#JHSJC

January #JHSJC Transcript

Thank you to everyone who participated in the first #JHSJC of the new year! We kicked off 2021 by discussing two articles from Volume 46, Issue 1 of The Journal of Hand Surgery: Epidemiology and Treatment of Radial Head Fractures: A Database Analysis of Over 70,000 Inpatient Cases and A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures.

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:
Happy New Year #OrthoTwitter #HandSurgery
It’s time for JHS Journal Club #JHSJC – Let’s get started!

Dr. Ray Raven @RayRavenMD:
Article #1 #JHSJC
Epidemiology and Treatment of Radial Head Fractures: A Database Analysis of Over 70,000 Inpatient Cases
By Alexander Klug, MD, Yves Gramlich, MD, Dennis Wincheringer, MD, Reinhard Hoffmann, MD, and Kay Schmidt-Horlohé, MD
Article #2 #JHSJC
A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures

Brent Graham @BgTalkinman:
Welcome the first session of 2021! Let’s start with the paper on radial head fractures. #jhsjc

Charles Goldfarb @Congenitalhand:
Good evening.  Happy 2021 #jhsjc

Dr. Ray Raven @RayRavenMD to @Congenitalhand:
Happy New Year! Thanks for playing! #jhsjc

RyanC @RPCalfeeSTL:
looking forward to this year of #JHSJC

Brent Graham @BgTalkinman:
This is a paper that is similar to another database study of radial head fracture in 2017, Kupperman et al #jhsjc
The database included only inpatients & the authors explain that; does the focus on inpatients introduce bias? #jhsjc

Dr. Ray Raven @RayRavenMD:
To your question does the focus on in-patients only introduce bias into the observations- #jhsjc
I would guess yes before reviewing the results, but the findings are what I would have guessed for outpatients as well #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD:
My guess is that in North Am many of these cases are done as outpatients. #jhsjc

Dr. Ray Raven @RayRavenMD to @BgTalkinman:
More than 80% of mine are #jhsjc

RyanC @RPCalfeeSTL:
if this were our patients then yes only the sicker ones have inpatient surgery #JHSJC

Brent Graham @BgTalkinman to @RPCalfeeSTL:
This is evidently the standard in Germany and that it wouldn’t have an impact on the main goal which was to show trends #jhsjc

Brent Graham @BgTalkinman:
Is the increasing use of locking plate technology and radial head arthroplasty consistent with current evidence? #jhsjc

Warren @whammert to @BgTalkinman:
I think the percentage of in patient DRF has to be really low and this hard to interpret #jhsjc
or radial head fractures or most other procedures below the elbow in the US #jhsjc

Jeffrey Greenberg @JAGhandsurgeon:
Is some of the bias related to improved technology, implants and arthroplasty components that developed during the course of the study? #JHSJC

Brent Graham @BgTalkinman to @JAGhandsurgeon:
that’s what I’m wondering. Is this similar to what it would like in North Am over the same period? #jhsjc

RyanC @RPCalfeeSTL:
personally I rely on screws for nearly all of these if doing ORIF as I make people stiff with plates here #JHSJC

Jeffrey Greenberg @JAGhandsurgeon:
agree completely with RC.  Usually if the fracture cannot be fixed with screws then my progression is to arthroplasty.  Although in the younger population I really try to avoid arthroplasty #jhsjc

Brent Graham @BgTalkinman:
They also report that there were increasing rates of RHA revision but decreased rates of “explantation”. What does that mean? #jhsjc

Charles Goldfarb @Congenitalhand:
I agree.  Not sure what a revision looks like w/o explant- very uncommon in my practice #JHSJC

Brent Graham @BgTalkinman to @Congenitalhand:
I didn’t really realize until the paper appeared that I should have had them explain that! #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman and @RPCalfeeSTL:
It is tough to explain – I agree with @RPCalfeeSTL screws are far and away my first choice. And that has nothing to do with economics although likely least expensive choice #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Screw fixation was the least common approach. Why do you think that was if it is very different from your experience? #jhsjc

