Thank you to everyone near and far who joined in for the #JHSJC event this month! The first article we discussed was “Five-Year Results of a Randomized, Controlled Trial of Collagenase Treatment Compared With Needle Fasciotomy for Dupuytren Contracture” (https://www.jhandsurg.org/article/S0363-5023(21)00761-9/fulltext) and the second was “Outcome of Simple Decompression of Primary Cubital Tunnel Syndrome Based on Patient-Reported Outcome Measurements” (https://www.jhandsurg.org/article/S0363-5023(21)00763-2/fulltext).
As a reminder, we are now using a new platform for our events, 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:
Welcome to the March discussion! #jhsjc
Let’s start with the lead article by Bystrom et al:https://www.jhandsurg.org/article/S0363-5023(21)00761-9/fulltext
RyanC @RPCalfeeSTL:
Looking forward to everyone’s thoughts today #jhsjc
Brent Graham @BgTalkinman:
This is a follow-up from an earlier report on the one year results that appeared in JHS in 2016. These are the 5-year results. #jhsjc
This is a link to the earlier study: https://www.jhandsurg.org/article/S0363-5023(16)30239-8/fulltext; this one has already been cited 46 times! #jhsjc
RyanC @RPCalfeeSTL:
Similar outcomes make sense as both treatments essentially break cord in small areas without disease removal #jhsjc
Brent Graham @BgTalkinman:
In this one they were able to follow-up with almost all patients – 92% – and the overall results mirror those of the earlier study: recurrence rate of 56% for #CCH and 45% for #needle fasciotomy. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Right! That is my first question re: recurrence vs disease extension. I find that continually problematic in these studies. Was that clearly defined in this study? #jhsjc
These figures for recurrence – 56% #CCH and 45% #needlefasciotomy – only considered those who hadn’t already undergone some additional treatment, which was another 27 patients. That suggests that the overall recurrence is even higher. #jhsjc
RyanC @RPCalfeeSTL:
Probably hard to know. I certainly use term “recurrence” in digits that correct and then get contracted again. #jhsjc
Warren @whammert:
These results are expected based on what we know. But the MP contracture here the easiest to treat and essentially we are using a surgical procedure for a medical problem (no cure) #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I agree – in other words not for “new” disease that has extended into a new area, correct? #jhsjc
RyanC @RPCalfeeSTL:
Recurrence probably higher as you say. But for quick in office procedure with immediate change in contracture and rare risks still a patient favorite. I only have experience with needle releases. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
Correct. not for new disease or in new fingers #jhsjc
Brent Graham @BgTalkinman:
I think that is a very important distinction because actual “recurrence” after surgical excision is much less common. #jhsjc
RyanC @RPCalfeeSTL to @whammert:
Agree. Really need something to change genetics or cells in tissue like biologic medications changing rheumatoid arthritis #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Agreed that patients may choose this but when the cost is much, much higher – #CCH is even more expensive than surgery in a 5-year time horizon (https://jhandsurg.org/article/S0363-5023(18)31491-6/fulltext) is it justified? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I have no CCH experience. Just talking from needle release perspective #jhsjc
Warren @whammert to @RPCalfeeSTL:
Someday, but D doesn’t end life – it just affects it so hard to get funding to find a cure #jhsjc
RyanC @RPCalfeeSTL to @whammert:
good point. #jhsjc
Brent Graham @BgTalkinman:
I’ve recently learned that #CCH was taken off the market in Europe and Australia – by the manufacturer and not for safety concerns. What is the future of this treatment in North America? #jhsjc
And #CCH has never been covered by provincial insurance in Ontario. Will it still be used in the US if it becomes something patients must pay for? #jhsjc
Warren @whammert to @BgTalkinman:
I think it has been off for a while – just not sure the cost can be justified with similar results and less costly options – value based health care #jhsjc
Brent Graham @BgTalkinman to @whammert:
That’s just my point and yet we have studies still showing its use to be growing in US. #jhsjc
RyanC @RPCalfeeSTL:
I find that as soon as something costs more out of pocket patients don’t favor that option #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I agree – like many other things. I would say that’s definitely in the near future. #jhsjc
Warren @whammert to @RPCalfeeSTL:
The push is insurance will cover it – marketing from the company – it works, but doesn’t appear better than the cheaper alternative. #jhsjc
Warren @whammert to @RPCalfeeSTL:
I think there are patients that would pay if clearly better – that is the issue #jhsjc
RyanC @RPCalfeeSTL to @whammert:
True. similar results then people choose less expensive option #jhsjc
Brent Graham @BgTalkinman:
How much does #CCH cost? A needle is about $0.05. #jhsjc
Warren @whammert to @BgTalkinman:
Approximately $3400 per vial (or possibly more now) #jhsjc
Avi Giladi @theaviram to @whammert:
I worry there will be some that develop relationships with industry and then “sell” it like so many other questionably beneficial treatments #jhsjc
Warren @whammert to @theaviram:
Yes, there will always be COI and this is often not apparent #jhsjc
Brent Graham @BgTalkinman to @theaviram:
That is why we publish these studies! #jhsjc
Warren @whammert to @BgTalkinman:
I think this is helpful in discussing wiht patients expectations following surgery #jhsjc
Brent Graham @BgTalkinman:
I guess my conclusion is that both have poor results, even after 1 year and one costs hundreds, if not thousands of times more than the other. The elephant in the room is that #surgery costs less than #CCH after 5 years and is much more effective. #jhsjc
Seemingly we are all – those of us here right now – on the same page about this. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other study by Mendelaar and the #handwriststudygroup. #jhsjc
This was a retrospective study that asked an important question: Does pre-op symptom #cubitaltunnelsyndrome severity effect the result of #simpledecompression? #jhsjc
From a methodologic standpoint, the main outcome was the #BCTQ. Is that valid for #cubitaltunnelsyndrome? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I think BCTQ reasonable for cubital tunnel as captures same sort of nerve symptoms as CTS #jhsjc
Warren @whammert to @BgTalkinman:
I think it is reasonable – similar to PRUNE and although not designed for ulnar nerve, helpful #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree! I think that is the most important message of the study. #jhsjc
Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
I agree, I can’t remember if there have been studies that actually validate it. I think there have been but I can’t seem to find any. It makes sense that it would be about equally effective for this as for #CTS. #jhsjc
Warren @whammert to @BgTalkinman:
I don’t know if validated, but used in a lot of studies previously #jhsjc
Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
The concern I have is that 8/11 questions on the #BCTQ symptom subscale are about a sensory disturbance or “pain”. If those with mild symptoms often do not show improvement on that scale – that’s what the study shows, what should be told to those patients? #jhsjc
Should this be interpreted as this small surgery being not indicated for patients with mild symptoms, given that they are not likely to note improvement? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
When you start with mild symptoms obviously less room to improve but some patients still feel worth it #jhsjc
Warren @whammert to @BgTalkinman:
I was not as concerned about the using BCTQ, but harder for me to feel good about the satisfaction question. #jhsjc
Brent Graham @BgTalkinman to @whammert:
We do not usually permit reports of satisfaction unless they are using a valid, reliable scale. They referenced a recent article showing those properties. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
This is a conundrum for me – is the finding a reflection of an insensitive measure? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
Not necessarily insensitive measure. Just some get surgery for mild symptoms that won’t change on any scale – eg cubital release for bothersome paresthesia #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Do you tell them to expect that? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I warn everyone that i can make environment better for the nerve but we will have to see if their body can heal it. With mild symptoms I try to talk out of surgery given risks #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That seems a fair and measured approach. #jhsjc
Warren @whammert to @BgTalkinman:
I have not read it, but published last year in CORR – but asked the question how satisfied are you. I wonder about the test retest reliability. #jhsjc
Brent Graham @BgTalkinman to @whammert:
I believe it also showed good reliability but like you, I haven’t read it myself. #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @RPCalfeeSTL:
We havent realiably figured how to handle the relationship between pre and postintervention data. the “room to move” issue often comes up. But perhaps very “bad” pre scores reflect more than just hand pathology too #jhsjc
Brent Graham @BgTalkinman to @theaviram:
That is possible and I agree that the “headroom” issue with improvement, ie room to improve, is tricky. That comes up with #nihPROMIS UE, where there is a clear ceiling effect as well. #jhsjc
Brent Graham @BgTalkinman:
The good news seems to be that whatever it is the procedure does – whether it is measured by #BCTQ or not – pts are satisfied with the result. #jhsjc
Brent Graham @BgTalkinman:
If both pts with mild or severe symptoms find the procedure helpful, what is the role for procedures like ulnar nerve transposition? Does that have role for primary rx of #cubitaltunnelsyndrome in 2022? #jhsjc
Warren @whammert to @BgTalkinman:
What we don’t know is whether they would have improved more with transposition. So the debate continues #jhsjc
Brent Graham @BgTalkinman to @whammert:
This is a personal opinion although it is based on a decision analysis I did decades ago (https://journals.sagepub.com/doi/abs/10.1016/j.jhse.2007.07.001), simple decompression is so small a procedure, that even if it doesn’t work it no bridges are burned. #jhsjc
Brent Graham @BgTalkinman:
Terrific discussion on two important topics! Thanks to all for participating! There is another session tomorrow with our Eurozone colleagues 3 pm EST. We return here April 12, 9 pm EST. #jhsjc
Brent Graham @BgTalkinman:
Welcome to the March JHSJC, Eurozone edition! #jhsjc
We are discussing the article by Mendelaaer and the Hand-Wrist Study Group. https://t.co/4NpcLXB4Cq #jhsjc
There was a very good discussion of this article in the session last night. That can be seen using the #jhsjc hashtag
Although a retrospective study, the authors asked an important question regarding whether pre-treatment status was an important factor in post-treatment outcome and satisfaction with that outcome. #jhsjc
Ryckie Wade @ryckiewade:
Welcome to #jhsjc Eurozone – thanks for hosting @BgTalkinman! what type of #CuTR should be done for primary disease – a scalding hot topic in the UK at the moment! @dominicpower1 & @ruudselles: are you live in the Twittersphere and ready?
