Thank you to everyone who participated in the February #JHSJC! Our riveting discussion addressed two articles from Volume 45, Issue 2 of The Journal of Hand Surgery: Variation in Offer of Operative Treatment to Patients With Trapeziometacarpal Osteoarthritis and Factors Associated With Reoperation and Conversion to Wrist Fusion After Proximal Row Carpectomy or 4-Corner Arthrodesis.
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
J Hand Surg Am- ASSH @JHandSurg:
February’s #JHSJC starts now! Let’s get the discussion going!
Brent Graham @BgTalkinman:
Welcome to the Feb #jhsjc! Please use the #jhsjc hashtag. Let’s start with the second article #4CF #PRC and #wristfusion
The debate about which of these two procedures is best when both are feasible continues! #jhsjc
Sandy Gebhart @SandyGebhartMD
#jhsjc
Nina Suh @NinaSuh9:
I was surprised the 4CF conversion rates were so high! I haven’t found that personally #jhsjc
Christopher J. Dy MD MPH FACS @ChrisDyMD to @NinaSuh9:
Agree. I also found that to be an interesting point this article #jhsjc
Nina Suh @NinaSuh9:
I wonder if it was bc the 4CF had more SLAC3 and small cohort than PRC #jhsjc
Brent Graham @BgTalkinman:
An earlier study in #JHandSurg showed that the rate of wrist fusion was 5X higher after #4CF than #PRC. #jhsjc
Robert Foster MD @RobertFosterMD1:
It seems that smoking dominated the results, and I would try anything over a 4CF in a smoker. Not so much for PRC. #jhsjc
Brent Graham @BgTalkinman to @ChrisDyMD and @NinaSuh9:
The previous study was based on admin data. Is that a factor in the divergent findings? #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
In this study smokers were less likely to undergo a 4CF which is probably a confounder. #jhsjc
Robert Foster MD @RobertFosterMD1 to @BgTalkinman:
Yes, as it would be for me. #jhsjc
Nina Suh @NinaSuh9:
definitely admin data has greater patient numbers #jhsjc
David Ring @DrDavidRing:
Surgery for arthritis is discretionary and preference sensitive. A second surgery is even more so. #jhsjc
Steve Lee @kichmd:
Both numbers of conversions to fusion for PRC and 4CF are higher (in this paper and the other paper that Brent referred to) than what I have experienced. #jhsjc
Sam Moghtaderi @DrMoghtaderi to @BgTalkinman, @ChrisDyMD, and @NinaSuh9:
I’m not sure, but that is certainly dichotomous enough to know which to believe. #JHSJC
Neal Chen @NealChen18:
#jhsjc The prior study used the code for partial carpal fusion which includes STT fusion, LT fusion and FCF
Brent Graham @BgTalkinman to @NinaSuh9:
The smaller number in the #PRC group was bc they avoided #4CF in smokers. #jhsjc
David Ring @DrDavidRing:
Smoking is associated with greater symptoms of depression and anxiety–factors that increase symptom intensity and more limitations #jhsjc
Brent Graham @BgTalkinman to @NealChen18:
The different data sources could be a factor. Explain why that makes a difference. #jhsjc
Robert Foster MD @RobertFosterMD1:
I admit I have gained an interest in adding AIN/PIN neurectomies, but I have not done them in the past. #jhsjc
Ray Raven @RayRavenMD to @DrDavidRing:
how are you managing this condition in smokers and nonsmokers? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Do you think that is a bigger factor in this finding or is it a confounder? #jhsjc
Warren @whammert to @RobertFosterMD1:
While I take out PIN runtiness, I wonder if adding AIN makes a difference? #jhsjc
Neal Chen @NealChen18 to @BgTalkinman:
#jhsjc STT fusion traditionally has a higher non-union rate (up to 40% and LT fusion may have similar rates). In addition, although surgeons that do high volume FCF may have lower non-union rates, there may be some surgeons who do fewer and have more re-operations.
