#JHSJC

May #JHSJC Transcript

This month’s #JHSJC was a great success! We wish to thank everyone who joined us, especially our European colleagues who participated in the second round! This month, we discussed two articles from the May 2021 issue of The Journal of Hand Surgery: Cost Comparison of Botulinum Toxin Injections Versus Surgical Treatment in Pediatric Patients With Cerebral Palsy: A Markov Model and Assessing the Relationship Between Bone Density and Loss of Reduction in Nonsurgical Distal Radius Fracture Treatment.

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:
The first May #JHSJC starts now! Let’s get the discussion going.

Brent Graham @BgTalkinman:
Welcome to the May session! Be sure to use the jhsjc hashtag with your tweets. #jhsjc
Feel free to join host @ryckiewade for tomorrow’s discussion too: 8 pm GMT, 3 pm EDT, 2 pm CDT, noon PDT #jhsjc

Brent Graham @BgTalkinman:
Let’s start with article #1, sx vs #botox for treatment of upper extremity spasticity in #CP #jhsjc
I interviewed senior author Lindley Wall for the monthly podcast https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/May_2021.mp3 #jhsjc

Charles Goldfarb @Congenitalhand:
Dr Wall shared that it was a great discussion! #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand:
One of the authors is here! #jhsjc

Brent Graham @BgTalkinman:
Many surgeons probably don’t treat #CP frequently. Does the model accurately represent what an episode of care should look like? #jhsjc
One reason for featuring this article is how this method might translate to other problems in hand surgery #jhsjc

RyanC @RPCalfeeSTL:
I’m glad to have great partners that know about these topics #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Does Lack of familiarity make us more susceptible to wishful thinking? #jhsjc
Direct to the point is BoTx just temporary/palliative? #jhsjc

Charles Goldfarb @Congenitalhand:
While I am biased as an author, I do believe it is a fair representation of treatment pathways #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
seemingly that is what the study may be suggesting. @Congenitalhand, do you agree? #jhsjc

Charles Goldfarb @Congenitalhand:
Agree on this model being an opportunity for other lines of research. #jhsjc

Charles Goldfarb @Congenitalhand to @DrDavidRing:
I agree. Botox has a very limited role in my practice (aside from the cost assessment information). #jhsjc
AND, while outside the scope of this study, Botox has negative effects long term! #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand:
Do you mean negative effects outside decreasing efficacy? #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
Yes. Negative effects long term on the motor end plate, suggestion neg effects on strength long term #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
something innovative the model did was to include parent absence from work as an important variable. #jhsjc

David Ring @DrDavidRing to @Congenitalhand:
Are patients aware of the potential benefits and the shortcomings of BoTx? #jhsjc

Charles Goldfarb @Congenitalhand to @DrDavidRing:
When the patient sees the orthopedic surgeon, I believe yes. When the patient sees neurology ??? #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand:
I might be showing my ignorance of the topic but isn’t #botox commonly used in #CP #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
It is used commonly, too commonly for most of us (us = surgeons). I say that recognizing surgeon biases #jhsjc

David Ring @DrDavidRing:
Should the marketing of palliative treatments without specifying that they are palliative a #ChoosingWisely opportunity? #jhsjc

Charles Goldfarb @Congenitalhand to @DrDavidRing:
That is a fantastic suggestion. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Is it truly palliative or just less effective? #jhsjc

David Ring @DrDavidRing:
There is probably a list of things in hand surgery where are not as clear as we might be: alleviation/salvage vs. altered natural hx #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Even if this is a question of efficacy, palliative or not, I agree that this is great for #ChoosingWisely #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
My point is that surgery is a salvage procedure. It changes the body and is more lasting. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I agree that there is a subtle and important distinction. #jhsjc

David Ring @DrDavidRing:
Do patients understand that surgery has some goals it can achieve, but BoTx is temporary? That would be interesting to study #jhsjc

