We started off the new year strong with our first #JHSJC discussion of 2022! We looked at two leading articles from Volume 47, Issue 1 of JHS: “Evaluation of Risk Factors for Loss of Acceptable Alignment for Distal Radius Fractures That Are Nondisplaced or Minimally Displaced on Initial Presentation” and “Utilization of Diagnostic Testing for Carpal Tunnel Syndrome: A Survey of the American Society for Surgery of the Hand.” We are grateful for everyone who joined our debate, especially our colleagues from overseas!
This discussion also marks our first use of a new platform, TwChat. Our former discussion platform, tchat.io, is no longer functional. Please review the information here on how to use TwChat and join us for the next event!
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:
If you are using TwChat the jhsjc hashtag will be added automatically. If not, please be sure to add it yourself #jhsjc
Let’s start with article 1. Souza et al #jhsjc
Charles Goldfarb @Congenitalhand:
Hello Brent and all- 2022 Twitter JC! #jhsjc
Brent Graham @BgTalkinman:
There were 110 pts with minimally or undisplaced #DRF followed 5 weeks. 30% eventually had displacement beyond the #AAOS guideline for acceptable alignment. That seems like a high figure. Is that the experience of others? #jhsjc
…in other words are these findings generalizable? #jhsjc
RyanC @RPCalfeeSTL:
hard to know if generalizable but certainly a good number of patients #jhsjc
Charles Goldfarb @Congenitalhand:
I agree that it seems a little high. Most treated with “orthosis”- splint. And not clear if converted to molded cast. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL and @Congenitalhand: On the basis of these findings should dorsal comminution be considered a relative indication for surgical mgmt? #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
I agree it is unclear whether a “cast” and an “orthosis” are equivalent treatments. I wouldn’t consider them the same. Would you? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
not yet indication, but at least consideration and important for further study. this + other recent studies may indicate that “instability” factors list we usually consider are incomplete #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I guess I’m wondering if it should be considered a surgical indication if the loss of reduction is considered a failure of non-op rx. It is like an impending failure if it can be expected in >30% #jhsjc
Charles Goldfarb @Congenitalhand
So I would not consider cast and orthosis to be the same and that is one concern. A molded cast may have limited displacement vs a splint. That likely contributed to displacement in my mind. #jhsjc
RyanC @RPCalfeeSTL:
I do believe age and comminution often predict the fracture losing alignment so the findings ring true #jhsjc
I agree with Goldfarb that cast and orthosis are not same. #jhsjc
Charles Goldfarb @Congenitalhand to @RPCalfeeSTL and @bgtalkingman:
Agree with risk factors but not that these become surgical indications on their own. #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
Do you have that feeling bc the decision is one shared with the pt? I’m asking more in the abstract. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
i think analyses/models not power or robust enough to consider other factors; and relying just on comminution as indication is potentially overdoing it #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
What about the combination of age (maybe a surrogate for osteoporosis?) and dorsal comminution? #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman: Certainly agree that this is shared decision. But also simply that a non displaced fracture might have a 30% displacement rate with age & comminution but might hold position w molded cast… #jhsjc
Charles Goldfarb @Congenitalhand to @theaviram:
Agreed! #jhsjc
Brent Graham @BgTalkinman to @theaviram:
As I asked @Congentialhand – how about the combination of the 2 main factors age and dorsal comminution? #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
What I’m getting at is that we recommend surgery when we can predict a bad result. Assuming that a loss of reduction (I know it’s just a radiographic finding) leads to a substantial risk of poor result, why not recommended surgery in that context? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
age gets tricky…>age and often settling/malunion less impactful, so making it an “indication” also perhaps misguided without stronger prediction on outcomes considering other factors #jhsjc
Brent Graham @BgTalkinman to @theaviram:
True! The CPG states” ““Strong evidence suggests that operative treatment for geriatric patients (most commonly defined in studies as 65 years of age and older) does not lead to improved long-term patient reported outcomes compared to non-operative treatment”. #jhsjc
RyanC @RPCalfeeSTL to @theaviram:
agree fully #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
I understand and agree. A 30% displacement rate in this population is too high to accept for me (even if older). So I agree. I guess my concern is that perhaps this is not real world if orthosis was used without molded cast. Not to nitpick but… #jhsjc
Brent Graham @BgTalkinman:
Given that #AAOS recommendation do the findings actually have any practical ramifications? #jhsjc
Rob Gray? @robgraymd to @RPCalfeeSTL and @theaviram:
The radiocarpal joint can take a joke. DRUJ—not so much. Just had a terrible osteotomy today in a young person bc RC “looked ok” #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
