measured. How would measuring out
of pocket expenses changed the findings? #jhsjc
Erika
Sears @ErikaDSears to @BgTalkinman and @RayRavenMD:
I think CCH is in wide use because many patients want to avoid surg, some would
rather do nothing (my VA pts) #jhsjc
Warren
@whammert:
Marketing – many patients come in asking about it #jhsjc
Warren
@whammert to @NealChen18:
Western Europe it is between $500-600 per vial.
#jhsjc
Ray
Raven MD, MBA @RayRavenMD to @whammert:
and now, John Elway! https://www.factsonhand.com/?gclsrc=aw.ds&&gclid=CjwKCAiAzanuBRAZEiwA5yf4us40Jdc8IEjP1ZEn0NLjpA3rOWadPY5de_hdh7le2VpU6Ixv8_R-shoCP-sQAvD_BwE #jhsjc
Marco
Rizzo @MarcoRizzo001:
You’re right Neal. However, there has
been a push towards a more hardline stance.
I don’t think it is available in Germany due to concerns about it’s
being better than other options. #JHSJC
Brent
Graham @BgTalkinman to @theaviram and @RayRavenMD:
This gets to the idea of patient preferences in Rx decisions but there
increasing lots of evidence against CCH #jhsjc
Ray Raven
MD, MBA @RayRavenMD to @whammert and @NealChen18:
– which is one of the major problems with the US health care system. #jhsjc
Avi
Giladi @theaviram:
great paper, puts the downside of early recurrence in great $ context. but w/o
cost of missed work, won’t change the cch truthers #jhsjc
Brent
Graham @BgTalkinman to @whammert:
Will that be the case when they pay OOP? #jhsjc
Erika
Sears @ErikaDSears to @BgTalkinman:
the difference in costs would likely be different for indirect costs (lost
productivity) #jhsjc
Brent
Graham @BgTalkinman to @theaviram:
My guess is that insurers will understand this fully #jhsjc
RyanC
@RPCalfeeSTL:
#jhsjc out of pocket always changes everything for patients
John
Seiler @jgseiler:
#jhsjc If it goes to OOP patient cost-
then don’t you think the value prop is in favor of percutaneous aponeurotomy?
Warren
@whammert to @BgTalkinman:
I don’t know how it is covered there, but at IFSSH meeting last summer, I was
told cost by MD and reps #jhsjc
Marco
Rizzo @MarcoRizzo001:
I’ve observed many patients sort of know what they’d like prior to coming. Fewer and fewer of them come to me with an
open mind. #JHSJC
Brent
Graham @BgTalkinman to @ErikaDSears:
Do you think that would hold if further treatment is required? Rate of
recurrence with surgery was 4% over 5 years. #jhsjc
Charles
Goldfarb @Congenitalhand to @MarcoRizzo001:
#JHSJC. I agree w @jgseiler- the value
has to be in percutaneous aponeurotomy
Brent
Graham @BgTalkinman to @JRHandSurg:
I agree! That has been the case for so many orthopaedic
“innovations”!! #jhsjc
Avi
Giladi @theaviram to @BgTalkinman:
i am skeptical — theyve known about value of preventive services and therapy
for years and most still won’t cover #jhsjc
Neal Chen
@NealChen18:
#jhsjc Needle aponeurotomy is the only cost effective option; at current costs
both open partial fasciectomy and collagenase are not cost effective in
decision analysis with Kevin Chung
Ray Raven
MD, MBA @RayRavenMD:
How many of you are using #CCH #collagenase over needle ap #NA #jhsjc
John
Seiler @jgseiler:
#jhsjc Check out the death of expertise
by Tom Nichols- great book and directly takes on this issue of patient bias
Marco
Rizzo @MarcoRizzo001 to @jgseiler:
I agree John. When it comes to money OOP
NA is almost always preferred. #JHSJC
Neal Chen
@NealChen18:
#jhsjc If you sell collagenase for less than $800 it becomes cost effective
Brent
Graham @BgTalkinman to @NealChen18:
The 2 RCT we have comparing #CCH to needle aponeurotomy were both from
Scandinavia. Treatment equal — equally poor #jhsjc
Ray Raven
MD, MBA @RayRavenMD to @NealChen18:
I disagree, it would have to cost half of that because of the follow-up
manipulation. #jhsjc
Brent
Graham @BgTalkinman to @jgseiler:
They also have a high rate of recurrence although much small costs up front.
#jhsjc
Joe
Rosenbaum, MD @JRHandSurg to @NealChen18:
Despite that, don’t you find that there’s a subset of pts who know they want a
definitive fix? i.e. fasciectomy? #jhsjc
Brent
Graham @BgTalkinman to @Congenitalhand, @MarcoRizzo001, and @jgseiler:
Recurrence rate is high within 2 years shouldn’t sx be the answer? #jhsjc
Ray Raven
MD, MBA @RayRavenMD to @NealChen18:
“direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and
$5,291, respectively. #jhsjc
Warren
@whammert to @JRHandSurg and @NealChen18:
I do fasciectomy under WALANT in the office procedure room – that brings the
cost down and probably more efec #jhsjc
Charles
Goldfarb @Congenitalhand to @JRHandSurg and @NealChen18:
#JHSJC I have some patients who seek most definitive treatment and some who
want to avoid the inconvenience of open fasciectomy.
Ray Raven
MD, MBA @RayRavenMD to @NealChen18:
#jhsjc
“cumulative costs per digit following NA, collagenase, surgery at 5 years
were $1,540, $5,952, $5,507, respectively.”