Avi Giladi @theaviram to @DrDavidRing:
I get the impression most know it’s temporary, but consider less risky/painful than surgery #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand:
This seems to be strong evidence for surgery #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
This adds to the understanding. See Van Heest JBJS 2015 #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand:
The sensitivity analysis showing that #sx was favoured even without the parental lost work time was very important #jhsjc

Warren @whammert to @Congenitalhand and @DrDavidRing:
I have used it to assess the effect of weakening the muscles – one time and if better more confident in sx #jhsjc

Brent Graham @BgTalkinman to @whammert, @Congenitalhand, and @DrDavidRing:
That is an interesting use. #jhsjc

Charles Goldfarb @Congenitalhand to @whammert and @DrDavidRing:
That is fair. Another reasonable use is for shoulder in BPP with casting to reduce joint #jhsjc

Brent Graham @BgTalkinman:
This type of analysis could have wide application to #costeffectiveness questions in hand surgery. #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
And we need more of this. #jhsjc

Brent Graham @BgTalkinman:
Could this be used to model very important questions like #sx for #DRF? #jhsjc
A similar study appeared in @JHandSurg recently showing that #sx was more #costeffective than #CCH in #Dupuytren disease #jhsjc
What other questions in hand surgery could benefit from this kind of approach? #jhsjc

Warren @whammert to @BgTalkinman:
corticosteroids vs surgery for many things #jhsjc

Brent Graham @BgTalkinman to @whammert:
Agreed! #jhsjc

Charles Goldfarb @Congenitalhand to @BgTalkinman:
I think this is helpful for surgeons to process but the US system still avoids cost/ value #jhsjc

Charles Goldfarb @Congenitalhand to @whammert and @BgTalkinman:
LRTI vs implant arthroplasty #jhsjc

Brent Graham @BgTalkinman to @Congenitalhand and @whammert:
Sure! #jhsjc

Brent Graham @BgTalkinman:
I hope to see more submissions using this great methodology! #jhsjc
Let’s move on to the second paper #jhsjc
Speaking about #DRF rx… this one looked at the effect of low #BMD on loss of reduction in cases treated with non-op mgmt #jhsjc
1st question: Is loss of 1.2 mm length clinically relevant? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Does that lead to an expensive test or would this be one very small part of a shared decision #jhsjc

RyanC @RPCalfeeSTL:
hard to know what amount of shortening matters #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Given the osteoporosis is often associated with greater willingness or accommodate, little clinical relevance #jhsjc

Warren @whammert to @BgTalkinman:
I think it depends on the starting point. we also know some patients are more tolerant than others for malunion #jhsjc

David Ring @DrDavidRing to @whammert and @BgTalkinman:
“Malunion” is in part defined by lower willingness to accommodate deformity #jhsjc
We see lots of deformity and the occasional malunion #jhsjc

RyanC @RPCalfeeSTL:
agree with lots of tolerated deformity #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I agree that this is a situation where context matters #jhsjc

Avi Giladi @theaviram to @BgTalkinman and @DrDavidRing:
small part of shared decision. hard to know in advance who/what will be tolerated #jhsjc

Warren @whammert to @DrDavidRing and @BgTalkinman:
I agree those with osteoporosis seem to tolerate deformity better – would be an interesting study? #jhsjc

David Ring @DrDavidRing:
If the idea is that measuring bone density improves wrist health after a distal radius fracture, I’m not sure I buy that. #jhsjc

Avi Giladi @theaviram to @DrDavidRing:
do more clinical data help the shared/decision convo? hurt? no change? #jhsjc

David Ring @DrDavidRing to @theaviram:
If “more clinical data” = unhelpful expensive test, then we do not need more. #jhsjc

Avi Giladi @theaviram to @DrDavidRing:
agreed. but cheap (or free) data points that frame discussion could help? or just muddy waters? #jhsjc

David Ring @DrDavidRing to @theaviram:
Each piece of data has the potential for benefit and the potential for harm #jhsjc