For me, the general rec of CPG makes sense. But patient centered care means involving patient in the decision and not all will accept deformity (at least in St Louis). #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
Understood! That’s why in the notes for this discussion I place it in the context of a patient who cares about the malunion. #jhsjc
Rob Gray? @robgraymd to @Congenitalhand and @BgTalkinman:
Deformity is in itself a form of disability. Like all disabilities, some are better able than others to cope. #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
That is a very good way of putting it! #jhsjc
Avi Giladi @theaviram to @robgraymd:
i see deformity as potential for impairment, while disability is all about the coping. and we are very bad at predicting disability #jhsjc
RyanC @RPCalfeeSTL to @robgraymd: very true about big differences in coping between people: appearance/pain/stiffness/surgical risk #jhsjc
Brent Graham @BgTalkinman:
Let’s move one to the other paper by Billig and Sears. Obviously I have some strong views on this one so I will be very interested in what others have to say. Here is a link to my editorial: https://www.jhandsurg.org/article/S0363-5023(21)00700-0/fulltext #JHSJC
Rob Gray @robgraymd to @theaviram:
But the problem is, so are the patients. I tell them that the straighter the bone, the better things tend to go, but some people can do very well with a very crooked wrist. #jhsjc
Avi Giladi @theaviram to @robgraymd:
Yes absolutely! patients maybe even worse than we are at anticipating how they will do, they have no real framework to go from…maybe the hardest part.
Brent Graham @BgTalkinman to @theaviram:
That’s why while shared decision-making is crucial, we have to give advice because we know the big picture. I understand that doesn’t apply to every person but this gives us a good basis for informing the conversation. #jhsjc
Brent Graham @BgTalkinman:
Let’s talk about the Billig/Sears paper. The response was only about 23%. Should the findings be considered generalizable? #jhsjc
Do the general findings reflect practice in your setting? Are #EDS obtained for the majority of #CTS cases regardless of the clinical findings? #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
I’m obviously biased bc I was in that basement in rosemont w you, but I think the response rate was v low and less generalizable than the CPGs themselves #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
I think generalizable. I (and our group and JC) were surprised by how many hand surgeons required #EDS prior to first office visit! #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
Ha! In the podcast the authors felt that the opinions of 800 hand surgeons from all around the country was representative. #jhsjc
RyanC @RPCalfeeSTL:
admittedly I get a good number of nerve tests to evaluate comorbid cubital, c spine, neuropathy #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
In fairness, the evidence seems to flip flop on several issues (vasc bone grafts, EDX, etc) and I think this frustrates people especially when lit runs counter to their experience #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
To me that just seems very expedient and something that puts the surgeon’s “efficiency” first. Personally I find that unacceptable. #jhsjc
Charles Goldfarb @Congenitalhand to @RPCalfeeSTL:
My younger population may have less co-morbidities– I obtain fewer. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I don’t necessarily see that as problematic because that is to identify additional diagnoses, not to confirm #CTS #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
I agree on the indication for pre- visit EDX being best for surgeon, not necessarily best for patient/ larger healthcare system. And agree – I do not believe in that approach. #jhsjc
Rob Gray @robgraymd to @BgTalkinman and @Congenitalhand: I wouldn’t mind it if test wasn’t painful and didn’t have a 22% false negative rate. #jhsjc
Charles Goldfarb @Congenitalhand to @robgraymd:
Agree on the pain issue (and I am not yet a convert to US). I did not realize 22% false negative. I quote around 10%. #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
Agreed! And it costs money and delays care. That has been shown. #jhsjc
Brent Graham @BgTalkinman:
Are any tests required for “confirmation” when the clinical evaluation is clear? More than 50% of respondents thought so? #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
Not for me except in workers compensation cases (and surgery often will not be approved without it). #jhsjc
Rob Gray @robgraymd to @Congenitalhand:
well #ultrasound is a game changer. Really helps with injections too. Patients like it. Honestly, if I’m having trouble figuring things out I find scratch collapse test is a great tie breaker. #jhsjc
Brent Graham @BgTalkinman:
This discussion might be among people of the same opinion. What do the general findings say about hand surgeons and evidence? The evidence for this approach to managing this common condition is clear! #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
I believe it emphasizes that things change SLOWLY. And that surgeons in particular are believers in processes that work for them, damn the evidence. Not ideal but, to me, reality. #jhsjc
Charles Goldfarb @Congenitalhand:
@robgraymd and @ChrisDyMD believes in US although still using EDX as well. Nice to hear it has been helpful for you. But the scratch collapse… I don’t buy it. #jhsjc
Rob Gray @robgraymd to @Congenitalhand and @ChrisDyMD: I’m telling you! 20% of the time it works every time! #jhsjc.
