#JHSJC

November #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 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!!

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