For our April JHS Journal Club discussion, we looked at the following two lead articles from April’s issue: Rate of Bone Mineral Density Testing and Subsequent Fracture-Free Interval After Distal Forearm Fracture in the Medicare Population and Outcomes Associated With Scapholunate Ligament Injury Following Intra-Articular Distal Radius Fractures. Thank you to everyone who monitored and participated!
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).
Brent Graham @BgTalkinman:
Welcome to the April session! #jhsjc
We’ll be here for the next hour discussing two papers that were in the April issue of JHS. #jhsjc
Summaries of there articles and some points to discuss are at jhsfocus.org/jhsjc #jhsjc
Please be sure to add the hashtag #JHSJC (or #jhsjc) to your tweets
RyanC @RPCalfeeSTL:
looking forward hearing what everyone thinks #JHSJC
Brent Graham @BgTalkinman:
Let’s start with the 1st article on #BMD testing by Parikh et al. A podcast with the senior author is here: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/April_2021.mp3 #jhsjc
Brent Graham @BgTalkinman:
This was an admin database study using the 5% Medicare database and searching for #DRF over a 10-yr period. #jhsjc
They looked for #BMD testing in the period after the fracture and also the occurrence of other fragility fractures. #jhsjc
RyanC @RPCalfeeSTL:
lots of evidence to support BMD testing and treatment and we are imperfect at getting it #JHSJC
Brent Graham @BgTalkinman:
The main assumption appears to have been that #BMD testing was a surrogate for treatment of #osteoporosis. Is that reasonable? #jhsjc
RyanC @RPCalfeeSTL:
not perfect but reasonable #JHSJC
Brent Graham @BgTalkinman:
What I’m wondering is whether pts are being treated on the basis of the fracture and not being tested. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
So would you consider this a baseline, lowest estimate? #jhsjc
…in other words that more patients are being treated than would be indicated by the rate of #BMD testing. #jhsjc
RyanC @RPCalfeeSTL:
not sure. I think many aren’t treated but my patients who get scanned usually are ones getting treated. #JHSJC
Avi Giladi @theaviram to @BgTalkinman:
osteoporosis lit supports link between testing and starting treatment, but some do get treated without testing #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Their data showed that the number of fractures was decreasing even as rate of #BMD testing stayed the same #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Are you aware of pts who receive treatment without #BMD testing? #jhsjc
RyanC @RPCalfeeSTL:
some may be treated without testing – certainly reasonable with likely fragility fracture #JHSJC
Brent Graham @BgTalkinman:
To me that suggests that testing may be a relatively poor surrogate for treatment but I don’t know if that is true. #jhsjc
Brent Graham @BgTalkinman:
For those of you who are here — do you use alternative methods to identify poor bone health? #jhsjc
There have been papers in JHS showing that cortical diameter of the metacarpals and CT parameters in the radius may be just as good. #jhsjc
Is #BMD testing with #DEXA required to have insurance coverage for #osteoporosis treatment? #jhsjc
As always, the question is the role of the surgeon treating the #DRF. What should that be? #jhsjc
RyanC @RPCalfeeSTL:
the use of metacarpals is a nice option – recently used in studies on this topic #JHSJC
Avi Giladi @theaviram to @BgTalkinman:
i thought that they reported decrease in % getting BMD as well (table 3)? #jhsjc
don’t the data in table 3 reflect a decrease in testing over time as well? #jhsjc
Brent Graham @BgTalkinman to @theaviram:
you’re right. Table 2 shows that the rate of before fx testing increased in the first few years and then stayed constant. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
…and I wonder if some of that is penetrating through to result in Rx even without #BMD testing with #DEXA #jhsjc
Avi Giladi @theaviram to @RPCalfeeSTL:
I like the metacarpal measurement, it’s helpful as a guide for me to refer patients. #jhsjc