Warren @whammert to @DrDavidRing:
but comparing t scores and outcomes following DRF non op treatment could be interesting. #jhsjc

Brent Graham @BgTalkinman:
Given the controversy re #surgical rx for #DRF in older pts what do these results mean? #jhsjc

Avi Giladi @theaviram:
some pts are ok with non-op tx, some pain, deformity…others struggle. no crystal ball. trying to chip away at the unknown #jhsjc

Warren @whammert to @theaviram:
what is there was a clear predictor – t scores, 2 metacarpal density, or something else that made the crystal ball clear #jhsjc

Avi Giladi @theaviram to @whammert:
not clear, but when eval the options/trying to guide, seeing low density + instabil might help frame risk? need more data #jhsjc

Brent Graham @BgTalkinman:
To come full circle, this seems like a great question for a #decisionanalysis like in the 1st paper #jhsjc

Brent Graham @BgTalkinman to @whammert and @theaviram:
This is exactly the kind of question #decisionanalysis informed by big data can address #jhsjc

Avi Giladi @theaviram:
knowing more about the patient (tolerance) AND their xrays (fx/healing) can combine to understand treatment approach. #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Agreed but this will never be adequately studied using a conventional approach like an RCT #jhsjc

Brent Graham @BgTalkinman to @theaviram and @whammert:
My opinion is that there is enough data to model this kind of clinical scenario. I would to see that! #jhsjc

Warren @whammert to @theaviram:
so the question is can tolerance be correlated to osteoporosis? #jhsjc

Avi Giladi @theaviram to @whammert:
that would be interesting! But my guess (hope) is that even if correlated, there are better ways to identify tolerance #jhsjc

Warren @whammert to @BgTalkinman and @theaviram:
agree despite the limitations of large databases, this would be needed I believe #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
completely agree. unlikely that low tolerance person would agree to RCT #jhsjc

Brent Graham @BgTalkinman to @whammert and @theaviram:
That “tolerance” fits more into a shared decision idea – informing that requires a #decisionanalysis model IMHO #jhsjc

Brent Graham @BgTalkinman:
Thanks for your insights! Consider joining the discussion tomorrow too! #jhsjc
We are back here for our last session before the summer on June 8 at 9 pm EDT. #jhsjc


Ryckie Wade @ryckiewade:
Welcome to part 2 of May’s #JHSJC! Many thanks to Dr Brent Graham @BgTalkinman for the invitation to host. #jhsjc
This journal club is 💯 unscripted, 💯 uncensored and open to all. Please do participate whoever you are, where ever you are! #jhsjc

Ryckie Wade @ryckiewade:
1st up, we’re discussing #botox for children with #CerebralPalsy 👉 https://www.jhandsurg.org/article/S0363-5023(21)00045-9/fulltext #jhsjc

Brent Graham @BgTalkinman:
My interview with senior author Dr. Lindley Wall can be heard here: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/May_2021.mp3 #jhsjc

Ryckie Wade @ryckiewade:
Friends outside the USA, how do these findings relate to your practice +/- experience? #jhsjc

Brent Graham @BgTalkinman:
Does the model accurately reflect what an episode of care should look like? #jhsjc
Cost-effectiveness is an important topic in North America. Do models like this accurately represent care? #jhsjc

Justin Wormald @JCRWormald:
Is it possible to make reliable economic analyses w/o definitive RCT data demonstrating clinical effectiveness/superiority of Rx? #jhsjc

Brent Graham @BgTalkinman to @JCRWormald:
That means that this variable didn’t have a definitive impact on the model. That kind of insight is not possible in RCTs #jhsjc
All study designs have their limitations. RCT’s are narrow and may not be generalizable. #jhsjc
Decision analysis models allow for assumptions that can be tested in a sensitivity analysis like was done in this study. #jhsjc

Justin Wormald @JCRWormald to @BgTalkinman:
Def an interesting area – my limited understanding is that you’d need v large (and v complete) observational dataset to do this – difficult to get in Paeds hand surgery? @ruudselles @ryckiewade thoughts?

