#JHSJC

September #JHSJC Transcript

The #JHSJC is back! Our September discussion was an excellent way to return after a brief break for the summer. Here are the two articles from the September issue of JHS that we addressed: 1) Geospatial Inefficiencies Associated With Digital Replantations at High-Volume Centers and Optimal Allocation Model for Centralization of Replantations and 2) The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period

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:
It’s time for the September #JHSJC! Let’s get the discussion going!

Brent Graham @BgTalkinman:
We are back after our summer hiatus! Let’s get right to it! “Geospatial Inefficiencies Associated With Digital Replantations at High-Volume Centers and Optimal Allocation Model for Centralization of Replantations”
https://www.jhandsurg.org/article/S0363-5023(21)00216-1/fulltext #jhsjc

UVAHandSurgery @HandUva:
Bobby Chhabra, Aaron Freilich, and Brent DeGeorge and our 2 fellows Andrew Ence and Eduardo Natal here at UVA. #jhsjc

Brent Graham @BgTalkinman to @HandUva:
Terrific! Welcome! #jhsjc

UVAHandSurgery @HandUva:
Congrats to Amy Moore on a fantastic article highlighting some of the issues with referral patterns for microvascular replant. #jhsjc

Andrew O’Brien @aob_1024 to @BgTalkinman:
Andrew O’Brien here from OSU, excited to chat about these articles! #jhsjc

Brent Graham @BgTalkinman:
Joining in is Andrew O’Brien the lead author on this article. Welcome! #jhsjc
This is an article like others we’ve published looking at issues related to replantation. #jhsjc

Brent Graham @BgTalkinman:
There were only 5500 cases – 500/yr – identified from a population of 40 million people (CA). Does that suggest a biased sample? #jhsjc

UVAHandSurgery @HandUva:
Our biggest question upon reading the article and comparing to our practice is how are transfers between ctrs of care accounted for. #jhsjc
Here it is common for replant candidates to present initially to a low-volume center and be transferred here for ultimate care. #jhsjc

Andrew O’Brien @aob_1024 to @HandUva:
That’s a great observation, each patient is a hospital discharge following surgery, so we couldn’t account for transfers… #jhsjc

Brent Graham @BgTalkinman to @aob_1024 and @HandUva:
Does that matter? Isn’t it more important to know where the care occurred? #jhsjc

RyanC @RPCalfeeSTL:
great article. I also wonder about high volume center vs role of high volume surgeons #JHSJC

Brent Graham @BgTalkinman to @RPCalfeeSTL:
I hadn’t thought about that. Does the centre matter more than the individual surgeon? #jhsjc

UVAHandSurgery @HandUva to @RPCalfeeSTL:
Yes. Good point. Surgeons may cover multiple hospitals in a given network. #jhsjc

Andrew O’Brien @aob_1024 to @HandUva:
but we did find some interesting predictors of where patients received surgery, which may allude to transfer motivations #jhsjc

Brent Graham @BgTalkinman to @aob_1024:
Can you expand on that? #jhsjc

UVAHandSurgery @HandUva to @BgTalkinman and @RPCalfeeSTL:
The individual surgeon’s skill level is the predictor of success and institution is a surrogate. #jhsjc

Andrew O’Brien @aob_1024 to @BgTalkinman and @HandUva:
Transfers are likely important resource allocation, but maybe less for outcomes. maybe a next study? #jhsjc

Warren @whammert to @HandUva, @BgTalkinman, and @RPCalfeeSTL:
Probably not many surgeons with a lot of experience at a center that does few #jhsjc

Brent Graham @BgTalkinman to @HandUva and @RPCalfeeSTL:
Yes, that’s my assumption too. Importantly, most of the cases were done in low volume centres #jhsjc

UVAHandSurgery @HandUva to @aob_1024:
That’s always the best answer, particularly when the journal editor is on the communication. #jhsjc

Andrew O’Brien @aob_1024:
A good previous study looked at high volume centers and high volume surgeons…both very important #jhsjc

Brent Graham @BgTalkinman to @aob_1024:
There is an interesting podcast that goes with that article (https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/May-2016.mp3) #jhsjc