Brent Graham @BgTalkinman to @JAGhandsurgeon:
Same question as for @RPCalfeeSTL. What do you think explains the difference?  #jhsjc
I know nothing about this topic other than what I read in JHS! I agree that seems to be true – more RHA through time #jhsjc
Our paper on this topic in 2017 indicated that revision from screw fixation was more frequent than after RHA. #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand:
Is it possible that “revision” refers to some kind of exchange? #jhsjc

RyanC @RPCalfeeSTL:
I’m not sure why screws were least common in the study #JHSJC

Brent Graham @BgTalkinman to @RPCalfeeSTL:
ORIF was the most common but that seems to have been primarily locking plates #jhsjc
Are locking plates in frequent use in North Am? #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
Locking plate are quite common.  Better than in past but still a high rate of removal, some risks of stiffness.  #jhsjc

RyanC @RPCalfeeSTL:
I see revision after RHA rarely whereas fixation can have healing issues (I don’t have huge volume though) #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @BgTalkinman and all:
Sorry I am late to the game but scrolling to catch up #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
Maybe but I don’t believe this is common practice (certainly not in NA).  Typically, just explant.  #jhsjc

Brent Graham @BgTalkinman:
It seems as if with the aging population we can expect more RHA in the future. Is that a reasonable expectation? #jhsjc

RyanC @RPCalfeeSTL:
I think that is reasonable #jhsjc

Brent Graham @BgTalkinman:
Let’s move on to article 2: smoking and outcome after surgical treatment of #DRF #jhsjc

Brent Graham @BgTalkinman:
We have had a lot of papers on smoking and post-operative complications but not specifically #DRF #jhsjc
There was a recent paper in JHS that showed smoking didn’t affect outcomes after ORIF of #DRF https://www.jhandsurg.org/article/S0363-5023(19)31362-0/fulltext #jhsjc

Brent Graham @BgTalkinman:
This study used an innovative analysis propensity score matching — almost like a case-control design #jhsjc
They matched patients in the smoking group to individuals with is liar characteristics in the non-smoking group. #jhsjc

Warren @whammert to @BgTalkinman:
While there was a statistical difference, the numbers were 1-2% and hard to change habits based on that #jhsjc

Brent Graham @BgTalkinman:
Should this be the standard for this kind of large database study where there is usually huge amounts of data? #jhsjc

RyanC @RPCalfeeSTL:
using propensity matching imperfect but good way to try and make groups comparable #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Would you recommend that that be a part of all of these studies? I hadn’t seen a study like this use it before. #jhsjc

Brent Graham @BgTalkinman:
This identification of an association not seen in the analysis of the raw data: increased risk of re-operation, an important finding. #jhsjc

Brent Graham @BgTalkinman to @whammert:
That is both the advantage and the disadvantage of these large data studies. There is increased risk  – how should it figure into everyday practice? Maybe as advice to patients? #jhsjc

Brent Graham @BgTalkinman:
Smoking is often considered a modifiable risk; not sure I agree with that especially for a relatively urgent situation like #DRF #jhsjc
Is this small risk something that should be part of risk stratification in discussions with patients? #jhsjc
There have been many papers showing increased risk for both minor and more serious adverse events after hand surgery. #jhsjc
Given that the benefit of surgery for #DRF remains controversial, would a smoking history make ORIF less indicated in some patients? #jhsjc

Brent Graham @BgTalkinman:
Looks like some are having problems with the tchat.io platform. Feel free to tweet to me and I will retweet your comments. #jhsjc

J Hand Surg Am- ASSH @JHandSurg:
Thank you for your comments and questions!
We look forward to your participation in next month’s Journal Club!
We’ll be back on February 9th, 9pm Eastern.
Have a great week! #JHSJC

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