Ryckie Wade @ryckiewade to @JCRWormald:
Thanks @JCRWormald – observational studies (if done well) can provide data on par with RCTs – your views? #jhsjc

Ryckie Wade @ryckiewade:
What are people’s views on the 2-step mapping (Ped-QL-parent –> GMFCS –> QALY) for calculating cost-effectiveness? #jhsjc

Brent Graham @BgTalkinman to @JCRWormald:
That allows variables that might be informed by lesser evidence to be varied to see how they affect the outcome. #jhsjc
That’s what this paper did by modelling with and without parent time lost from work. The result was the same. #jhsjc

Brent Graham @BgTalkinman to @ryckiewade and @JCRWormald:
Observational studies have their biases but can be extremely useful if those are understood. #jhsjc
Most of what is known in hand surgery is the result of observational study #jhsjc

Justin Wormald @JCRWormald to @BgTalkinman and @ryckiewade:
💯💯💯 #jhsjc

Brent Graham @BgTalkinman to @ryckiewade and @JCRWormald:
Administrative database studies are also observational and may be more informative than many RCTs #jhsjc
Many administrative databases will contain rich information about children #jhsjc

Ryckie Wade @ryckiewade:
True – and without observational data, the ‘best’ comparisons to interrogate via RCTs would be less clear 😉 #jhsjc

Brent Graham @BgTalkinman to @ryckiewade:
That is very true. #jhsjc

Ryckie Wade @ryckiewade:
Before we turn our attention to paper #2, does anyone plan to stop using #botox and go direct to surgery now? #jhsjc

Brent Graham @BgTalkinman to @ryckiewade:
Patient preference is a consideration but the evidence from this study in favour of #sx seems compelling. #jhsjc

Gurdas V. Singh S. R. @Gurdas2209:
To the question of observational vs RCT: I don’t think it is a case of either/or, you need both to make up for the weaknesses of the other #jhsjc

Brent Graham @BgTalkinman to @Gurdas2209:
Evidence is something built over time and on the basis of many sources. #jhsjc

Justin Wormald @JCRWormald to @ryckiewade and 6 others:
Could we replicate this study in UK using HES? Would be a big database but can it reliably inform Markov? #JHSJC

Gurdas V. Singh S. R. @Gurdas2209 to @JCRWormald, @ryckiewade, and 5 others:
You’ve nailed the crux of the argument, @JCRWormald, a Markov is only as good as its data, as Drummond has said. I’m always hesitant about replicating Markovs across different pay systems, but there definitely needs to be a way to do so for reliable comparison #jhsjc

Ryckie Wade @ryckiewade:
Shall we move onto paper #2 #BMD & non-operative treatment of #DRF 👉 https://www.jhandsurg.org/article/S0363-5023(21)00087-3/fulltext #jhsjc
Given that we can’t modify bone density quickly, does measuring #BMD add value to the acute management of #DRF? #jhsjc

halseyhands @halseyhands1 to @ryckiewade:
Yes, for prevention of subsequent fractures. Perhaps less so for the management of the acute fracture in front of you. Assessment of likelihood of further fractures using FRAX is part of appropriate fracture management #jhsjc

dani prieto-alhambra @prieto_alhambra to @xlgriffin, @DominicFurniss, and 7 others:
The randomisers of this world seem to have gone rather quiet since we heard of vaccine side effects.. ehem..
No, seriously, we need both. Nothing better than RCTs for efficacy, but no trial does characterisation or true safety better than routine data

Brent Graham @BgTalkinman to @ryckiewade:
How about in terms of risk stratification for various treatment options? #jhsjc
I would say “yes, it does”. #jhsjc

Jenny Lane @jennifercelane to @JCRWormald, @BgTalkinman, and 3 others:
did i hear the word observational?! i’m coming in! #jhsjc

Brent Graham @BgTalkinman:
The loss of reduction associated with poor #BMD was 1.2 mm. Is that clinically relevant? #jhsjc