Brent Graham @BgTalkinman to @whammert, @HandUva, and 2 others:
I agree! #jhsjc

UVAHandSurgery @HandUva:
We were also impressed that the uncorrected difference in outcomes vs. attempts was not as high as I would’ve expected. #jhsjc

Brent Graham @BgTalkinman to @HandUva:
Do you mean that the attempts paralleled the outcomes? few attempts – poorer outcomes? #jhsjc

Brent Graham @BgTalkinman:
There are a lot of factors to consider but seemingly it’s more important to be at the best centre not necessarily the closest centre. #jhsjc

Warren @whammert to @BgTalkinman:
yes – this would seem obvious. But maybe ambulance contracts. Also, location of injury may not be same as home addres #jhsjc

Andrew O’Brien @aob_1024 to @HandUva:
Totally, this could be consistent with national trends, may also be due to case complexity at high volume centers #jhsjc

UVAHandSurgery @HandUva to @BgTalkinman:
Predicted replant success was 5.49% in low vs. high volume centers, I would’ve expected greater. #jhsjc

Andrew O’Brien @aob_1024 to @whammert and @BgTalkinman:
key point, tried to account for this with sub-analysis excluding worker comp, but definitely a limitation #jhsjc

UVAHandSurgery @HandUva to @whammert and @BgTalkinman:
Wonder if referral criteria analogous to burn referral criteria can be developed and distributed? #jhsjc

Brent Graham @BgTalkinman to @HandUva:
That is a great suggestion. #jhsjc

Brent Graham @BgTalkinman:
What do people think about the modelling? If all cases were concentrated in a few high volume centres, wouldn’t results be better? #jhsjc

Brent Graham @BgTalkinman to @aob_1024 and @whammert:
I agree it’s a limitation but my guess is that home address is a good surrogate. #jhsjc

Brent Graham @BgTalkinman:
The Hand Trauma Network idea hasn’t been effective as shown in our lead article from 2 months ago https://www.jhandsurg.org/article/S0363-5023(21)00194-5/fulltext #jhsjc

Brent Graham @BgTalkinman:
Like other studies we’ve published, race and payer type were factors. What is the best way to tackle that? #jhsjc

Andrew O’Brien @aob_1024 to @HandUva, @whammert, and @BgTalkinman:
Does a burn center designation change reimbursement? Maybe an new approach to centralizing replants? #jhsjc

Brent Graham @BgTalkinman to @aob_1024, @HandUva, and 2 others:
This is a very important question? Does anyone know the answer? #jhsjc

UVAHandSurgery @HandUva to @BgTalkinman:
Education and establishing pathways to high volume centers regardless or race or gender would potentially help #jhsjc

Warren @whammert to @BgTalkinman:
hard to know, but there may be a relationship between race and payer type. Not sure there is a fix with current system #jhsjc

Brent Graham @BgTalkinman to @whammert:
It seems emblematic of the many problems with the status quo – fragmentation is a huge issue! #jhsjc

Brent Graham @BgTalkinman to @HandUva:
Seemingly that education has to be at the level of ambulance services! The reimbursement piece seems the most critical. #jhsjc

UVAHandSurgery to @BgTalkinman:
Seems like grass roots level organizing at the level of the paramedic / ED transfer center may have an impact #jhsjc
Agree that reimbursement will be critical at the surgeon and at the center level! #jhsjc

Brent Graham @BgTalkinman to @HandUva:
That would follow organization at the hospital system level. #jhsjc

Avi Giladi @theaviram to @BgTalkinman, @aob_1024, and 2 others:
Designated specialty centers (trauma, burn,etc) often get more $$ but the amount/criteria/etc vary by state #jhsjc

Andrew O’Brien @aob_1024 to @whammert and @BgTalkinman:
not a complete answer to health equity, but this study showed that being close to a center helps… #jhsjc
…maybe designate centers close to vulnerable populations? #jhsjc

Warren @whammert to @HandUva and @BgTalkinman:
I think it is more than reimbursement even though that is a part – time of day, cancelling patients,… #jhsjc

Brent Graham @BgTalkinman to @whammert and @HandUva:
Better organization at a system level would help that. Money will also be very influential. #jhsjc

Brent Graham @BgTalkinman:
These are some great points. Hopefully the discussion continues! Let’s move on to another controversial topic #CTR revision. #jhsjc