Nina Suh @NinaSuh9:
this manuscript benefits from manual chart review vs admin data depends on coders #jhsjc
Brent Graham @BgTalkinman to @kichmd:
The conventional wisdom would be that biomechanically #PRC is a higher risk for fusion and that’s what was found. #jhsjc
Ray Raven @RayRavenMD to @NinaSuh9:
good point. Another limitation of admin data. #jhsjc
David Ring @DrDavidRing:
I doubt AIN/PIN does much. It may bias the surgeon to be less likely to offer more surgery #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
That’s true but the reliability of that coding is generally thought to be high. #jhsjc
Neal Chen @NealChen18 to @DrDavidRing:
#jhsjc We felt that the regional bias in performing PRC in smokers may be a factor that increases the reoperations/ fusions in PRC and may also decrease those in FCF
Robert Foster MD @RobertFosterMD1:
In 23 years of PRCs, even including the young, I have only converted 1, so not sure if neurectomy would have altered #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
They found that it was associated with a lower conversion rate. What is the explanation for that? #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman and @kichmd:
May be technique dependent. Interposition arthroplasty during #PRC extends the life of the construct. #jhsjc
Nina Suh @NinaSuh9:
I have to say the AIN neurectomy was an interesting point and I do not do it but maybe I should consider…. #jhsjc
Brent Graham @BgTalkinman to @NealChen18 and @DrDavidRing:
Actually not necessarily “regional” but possibly “institutional”. #jhsjc
Nina Suh @NinaSuh9 to @RayRavenMD:
I don’t routinely do an interposition for PRC, do you? #jhsjc
Ray Raven @RayRavenMD to @NinaSuh9:
I do always perform interposition as described and taught to me by Dick Eaton. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
#JHSJC It’s noteworthy that surgeons jump to the biomedical (it might hinder fusion) when the association with mental and social health seems at least equally important
Sam Moghtaderi @DrMoghtaderi to @NealChen18:
Why proportion do you think would be STT’s and the like? I would think small. Agree that chart review study much superior for sure. #JHSJC
Ray Raven @RayRavenMD to @DrDavidRing:
how do you explain the studies showing the AIN/PIN neurectomy resulting in improvement in pain scores? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
We will prob disagree. I think these are definitely factors but I doubt they dominate generally – clearly important in some cases #jhsjc
David Ring @DrDavidRing to @RayRavenMD:
#JHSJC Most people with advanced arthritis have very little motion and total wrist arthrodesis is a fool proof win. In general most people with good motion don’t want to sacrifice it for pain relief.
Brent Graham @BgTalkinman:
How important are factors like poor indications for #PRC or surgical skill for #4CF as explanations for there findings? #jhsjc
Nina Suh @NinaSuh9:
maybe the capitate wasn’t as well matched for the failed PRCs which caused the conversion rates #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman:
Great question. I would expect that technique would play a significant role #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
When I have converted, few like you, the cause has been a bad judgement by me in deciding the initial treatment. #jhsjc
Nina Suh @NinaSuh9:
and surgical technique for 4cf I believe always matters #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
That would be my interpretation of the studies that show high rates of conversion from #4CF. #jhsjc
David Ring @DrDavidRing to @RayRavenMD:
Placebo effect #jhsjc
Warren @whammert to @BgTalkinman:
I think this plays a big role. 4CF is a good operation but more technique sensitive to get the carpal alignment #jhsjc
Brent Graham @BgTalkinman to @whammert:
Agreed! I use ICBG, Kwires and 2 months of immobilization which helps but it’s a big intervention. #jhsjc
Ray Raven @RayRavenMD to @NinaSuh9:
I agree. #jhsjc
Brent Graham @BgTalkinman:
The idea that surgical skill plays a role is infrequently considered but I suspect it matters. #jhsjc
Neal Chen @NealChen18:
#jhsjc We had independent observer staging and in the observers’ opinion some stage 3s did undergo PRCs
David Ring @DrDavidRing to @RayRavenMD:
When the outcome is subjective, we need simulated surgery controls. We need simulated AIN / PIN #jhsjc
Steve Lee @kichmd to @BgTalkinman:
That is the inherent problem with surgical literature. #jhsjc
Conclusions don’t take into account the nuances of patient selection or surgical technique #jhsjc