Justin Wormald @JCRWormald:
@xlgriffin @halseyhands1 @maximhorwitz @Ecko1957 @hand_specialist thoughts on this? #jhsjc

Brent Graham @BgTalkinman:
Is #ORIF justified to avoid this amount of shortening? #jhsjc
Because #ORIF is a frequent treatment for #DRF in older individuals in North America. How is this managed in Europe? #jhsjc
To come full circle back to the 1st article, this is a question that is well-suited to decision analysis. The data is there. #jhsjc
There is enough information to have a decision analysis stratify risk for op and non-op treatment for #DRF in different age groups. #jhsjc

Jenny Lane @jennifercelane:
well, this is a massive DRAFFT(y) issue! DRAFFT is definitely leading practice now in the UK, but there are still critics #jhsjc

Brent Graham @BgTalkinman to @jennifercelane:
What is DRAFFT? #jhsjc

Jenny Lane @jennifercelane to @BgTalkinman:
DRAFFT=multicentre distal radius RCT based in the UK randomising to plate or k wire; now #DRAFFT2- guess what that is? #jhsjc

Brent Graham @BgTalkinman to @jennifercelane:
That is a strange comparison. #jhsjc

Ryckie Wade @ryckiewade:
https://www.ncbi.nlm.nih.gov/books/NBK276570/ “this trial shows that there is no difference between Kirschner wires and volar locking plates” #jhsjc

Brent Graham @BgTalkinman to @ryckiewade:
Power? What was measured as an outcome? #jhsjc

Ryckie Wade @ryckiewade to @BgTalkinman:
The primary outcome was PRWE at 12 months. This might have been mandated by the funder (NIHR HTA)? #jhsjc

Jenny Lane @jennifercelane:
suppose to bring it back to the paper- 1mm variance. is that bad enough compared to risk surgical complications? #jhsjc

Brent Graham @BgTalkinman to @jennifercelane:
I often don’t understand why investigators spend a lot of energy, time and money oil questions of unclear relevance. #jhsjc

Deborah Eastwood @deboraheastwood to @JCRWormald, @ryckiewade, and @MrDavidIzadi:
Plenty!! But difficult to fit into a tweet!! My main concern? In my practice – indics for surgery and BoNT differ and I always find the economic’ analysis ‘difficult’ to cope with (never was good with money!) … #jhsjc

Xavier Griffin @xlgriffin to @JCRWormald, @ryckiewade, and 4 others:
I’m thinking the only reason is prompt assessment and management future fracture risk #jhsjc

Justin Wormald @JCRWormald to @xlgriffin, @jennifercelane, and 4 others:
With @xlgriffin on this one 😁 #jhsjc

Brent Graham @BgTalkinman to @xlgriffin, @jennifercelane, and 4 others:
When that happens the reason for the discrepancies has to be evaluated – that’s what an editor is supposed to do. In my experience, the results of well performed research using varying designs usually does align – eventually #jhsjc

Ryckie Wade @ryckiewade:
Thank you everyone for your vibrant participation! All good things must come to an end and so this concludes the session for May. #jhsjc
Thank you @BgTalkinman for hosting – it’s vital that research generates candid debate so we can improve the next project #jhsjc
We hope to see you next month @ #JHSJC for more hand surgery research chat 🤩

Jenny Lane @jennifercelane to @ryckiewade:
thanks for leading it- now that I’ve got myself up to speed with tchat.io next session I’ll be all over it! #jhsjc

Xavier Griffin @xlgriffin:
Just discovered #jhsjc – some good looking #orthotwitter debate to be had. Just warming up my list of ‘alternative explanations’ @jennifercelane

Jenny Lane @jennifercelane to @xlgriffin:
I KNOW! I was too late to the party- evidently twitter battles are best delivered on point and on time. next month, I’ll be ready #JHSJC

Ryckie Wade @ryckiewade:
Thanks, everyone for your participation! 💪 #jhsjc

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