UVAHandSurgery @HandUva:
An interesting article. Was anyone else surprised by a 4.8% overall 1-year revision rate? #jhsjc

Brent Graham @BgTalkinman:
This study looked at admin data to track revision #CTR, made possible by the introduction of codes for laterality. #jhsjc

Warren @whammert to @BgTalkinman:
interesting paper, but hard to determine from databases indications for surgery, same or different surgeon and variable #jhsjc

Brent Graham @BgTalkinman to @whammert:
With these large numbers, surgeon identity likely not really a factor. #jhsjc

Brent Graham @BgTalkinman:
The pt factors associated with revision sx seem mostly unmodifiable but the surgical approach endoscopic or open is clearly a choice. #jhsjc

Brent Graham @BgTalkinman:
If anyone listening does #ECTR, do you tell pts that they are at a 30% greater risk of requiring revision than if they have open CTR? #jhsjc

Warren @whammert to @BgTalkinman:
do you think second surgeon may be more likely to do revision? #jhsjc

Brent Graham @BgTalkinman to @whammert:
I’m guessing but I might expect less likely. #jhsjc

Warren @whammert to @BgTalkinman:
Hmm. I would think the opposite – persistent symptoms and second surgeon more apt to do revision #jhsjc

Brent Graham @BgTalkinman to @whammert:
Maybe but does that explain the 30% excess risk associated with ECTR? #jhsjc

Brent Graham @BgTalkinman to @aob_1024:
No causality can be proven, just associations but the increased risk by 30% associated with ECTR is hard to explain #jhsjc

Brent Graham @BgTalkinman:
The 2016 #AAOS #CPG indicated that #ECTR and #OCTR were essentially equivalent. Is that still a reasonable assumption? #jhsjc

UVAHandSurgery @HandUva to @BgTalkinman:
In PearlDiver, the database is at patient level so regardless of who does the surgery, revisions are accounted #jhsjc

Brent Graham @BgTalkinman to @HandUva:
I agree! The point seems to be the association of #ECTR with revision #CTR. That seems more important than surgeon identity #jhsjc

Warren @whammert to @HandUva and @BgTalkinman:
yes, but we don’t know the indication for repeat surgery – are you more likely to revise your own surgery? #jhsjc
This seemed to be a point, but I was surprised with this finding. #jhsjc

Brent Graham @BgTalkinman:
Well #ECTR costs more than #OCTR and is associated with a greater risk of requiring revision within 1 yr. #ECTR and #OCTR dont seem equiv #jhsjc

Andrew O’Brien @aob_1024 to @BgTalkinman and @HandUva:
Would be interesting to know technique of revision surgery…was open a more common approach following ECTR? #jhsjc

UVAHandSurgery @HandUva to @whammert and @BgTalkinman:
The use and timing of Electrodiagnostics would be interesting here (pre-op v. pre-revision) #jhsjc

Warren @whammert to @BgTalkinman:
yes – one study. Would be interesting to see if similar results in other databases? #jhsjc

Brent Graham @BgTalkinman to @whammert and @HandUva:
There is lots of evidence to show the cause of persistent symptoms is ongoing numbness usually incomplete release. #jhsjc

Brent Graham @BgTalkinman to @aob_1024 and @HandUva:
I dont think they reported own that but it is probably knowable from the data. #jhsjc

Warren @whammert to @BgTalkinman and @HandUva:
so if NTA resolves but still have numbness, do you revise? #jhsjc

Brent Graham @BgTalkinman to @aob_1024 and @HandUva:
It isn’t really a study about outcomes of revision surgery just the associations with revision. #jhsjc

Brent Graham @BgTalkinman to @whammert:
If the symptoms of CTS are the same as preop and there is no evidence of wallerian degen I assume incomplete release. #jhsjc

Brent Graham @BgTalkinman to @HandUva:
What little evidence there is about #EDX in this setting indicates that it might not be helpful. #jhsjc
No evidence that the median nv abnormalities return to normal on #EDX after symptomatically successful #CTR #jhsjc

Warren @whammert to @BgTalkinman and @HandUva:
I think EDX are only helpful if available prep and show worsening. Otherwise, I find injection more helpful #jhsjc