Charles Goldfarb @Congenitalhand to @robgraymd:
HaHa. #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
Fair question. I ignore the lit if I think it’s wrong. I stopped doing vascular bone grafts for scaphoids in the days lit found better union rates w them. I also ignored CtS CPG b4 ours that supported EDX. Now lit has caught up to me! #jhsjc
RyanC @RPCalfeeSTL:
I like the complementary structural (u/s) and physiologic (edx) data as add to our understanding in tough cases #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
I understand the reality but it greatly disappoints me. If this was how cancer was managed how would that look? #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
I think U/S has a lot of promise and it would be acceptable as a “confirmation” bc it adds very little cost, it doesn’t hurt and it is very accessible – that’s only going to increase in the future. #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
I hear you and agree. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
I am a low EDX user, and try to teach our fellows whenever I can that they often don’t need it (use u/s, exam, etc as discussed). but, in defense of those who continue to overuse it’s very difficult to dispute the medicolegal (although rare) issues and the efficiency challenges of modern US healthcare. the incentives are all wrong for this problem to gt better #jhsjc
Brent Graham @BgTalkinman:
When there are bundled payments and the insurers say “Here’s your money to manage this. If you want to spend it confirming an obvious diagnosis, go ahead. We’re not giving you more” #EDS will disappear pretty quickly. #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
In my opinion, all tests are really just confirmatory. Diagnosis is made on history in our business. #jhsjc.
Brent Graham @BgTalkinman:
Last thought: In Canada with a single payer, I can assure you that an insurer has never told me how to evaluate a patient. It’s really a ridiculous situation. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
yeah I think all of us agree on that! ridiculous indeed #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
That was what Sir William Osler said in the 19th century and in a field like hand surgery it is as true today as it was then. #jhsjc
Brent Graham @BgTalkinman:
Please feel free to join the conversation tomorrow at 3 pm EST. There will be some UK investigators attending with a strong interest in this area and I expect the discussion to be very interesting. Thanks for all of your insights! #jhsjc
Brent Graham @BgTalkinman:
Welcome to round 2 of our January 2022 session! Please use the hashtag so we can all see your comments. If you are using TwChat, the hashtag will be added automatically. Unfortunately there is no phone app for the chat app – just use Twitter #jhsjc
Brent Graham @BgTalkinman:
We are going to focus on the article by Billig/Sears. Here is a link to the podcast I did with Dr. Sears: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/january_2022.mp3 #jhsjc
I’ve also written an editorial on this paper: https://www.jhandsurg.org/article/S0363-5023(21)00700-0/fulltext #jhsjc
Brent Graham @BgTalkinman:
The paper reported the results of a survey of #ASSH members regarding diagnostic practices around #CTS and found some surprising attitudes with respect to how respondents approach diagnosis. #jhsjc
The response rate to the survey was just over 23%. Is that sufficient to consider the findings valid and generalizable? #jhsjc
Jane McEachan @jmceachan to @BgTalkinman:
Hard to say – 23% of all providers who claim to have an interest but actually may be a far higher proportion of surgeons who regularly undertake CTD – In private medicine in the UK many more surgeons do CTD than in the NHS #jhsjc
Brent Graham @BgTalkinman to @jmceachan:
When I asked Dr. Sears the same question in the podcast her response was that it represented the opinions of 800 surgeons from all over the US, so I find that reasonably convincing. #jhsjc
I also recognize that attitudes may be very different btw the US and UK … or maybe not. Do these findings resonate with UK/European hand surgeons? #jhsjc