Brent
Graham @BgTalkinman to @whammert, @JRHandSurg, and @NealChen18:
I suspect we will see much more of that in the post-CCH eras. #jhsjc
Brent
Graham @BgTalkinman to @RayRavenMD and @NealChen18:
The evidence shows high rate of recurrence with NA so costs will be higher if
they move on to sx eventually #jhsjc
Marco
Rizzo @MarcoRizzo001 to @JRHandSurg:
Joe – I would’ve the same thing. But
there is an entire population of folks with DD who want nothing to do with
surgery. #JHSJC
John
Seiler @jgseiler to @whammert:
#jhsjc Warren- do you find the
dissection satisfactory using a WALANT approach or would it be easier for you
with a tourniquet – maybe forearm based for simpler cases?
Brent
Graham @BgTalkinman to @NealChen18:
Doesn’t “cost effective” imply a benefit? This study seems to show
that benefit is not high if there are recurrences #jhsjc
Joe
Rosenbaum, MD @JRHandSurg to @MarcoRizzo001:
Absolutely. In my admittedly brief experience, I’ve already met a few. #jhsjc
Brent
Graham @BgTalkinman to @theaviram:
Might that be different when they are paying for a service that just doesn’t
work? #jhsjc
Warren
@whammert to @jgseiler:
I think patients like this as many are older and not the healthiest – they like
they can eat, come in and go home themselve #jhsjc
IT is different than under tourniquet and not the starting point for WALANT, but they swell much less and are less stiff #jhsjc
Ray Raven
MD, MBA @RayRavenMD to @jgseiler:
I find it a lot easier (safer) under local with tourniquet control. #jhsjc
Brent
Graham @BgTalkinman to @ErikaDSears:
This needs a decision analysis with costs instead of expected utility. #jhsjc
Avi
Giladi @theaviram to @BgTalkinman:
hopefully. but many don’t tend to look
at the longer time horizon because of how many patients switch plans. #jhsjc
Neal Chen
@NealChen18:
#jhsjc Duputyren’s interventions inherently have very low Utility in Standard
Gamble or Time Trade off
Joe
Rosenbaum, MD @JRHandSurg to @BgTalkinman and @theaviram:
I’ve heard some of my mentors describe the treatments for DD as “haircut procedures”
(NA, CCH) where recurrence is probable, versus “excision” procedures
attempting cure. Although it’s pessimistic, the analogy seems to resonate with
pts and helps in shared decision making #jhsjc
Marco
Rizzo @MarcoRizzo001:
Recently, I’ve noticed an uptick in patients with recurring disease ultimately
deciding to move forward with surgery. #JHSJC
Ray Raven
MD, MBA @RayRavenMD:
How many of you are actually taking cost into consideration when treating
#dupuytren disease? #jhsjc
Brent
Graham @BgTalkinman to @NealChen18:
It should be >0.95 – it’s non-lethal. Instead of utility, cost should be the
output. #jhsjc
Warren
@whammert to @RayRavenMD:
I mention cost and recurrence in the context of each. Some patients care and others say insurance
will pay #jhsjc
Steve Lee
@kichmd to @MarcoRizzo001:
#jhsjc How has this paper changed your practice Marco?
Brent
Graham @BgTalkinman to @NealChen18:
I’m referring to the utility of the condition. Decision analyses are
interpreted in relative terms. $ as output is ideal. #jhsjc
Brent
Graham @BgTalkinman to @whammert and @RayRavenMD:
…they will pay for now. It’s not a benefit in Ontario. Infrequently done
compared with US. #jhsjc
Neal Chen
@NealChen18:
#jhsjc I think Kevin’s study the output was cost per QALY
#jhsjc but they use utility to get the QALYs
Brent
Graham @BgTalkinman:
? long-term implications if patient preferences are non-op treatment that costs
less than operative treatment but is less effective? #jhsjc
Brent
Graham @BgTalkinman to @NealChen18:
I don’t favor QALY for this bc it is not a serious condition. Should use
estimates of direct/indirect cost. #jhsjc
Sensitivity analysis would find the key drivers. there is a home in JHS for that study! #jhsjc
Neal Chen
@NealChen18:
#jhsjc That’s fair. I think the problem becomes in non lethal conditions, the
improvement in QALY is so small that analysis difficult to interpret
Erika
Sears @ErikaDSears to @BgTalkinman:
depends on the patient. for me older pts who are higher risk for surgery or
diff w/ access to OT rightfully favor non-op #jhsjc
Steve Lee
@kichmd:
#jhsjc Kudos to Marco and group for the message of the need to contemplate the
relative value of different treatment options
Brent
Graham @BgTalkinman to @NealChen18:
That’s why I don’t like it. #jhsjc
Marco
Rizzo @MarcoRizzo001 to @kichmd:
Steve – I still give pts my standard discussion of options with advantages and
disadvantages but I find that I can be more confident with surgery in terms of
the anticipated reintervention rates.
Pts with an open mind or who’ve had recurrence are more likely to
surgery #JHSJC
Brent
Graham @BgTalkinman to @kichmd:
Agreed! #jhsjc
Brent
Graham @BgTalkinman to @ErikaDSears:
Still a role for choice but the evidence is clear that non-op rx isn’t as
effective. Some pts may still prefer that.
#jhsjc
Brent
Graham @BgTalkinman:
Obviously a very contentious topic! Keep the discussion going! Here next month!
Thanks to everyone for the stimulating discussion! #jhsjc
Steve Lee
@kichmd:
#jhsjc Thank you all for great discussion. Good night!
Ray Raven
MD, MBA @RayRavenMD:
Thank you all for participating. Great discussion! #jhsjc
John
Seiler @jgseiler:
#jhsjc Thanks great discussion tonight!!