Brent Graham @BgTalkinman:
My guess is that this study will figure importantly in the next #AAOS #CPG and that #ECTR will no longer be considered equiv to #OCTR #jhsjc

UVAHandSurgery @HandUva to @BgTalkinman:
EDX severity and likelihood of symptomatic resolution of NTA and numbness correlate. #jhsjc

Brent Graham @BgTalkinman to @whammert:
I would agree with that. If they are the same I don’t think it means anything. #jhsjc

Warren @whammert to @BgTalkinman:
that will be interesting. I am not sure how CPG recommendations looks at database studies? #jhsjc

Brent Graham @BgTalkinman to @whammert:
It’s usually level II evidence so it is considered important. #jhsjc

Brent Graham @BgTalkinman to @HandUva:
I wouldn’t agree that has been clearly shown. Pts doing well don’t undergo #EDX in follow-up. #jhsjc

UVAHandSurgery @HandUva to @BgTalkinman:
Preop EDX severity (mild-mod v. severe) has been shown to correlate with PROMs post-op #jhsjc

Brent Graham @BgTalkinman:
We are at the end of our hour! Thanks all for the stimulating conversations! There is another session tomorrow 8 pm GMT (3 pm EDCT) #jhsjc

UVAHandSurgery @HandUva:
Thank you all! Great discussion. #jhsjc

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Ryckie Wade @ryckiewade:
Welcome back to #JHSJC – Round 2, EuroZone – to follow the discussion visit tchat.io, enter #JHSJC (and sign-in Tweet from the browser)
Today, we will focus on “The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period” https://www.jhandsurg.org/article/S0363-5023(21)00208-2/fulltext #jhsjc

Ryckie Wade @ryckiewade:
Friends in epidemiology research (@ruudselles @MichielZuidam @migueljansen @jennifercelane) what do you think of this study? #jhsjc
Any proponents of #ECTR or stats nerds want to argue the purported increased risk of revision surgery?? #jhsjc

Brent Graham @BgTalkinman:
obviously there were non-modifiable factors identified but #ECTR is a choice. #jhsjc

Brent Graham @BgTalkinman to @ryckiewade:
How prevalent is #ECTR in Europe? #jhsjc
Is the choice btw #ECTR and #OCTR even a question? #jhsjc

Ryckie Wade @ryckiewade to @BgTalkinman and others:
as far as I can see #ECTR is vanishingly rare in Europe – @Lisa_Newington @jmceachan @Nerve_Clinic @dominicpower1 @NeonStudy crew & @DeanBoyce6 am I mistaken?

Lisa Newington @Lisa_Newington:
We found very few UK #ECTR in our survey: https://journals.sagepub.com/doi/abs/10.1177/1753193418786375 and systematic review: https://sjweh.fi/show_abstract.php?abstract_id=3762 Anecdotally, speaking to surgeons, they saw no cost benefit. Might have slightly faster healing, but higher risk of complications…

Brent Graham @BgTalkinman to @Lisa_Newington, @ryckiewade, and 5 others:
In my view these recent publications have confirmed those anecdotal impressions with evidence. #ECTR costs more and is associated with a higher risk of important complications, notably re-operation. #jhsjc

Brent Graham @BgTalkinman:
The 2016 #AAOS #CPG consider #ECTR and #OCTR equivalent. Is that still reasonable? #jhsjc
For those who do #ECTR will you advise pts that there is a 30% increased risk of reop in the year after sx? #jhsjc

Ryckie Wade @ryckiewade to @BgTalkinman and 6 others:
We’re talking about this study btw https://www.jhandsurg.org/article/S0363-5023(21)00208-2/fulltext

Ryckie Wade @ryckiewade:
Seems like it’s just you and me @BgTalkinman – everyone must be science’d out from the @BSSHand conference & #BSSHstudyathon last week 🤣 #jhsjc

Brent Graham @BgTalkinman to @ryckiewade @Lisa_Newington and 5 others:
That is interesting because it accounts for 15% of cases in North America. That is the only approach of many surgeons. #jhsjc

Justin Wormald @JCRWormald:
I’m here too! Have seen a few ECTRs with @rebecca5hirley – would be interested to hear her experience

@BgTalkinman:
We have papers showing that it is more expensive and now assoc with more reoperation – the end may be near!