Ray Raven @RayRavenMD to @whammert and @BgTalkinman:
exactly what @NinaSuh9 is stating. #jhsjc
Brent Graham @BgTalkinman to @kichmd:
Agreed! We had a paper in the summer on this topic with respect to flexor tendon surgery. Its probably very important. #jhsjc
Warren @whammert to @BgTalkinman:
I think type of fixation is less important than not impinging – wires, circular plate, screw and staples a #jhsjc
Brent Graham @BgTalkinman to @NealChen18:
And yet the rate of conversion was overall lower in the #4CF group. #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
Or poor indications. #jhsjc
Brent Graham @BgTalkinman:
Which of these sample is more likely valid, single institution or admin data? What do we conclude about the true rate of conversion? #jhsjc
Brent Graham @BgTalkinman to @whammert:
Bone graft? #jhsjc
Warren @whammert to @BgTalkinman:
yes – distal radius. and I do 4 bones with CL and TH fixation #jhsjc
David Ring @DrDavidRing:
I’d like a better understanding of “poor indications” #JHSJC
Nina Suh @NinaSuh9 to @BgTalkinman:
That is a hard question to answer haha! both single institutions and admin data have pros/cons #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
#JHSJC There is likely wide surgeon-to-surgeon variation in the rates of surgery for wrist arthritis and the rates of a second surgery due to dissatisfaction with the first
Robert Foster MD @RobertFosterMD1 to @DrDavidRing:
I’d say PRC with a worn or pointed capitate is “poor indications” #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman:
Great question, @BgTalkinman. My belief is single institution over admin. But I agree with @NinaSuh9 that both have their advantages. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I did a #PRC when there was cartilage wear on the capitate. Now I do #4CF if the cartilage looks normal but there’s DISI #jhsjc
David Ring @DrDavidRing to @RobertFosterMD1:
And yet, many patients do very well even with imperfect capitate. Are we focusing too much on a small number of dissatisfied? #JHSJC
Brent Graham @BgTalkinman to @RobertFosterMD1 and @DrDavidRing:
I agree and when I’ve made a bad call that was the problem #jhsjc
Robert Foster MD @RobertFosterMD1 to @whammert and @BgTalkinman:
Seems to me the scaphoid makes plenty of bone graft – maybe better quality than DR? #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD and @NinaSuh9:
We need an answer and I’m not sure what it is. My sense is that the more valid is that based on admin data #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman, @DrDavidRing, and @RobertFosterMD1:
This is when an interposition with #PRC may have different results. #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD and @NinaSuh9:
In general research question should dictate the data source. Here I think the admin data is more informative. #jhsjc
Robert Foster MD @RobertFosterMD1 to @BgTalkinman and @DrDavidRing:
I always choose PRC over C/L or 4CF if both are options. Surgery easier and recovery MUCH easier. and post op patients happier #jhsjc
Ray Raven @RayRavenMD to @RobertFosterMD1, @BgTalkinman, and @DrDavidRing:
I am in the same camp as @RobertFosterMD1. #PRC over #4BF #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1 and @DrDavidRing:
I completely agree! #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other article. @DrDavidRing is with us! #jhsjc
Ray Raven @RayRavenMD:
Thanks for joining us @DrDavidRing! #jhsjc
Brent Graham @BgTalkinman:
This article seems to show that the respondents have what I would consider reasonable indications for these procedures. #jhsjc
Ray Raven @RayRavenMD:
@DrDavidRing what is your biggest take away from the results of this study? What are you teaching residents? #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD and @DrDavidRing:
How do we determine which pts are depressed bc of their symptoms? #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman and @DrDavidRing:
I think it is important to collect patient-reported surveys on all patients these days. #jhsjc
Nina Suh @NinaSuh9:
Intuitively these conclusions make sense but I don’t know how to change my practice to incorporate w/o insulting patients #jhsjc
Brent Graham @BgTalkinman:
If depression is due to thumb pain sx may not be a good idea but is it appropriate when thumb pain is the cause of the depression? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
#JHSJC The data merit reflection. For instance, greater symptoms are associated with surgery. And so is fewer symptoms of depression.