RyanC @RPCalfeeSTL:
I am not great. I encourage testing and treatment but send to endocrine and primaries #JHSJC
Brent Graham @BgTalkinman:
What do you do when you treat a person with a fragility fracture as far as evaluation and Rx for #osteoporosis? #jhsjc
Warren @whammert to @BgTalkinman:
We are fortunate as we have a bone density clinic, where they communicate with PCP and decide who will treat #jhsjc
and EMR has a link that pops up for referral for DRF diagnosis #jhsjc
Brent Graham @BgTalkinman to @whammert:
Is that a referral to endo or PCP or for testing? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
yeah interesting to see the jump then plateau in pre-testing…i wonder how 2009 launch of “own the bone” impacts #jhsjc
RyanC @RPCalfeeSTL:
I really like the idea of automated EMR alert/referral #JHSJC
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I always thought that was the point of EMR – decision aids. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Tbl 4 after-fracture testing was 26% combined with the pre-fx testing suggests around 50% are tested overall? #jhsjc
Their authors attribute some effect to that in the podcast #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
ah makes sense…haven’t had a chance to listen yet! it’s in the queue #jhsjc
Brent Graham @BgTalkinman to @whammert:
is that what your EMR prompts you to do — bone density clinic? #jhsjc
Warren @whammert to @BgTalkinman:
DX DRF – Recommend referral to metabolic bone clinic #jhsjc
Brent Graham @BgTalkinman:
It’s a somewhat dry but important topic — I’ve already had my first #DEXA scan!! #jhsjc
RyanC @RPCalfeeSTL:
great when EMR actually helps #JHSJC
Brent Graham @BgTalkinman:
Let’s move on to the other paper – a somewhat controversial topic intra-articular #DRF and #SLIL injury #jhsjc
The authors looked at their intra-art #DRF and stratified them by the SL angle at the time of injury – above or below 70 degrees #jhsjc
There’s a typo in the summary – “700” is supposed to be 70 degrees; none of the pts had SLIL repairs. #jhsjc
Brent Graham @BgTalkinman:
During follow-up the mean SL angle got worse in those in whom it was increased but there appeared to be no clinical effects #jhsjc
The clinical results were the same in the 2 groups at 2 year follow-up. #jhsjc
Warren @whammert to @BgTalkinman:
It is not an all or none phenomenon and I think you need longer follow up to make definitive statements #jhsjc
RyanC @RPCalfeeSTL:
I think evidence points toward less aggressive with SL in setting of DRF. I still treat big obvious ones though #JHSJC
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I agree but Why should that be the case? Don’t we tend to be aggressive when the SL injury occurs without the #DRF? #jhsjc
Brent Graham @BgTalkinman:
The dx of SL instability was based on the plain radiographs, not on arthroscopy. Does that have an effect on the observations? #jhsjc
Warren @whammert to @BgTalkinman:
And SL injury in 60 year old attorney is different than 25 year old high level athlete #jhsjc
Brent Graham @BgTalkinman to @whammert:
Agreed! In many of those oldsters, it may have been an asymptomatic pre-existing condition. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Do you not think 2 years is sufficient? Wouldn’t you expect problems during that time frame? #jhsjc
Warren @whammert to @BgTalkinman:
I think many take much longer – we don’t really understand the natural hx and the secondary stabilizers critic #jhsjc
RyanC @RPCalfeeSTL:
agree that age matters here #JHSJC
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
I think many are acute injury on chronic condition – the obvious, like perilunate are different #jhsjc
Brent Graham @BgTalkinman to @whammert:
It’s absolutely true that there are no natural hx studies of SL ligament injury – and I don’t expect to see any soon. #jhsjc
Warren @whammert to @BgTalkinman:
There is also a component of adapatibilty that is not accounted for in any study like this. #jhsjc
RyanC @RPCalfeeSTL:
I wonder if healing or pain different in SL with DRF – bleeding/scar formation/immobilization #JHSJC
Avi Giladi @theaviram to @RPCalfeeSTL:
or perhaps the residual stiffness from DRF helps #jhsjc
Brent Graham @BgTalkinman:
The notion that SLIL injury is present in intra-artic #DRF has been around a long time and yet we don’t see much fallout from that #jhsjc
What are the indications for treating #SLIL injury in the context of #DRF? #jhsjc
Brent Graham @BgTalkinman to @theaviram and @RPCalfeeSTL:
96% of these pts were operated on. Presumably one reason to operate is to avoid stiffness. #jhsjc
I could see that if there was a lot of non-op treatment. #jhsjc
Warren @whammert to @BgTalkinman:
For me – large diastasis with no history of wrist trouble. Then will likely scope #jhsjc
Brent Graham @BgTalkinman to @whammert:
Do you compare with the contralateral wrist? #jhsjc
Warren @whammert to @BgTalkinman:
usually not for acute injury – I do otherwise with bilateral clench pencil view #jhsjc
RyanC @RPCalfeeSTL:
indications for me is complete rupture – nothing partial. Even then – younger patients #JHSJC
Brent Graham @BgTalkinman to @RPCalfeeSTL:
How do you identify those? #jhsjc
Brent Graham @BgTalkinman:
For those who are here – do you evaluate, if that is possible, for #SLIL injury in pts with intra-artic #DRF? #jhsjc
Brent Graham @BgTalkinman:
Even if the ligament injury is identified is it too much treatment all at once to treat it surgically? #jhsjc
IOW, should the fracture be managed appropriately and then the ligament injury if symptomatic? #jhsjc
These authors suggest that radiographic deterioration will occur but there may be no clinical symptoms. #jhsjc
RyanC @RPCalfeeSTL:
I only identify if obvious on X-ray or if saw complete tear during dorsal plating (still has a role) #JHSJC
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Happy you mentioned dorsal plating!! I’ve never done a volar locking plate! #jhsjc
Warren @whammert to @BgTalkinman:
For truely acute injury, I think you have to treat the SL at the same time. Waiting will likely miss acute repair #jhsjc
Brent Graham @BgTalkinman to @whammert:
Is it clear that the acute repairs are better than chronic reconstr? Personally, I’m not sure it is. #jhsjc
Warren @whammert to @BgTalkinman:
That is what I would want for my wrist. While may not be normal, no reconstructions consistently great -yet #jhsjc
Brent Graham @BgTalkinman to @whammert:
That is true. #jhsjc
Brent Graham @BgTalkinman:
I always wonder how well the acutely ruptured, edematous ligament can really be repaired. I admit I’ve never done it. #jhsjc
Warren @whammert to @BgTalkinman:
This is a perilunate dislocation. Ligament and secondary stabilizers injured at the same time- better chance I think #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree with that, although for those I have just reduced, pinned and let the inflamm reaction heal the SL injury #jhsjc
Warren @whammert to @BgTalkinman:
I always repair and pin – maybe the repair is not needed, but if it fell apart, I would regret not repairing #jhsjc
Brent Graham @BgTalkinman:
My conclusion from this paper is that its safe to watch, monitor for deterioration in wrist fx. As @whammert said- might take >2 yrs #jhsjc
The whole #SLIL area is one that is still lacking anything like actual evidence – like #ACL from 25 yrs ago. #jhsjc
Brent Graham @BgTalkinman
For those out there monitoring the discussion feel free to join in! We’d love to hear from you! #jhsjc
Warren @whammert to @BgTalkinman:
I guess we need a SLIL moon equivalent?♂️ #jhsjc
RyanC @RPCalfeeSTL:
I agree Warren #JHSJC
Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
is a “moon” style registry on the horizon? #jhsjc
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
baby steps #jhsjc
Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
It’s one project for which an ASSH registry might be helpful. #jhsjc
Brent Graham @BgTalkinman:
As usual, great thoughts! Thanks to all for sharing those! We are back May 11, 9pm EDT. #jhsjc