Ryckie Wade @ryckiewade to @JCRWormald, @BgTalkinman, and @rebecca5hirley:
👆 #jhsjc

Claire Simpson @diving_digits to @ryckiewade:
Crikey that’s a high revision rate. I’d be interested in seeing the stats on the surgeons whose pts went onto early revision, and see how many ECTR they do a year.

Ryckie Wade @ryckiewade to @jmceachan, @BgTalkinman, and 5 others:
Thanks @jmceachan – what keeps you away from offering #ECTR? Queue the can of worms… #jhsjc

Jane McEachan @jmceachan to @ryckiewade, @BgTalkinman, and 6 others:
Fife data shows reliable and reproducible improvement in CTR, less reliable in CuTR.
CuTR very different! CTR divides the biggest extrinsic ligament of the wrist, affects the flexor ‘pulley’ and destabilises the thenar and hypothenar muscles until healing process stabilises things. No such loss in CuTR = easy rehab.

Ryckie Wade @ryckiewade to @jmceachan, @BgTalkinman, and 6 others
Thanks @jmceachan, he certainly makes #ECuTR look easy youtube.com/watch?v=3JpobH… ! I wonder if the upcoming HTA trial of open vs endo #CuTR will go the same was as #CTR…? #jhsjc

Brent Graham @BgTalkinman to @jmceachan, @ryckiewade, and 6 others:
Whether the increased risk of re-operations reflects a “learning curve” cannot be told, but I think it is safe to say that we shouldn’t be “learning” at the expense of pts, although that has been frequently done in surgery in times past. #jhsjc

Ryckie Wade @ryckiewade to @BgTalkinman, @JCRWormald and @rebecca5hirley:
28 trials later and still little meaningful difference between #ECTR and #OCTR – https://doi.org/10.1002/14651858.CD008265.pub2 – perhaps large-scale database studies like this will show what a 29th trial couldn’t? I feel @jennifercelane and the @XpertClinic team need to chime in here #jhsjc

Justin Wormald @JCRWormald to @ryckiewade and 3 others:
If there are 29 trials and the question isn’t answered then either: there is no difference OR those 29 trials were inadequately powered to detect one (in the most relevant outcome)

Brent Graham @BgTalkinman to @JCRWormald:
The study showed a 4.8% overall rate of re-operation, around 250 individuals out of nearly 5000. Only 15% of the cases were #ECTR so it seems quite possible that these trials are, in fact underpowered for that outcome. That is the power of admin data.

Justin Wormald @JCRWormald to @ryckiewade and 3 others:
‘Conclusions from this review are limited by the high risk of bias, statistical imprecision and inconsistency in the included studies.’ We need more, better data.
Spoken like a true trialist Face with hand over mouth Although it’s impossible to disagree #jhsjc

Brent Graham @BgTalkinman to @JCRWormald:
While there is obviously an important place for #RCT, I don’t think they are very effective in the investigation of relatively rare events like re-operation after #CTR. An alternative would be a case-control design. #jhsjc

Brent Graham @BgTalkinman:
Any interest in discussing replant allocation? My guess is there is less access disparity in European in the US. Is that accurate? #jhsjc

Ryckie Wade @ryckiewade to @homomediocritus, @ruudselles, and 3 others:
Factors were selected for the multivariable model based on univariable associations… I couldn’t see a protocol… Could we be victim to p-🎣… discuss…. doi.org/10.1016/j.jhsa… #jhsjc

Brent Graham @BgTalkinman to @JCRWormald, @ryckiewade, and 3 others:
The study showed a 4.8% overall rate of re-operation, around 250 individuals out of nearly 5000. Only 15% of the cases were #ECTR so it seems quite possible that these trials are, in fact underpowered for that outcome. That is the power of admin data. #jhsjc
While there is obviously an important place for #RCT, I don’t think they are very effective in the investigation of relatively rare events like re-operation after #CTR. An alternative would be a case-control design. #jhsjc

Brent Graham @BgTalkinman to @homomediocritus, @DeanBoyce6, and 7 others:
IMO the issue is the validity of the dx of #CTS and there is a lot of evidence to show that #EDX do not add to the probability of a correct dx based on clinical evaluation alone. They do add cost and lengthen the time to sx #jhsjc

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