Jane McEachan @jmceachan to @BgTalkinman:
I think far more surgeons in the UK do not use NCS – there is under provision and long waiting times which influence practice. #jhsjc
Brent Graham @BgTalkinman to @jmceachan:
How do those wait times affect whether #EDS #NCS are used? #jhsjc
Brent Graham @BgTalkinman:
A frequent reason given by US surgeons for using #EDS are insurance requirements for approval. Would that be true in the UK as well? #jhsjc
Han Hong ? @HanChong90:
My collaboration group recently conducted a similar survey in the UK, looking at variation in practise in the initial diagnosis of patients with suspected CTS, as well as assessing how NCS findings influence clinical decision making. #jhsjc
Jane McEachan @jmceachan to @BgTalkinman:
The guidelines in England state that all patients should have a steroid injection prior to referral – response to steroid has a high correlation with response to CTD. We do not have insurance companies insisting on NCS. #jhsjc
Brent Graham @BgTalkinman to @HanChong90:
Were the findings similar? If not, how did they differ? #jhsjc
Kunal Kulkarni @doktor_kk to @jmceachan and @BgTalkinman:
Well >50% respondents in our ELECTS survey reported to using NCS ‘often’ or ‘routinely’…but definitely regional/unit/training based variation #jhsjc
Brent Graham @BgTalkinman to @doktor_kk:
That is a similar proportion to what was found in this study. That was also approx the proportion who obtained #EDS even when given a case demonstrating a classic #CTS clinical presentation. #jhsjc
Han Hong ? @HanChong90:
In UK, the management of CTS are greatly influence by regional Clinical commissioning groups. A study conducted by Ryan et al 2017 suggested that there are wide variation at different centres. #jhsjc
https://publishing.rcseng.ac.uk/doi/10.1308/rcsbull.2017.28
Brent Graham @BgTalkinman:
Regional variations are always interesting although in the Billig/Sears study, the authors didn’t really feel there was regional variation. What is the role of “clinical;commissioning groups? #jhsjc
Kunal Kulkarni @doktor_kk to @BgTalkinman:
Essentially local groups that commission hospital and community NHS services for their local areas. Can mean different referral criteria for different regions: https://www.england.nhs.uk/ccgs/
Jane McEachan @jmceachan to @BgTalkinman and @doktor_kk:
Here in Fife we rely on NCS for all patients – we have developed a pathway where this is more cost-effective – highly experienced technician led service. I think local resources must be considered when deciding #jhsjc
Brent Graham @BgTalkinman to @jmceachan:
Ok, but aside from cost, the tests are painful and they have both false -ve and false +ve results. What do they add to a clinical evaluation? #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
CCGs are groups of GPs which come together in each area to commission the best services for their patients and population. They are responsible for about 60% of the NHS budget and commission most secondary care services. #jhsjc
Brent Graham @BgTalkinman to @HanChong90:
So do they function as gatekeepers? What expertise do they bring? On the surface that sounds even more problematic than trying to get surgeons to listen to guidelines based on evidence! #jhsjc
Jane McEachan @jmceachan to @BgTalkinman:
I think in straightforward cases there is no benefit! But we have around 800 referrals in to our service with CTS, and our pathway is cheap and efficient – so purely logistical for me! #jhsjc
Brent Graham @BgTalkinman to @jmceachan:
I find that interesting because in the Billig/Sears study there were 26% who said they got the tests before they saw the patients and that seems parallel to what you are describing. Doesn’t that make it seem more a service to doctors than patients? #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
in my own simpler way of describing, they decide how the local health services should run based on population requirement, and decide how much budget to provide per service. #jhsjc
Brent Graham @BgTalkinman to @jmceachan:
What if your referral system used a clinical basis for referral, like the CTS-6 for example. Wouldn’t that serve patients better and be even less expensive? That is what the #AAOS #CPF of 2016 suggested. #jhsj