Ray Raven @RayRavenMD to @NinaSuh9:
I like PROMIS-29. Patients sense your interest and feel more comfortable talking after the survey. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
#JHSJC The “direction” of symptoms of depression is likely irrelevant. What’s relevant is that people feel less pain and can do more when their mood is better.
Brent Graham @BgTalkinman to @DrDavidRing:
I agree that it is very important. Should surgeons make formal psychosocial evals of all pts or is it “common sense”? #jhsjc
David Ring @DrDavidRing to @BgTalkinman and @RayRavenMD:
#JHSJC With age-related diseases as common as TMC arthrosis, misconception and somatic focus are important health considerations.
Brent Graham @BgTalkinman to @DrDavidRing:
I agree but can their mood be improved by addressing their pain surgically? I think it can. #jhsjc
Rob Gray @robgraymd to @BgTalkinman and @DrDavidRing:
People feel better when they can sleep through the night w/o pain. #jhsjc
Brent Graham @BgTalkinman to @robgraymd and @DrDavidRing:
That’s what I’m getting at. Aren’t both the medical and the psychosocial models are in play? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
#JHSJC Another study on the way that found–among common hand surgeries–only carpal tunnel release seemed to be good for symptoms of depression
Ray Raven @RayRavenMD to @BgTalkinman and @DrDavidRing:
I have had many patients with severe pain report significant increase in quality of life after surgery. #jhsjc
Steve Lee @kichmd:
@BgTalkinman makes a great point about – how do hand surgeons assess psychological factors? #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman and @DrDavidRing:
In my practice, patients with chronic severe pain for years are the happiest. #jhsjc
Robert Foster MD @RobertFosterMD1 to @DrDavidRing and @BgTalkinman:
If they come in painful because of depression and leave me painless, have I cured their depression? #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman and @DrDavidRing:
those with minimal pain or occasional symptoms report lower scores on #PROS #jhsjc
David Ring @DrDavidRing to @RayRavenMD and @BgTalkinman:
#JHSJC People also report notable increases in quality of life with the passage of time, with nonoperative treatment, with reassurance, and with simulated surgery #lovescience #behumble #becurious
Sam Moghtaderi @DrMoghtaderi to @robgraymd, @BgTalkinman, and @DrDavidRing:
CTS has been shown to cause actual diagnosable insomnia, which is then cured rapidly after CTR. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Pain can cause depression, surgery can address pain so if we choose pts well shouldn’t we operate on these people? #jhsjc
Steve Lee @kichmd:
I think more training in this would be great for the teachers and trainees. ICLs etc. #jhsjc
Ray Raven @RayRavenMD to @RobertFosterMD1, @DrDavidRing, and @BgTalkinman:
if their depression was related to that condition, my answer is yes. #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD and @DrDavidRing:
Studies on that topic show that your impression is correct. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Surgeons find pain –> depression intuitive. What about depression –> pain? #jhsjc
Ray Raven @RayRavenMD to @BgTalkinman and @DrDavidRing:
I’ve had many patients tell me how they finally slept through the night after #CTR. Life-changing for some #jhsjc
Brent Graham @BgTalkinman to @kichmd:
We are doing our best @JHandSurg to be sensitive to this very need. The feasibility in everyday practice is the challenge. #jhsjc
David Ring @DrDavidRing:
What do y’all think about the notable variation in surgeon recommendations we found? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Agreed – it can go both ways. I truly believe that, but my bias has been to operate when I think I can help. #jhsjc
David Ring @DrDavidRing:
Lay people feel uncomfortable that what is recommended depends to a large degree on who they see #jhsjc
Ray Raven @RayRavenMD to @DrDavidRing and @BgTalkinman:
That’s a difficult one, @DrDavidRing. I have seen many patients who somaticize and nothing we do helps. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Actually I was surprised that it was less variable than I expected. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Spoken like a true surgeon. I think we need a little balance. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
What if attention to mental and social health worked as well as surgery? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
It feels to me like that is very important and I see that in my own approach. I have never done an injection for #CMCOA #jhsjc
Ray Raven @RayRavenMD to @DrDavidRing:
where is the balance when patients have failed years of conservative treatment and they are depressed because of pain? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Again I agree but its been very successful. #jhsjc
Ray Raven @RayRavenMD to @DrDavidRing:
if you have a surgery that has worked in your hands to reduce or eliminate their pain, what do you do? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I work in a place where people come seeking out this kind of treatment. #jhsjc
We need an RCT!!! #jhsjc
I would be a believer if we had that level of evidence. #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
Really? NO injections? What do you do as a step between ibuprofen and surgery? #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
Zero. By the time they get to me, all of that has been tried. #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
Fair enough. But SOMEBODY stuck them. #jhsjc
David Ring @DrDavidRing to @RayRavenMD:
Research. See if I’m wrong about what I think I’m observing. #jhsjc
Traditional surgical mindset. There is some evidence suggesting it’s not accurate or helpful. #Curiosity #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I think you are right-to a certain extent. We all have our biases. As usual, the truth is prob somewhere in the middle. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
And yet the study shows that a “failed injection” makes surgeons recommend surgery. Surgery = last hope #jhsjc
Nina Suh @NinaSuh9:
I think the observations about depression being important is so true. I have a patient like this. #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
Maybe. It doesn’t make sense to me. #jhsjc
Ray Raven @RayRavenMD to @DrDavidRing:
My favorite basal case is the PT who has severe pain for years and has tried everything. For them, surgery cures #jhsjc
Robert Foster MD @RobertFosterMD1 to @DrDavidRing and @RayRavenMD:
But it is very hard to ignore post-op patients who say they are now normal, with zero pain and strong pinch #jhsjc
Ray Raven @RayRavenMD to @RobertFosterMD1 and @DrDavidRing:
I have made similar observations. I am extremely conservative. Rx for years before surgery #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Like you always say, it’s discretionary and that is how I describe it to them. It’s their choice. #jhsjc
Robert Foster MD @RobertFosterMD1:
My Pavlovian response to being told “Best thing I ever did” a lot is to do it more. #jhsjc
David Ring @DrDavidRing:
And here we see the variation captured in this study and others. Brilliant! #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I agree! That is what is so great about this forum! #jhsjc
That tells me that treatment should fit the pt and may involve a spectrum of approaches. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
#JHSJC For me this is the ethical and moral imperative. Is the expressed preference based on false hope? Misconceptions? If so, what is my duty?
Brent Graham @BgTalkinman to @DrDavidRing:
That is very eloquently put. We need open minds! No dogma! #jhsjc
David Ring @DrDavidRing to @RobertFosterMD1 and @RayRavenMD:
#JHSJC That’s a feeling that is not unique to hand surgeons. It’s why humans invented science. There are many compelling reasons why we should not accept gratefulness and satisfaction as the arbiter. https://www.nejm.org/doi/full/10.1056/NEJMra1907805?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
Brent Graham @BgTalkinman:
Fantastic, thought-provoking discussion! Thanks to all! Keep the discussion going. Back next month! #jhsjc