Brent Graham @BgTalkinman to @HanChong90:
That must lead to a great deal of regional variation if they make those decisions based on considerations other than evidence. #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
in our collaborative survey, 6% clinician stated that new referrals from primary care with suspected CTS were always made after NCS; 64% stated ‘sometimes’. #jhsjc
Brent Graham @BgTalkinman to @HanChong90:
Was that subject too much regional variation? #jhsjc
Brent Graham @BgTalkinman:
In some ways, I’m more interested in the bigger question of how we disseminate evidence and, once disseminated, how it is used by hand surgeons. I don’t find the study makes me feel very optimistic on this issue. Thought for the UK/Europe? #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman
On the other hand, 91% of respondents never uses clinical questionnaire in CTS diagnosis according to our survey – the top reason given was diagnosis is sufficient based on clinical findings, followed by the availability of NCS #jhsjc
Brent Graham @BgTalkinman to @HanChong90:
Maybe we are talking about the same thing bc the CTS-6 is meant to model the clinical evaluation an expert would use and its output is a probability that the diagnosis is #CTS. It formalizes and quantifies the clinical eval. #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
I believe regional variation is due to multiple factors, as stated so far local CCG policy / budget, the availability of NCS, the quality of report etc… #jhsjc
Brent Graham @BgTalkinman:
Well #CTS is a very common condition. Isn’t the best way to contain costs to avoid #EDS for all but cases where there is uncertainty? #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
Regarding the use of questionnaire, interestingly from our survey where clinician use a questionnaire in diagnosis, CTS-6 were not mentioned. So I may not be able to comment on this. #jhsjc
Brent Graham @BgTalkinman:
In the US, the main driving forces seem to be insurance requirements (including workers’ compensation) and a focus on medico-legal considerations – in other words issues that are somewhat removed from the actual care of the patients. #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
Our UK Hand Society (BSSH) is in the process of formulating a pathway / guideline in CTS. I would echo that clinical diagnosis should be sufficient for diagnosing ‘typical’ CTS, and consider EDS in ‘atypical’ or ‘alternative’ diagnosis. #jhsjc
Brent Graham @BgTalkinman to @HanChong90:
Disclaimer! I developed the CTS-6, which has been validated and found to be reliable in level I studies. Obviously, I am biased but given the goal of the scale was to model what experts do, it seems another example of inadequately disseminated evidence. #jhsjc
Brent Graham @BgTalkinman to @HanChong90:
Good to hear! I would recommend that you check out the 2016 #AAOS clinical practice guideline (yet another disclaimer – I was chair of that) bc it provides a lot of good information to inform a process like that. http://orthoguidelines.org #jhsjc
Brent Graham @BgTalkinman:
Overall, I would conclude that we have a lot of work to do in disseminating evidence and convincing people to use it, not just in #CTS but throughout hand sx. I’m disappointed that we haven’t made more progress but there are many factors playing a role in that. #jhsjc
Han Hong ? @HanChong90 to @BgTalkinman:
strongly echo that #jhsjc
Kunal Kulkarni @doktor_kk:
Great Pulvertaft webinar by Prof Tim Davis on this topic – highlights his thoughts on the merits of steroid rather than NCS in most straightforward cases
Brent Graham @BgTalkinman to @doktor_kk and @jmceachan:
There is lots of evidence on steroid injections, including on its prognostic value, but is it any better – diagnostically – than a proper and knowledgeable clinical evaluation? #jhsjc
Brent Graham @BgTalkinman:
I am grateful to all of you for contributing to this great discussion! We return on February 8. Please feel free to contact me with comments and suggestions. You will be answered! bgraham@assh.org #jhsjc