Brent Graham @BgTalkinman to @ryckiewade, @dominicpower1, and @ruudselles:
Use the TwChat platform or the #jhsjc hashtag!!
Brent Graham @BgTalkinman:
The main outcome measure was the #BCTQ. That is a scale developed as a status instrument for #CTS. Is this a valid use – i.e., in a different, although similar, condition? #jhsjc
Ruud Selles @ruudselles:
I am here, also with @nmendelaar, the first author. We enjoyed reading the discussion taking place last night when we were asleep 🙂 #jhsjc
Brent Graham @BgTalkinman to @ruudselles:
Great! Hopefully we can touch on some of the points raised then. #jhsjc
Dominic Power @dominicpower1:
Thanks for selecting this article. Does this change our approach to patient selection. All may benefit but should we preferentially treat those who will benefit the most? Is there a difference with procedure type? #jhsjc
Ruud Selles @ruudselles:
We decided on the BCTQ a long time ago. Since we collect PROMS from all patient data, we feel it is unfeasible to use too many different PROMS. And our idea is that the BCTQ is as good as any as we know of for cubital tunnel #jhsjc
Brent Graham @BgTalkinman to @dominicpower1:
This is an important point for discussion if pts with mild symptoms didn’t seem to improve but were still satisfied. I’m not sure what that means. @ruudselles and @nmedelaar is that related to #BCTQ being an insensitive or unresponsive measure? #jhsjc
Ruud Selles @ruudselles to @BgTalkinman and @dominicpower1:
I agree this is striking and interesting. There might be several reasons for this. We see this pattern in many of our outcomes: the most severe patients improve most but, on average, still have the poorest function on follow-up. #JHSJC
Brent Graham @BgTalkinman to @ruudselles:
Why not use a scale like #BCTQ but specifically for cubital tunnel syndrome, like #PRUNE? #jhsjc
Ruud Selles @ruudselles:
the ICHOM Hand And wrist set recommends the BTCQ for all nerve decompressions #jhsjc
Brent Graham @BgTalkinman to @ruudselles:
Understood. Has it been validated for use in all nerve compression conditions? #jhsjc
Brent Graham @BgTalkinman to @ruudselles:
There appeared to general agreement during last night’s discussion that #BCTQ was satisfactory but I wonder if limited responsiveness explains the observations made in the group with mild symptoms. Thoughts? #jhsjc
nienke mendelaar @NMendelaar:
Also, previous studies (Zimmerman et al. 2009, Song et al. 2013) stated that the BCTQ demonstrated strong validity, originating from a correlation with functional outcomes and a high responsiveness over time for cubital tunnel syndrome. #jhsjc
Dominic Power @dominicpower1:
The PRUNE hasn’t been around as long and fewer publications. The BCTQ is the workhorse of nerve compression outcomes assessment. #jhsjc
Brent Graham @BgTalkinman to @NMendelaar:
Okay! That helps! What are your thoughts about its responsiveness? Theoretically it is a status measure, not really an outcome measure as that is usually thought of. Is that important? #jhsjc
Ruud Selles @ruudselles to @BgTalkinman and @NMendelaar:
We are not quite sure what you mean. Aren’t PROMS commonly status measures? Asking about symptoms at this moment? And then you follow them over time
Brent Graham @BgTalkinman to @ruudselles and @NMendelaar:
That is correct but while that is similar to an “outcome”, it isn’t the same. The idea of a disease status scale is used in many other fields of medicine where “outcome” might not be measured. #jhsjc
Brent Graham @BgTalkinman to @dominicpower1:
Understood, but the concern here is responsiveness bc the finding of good satisfaction for a procedure where the main measure, the symptom severity component of the BCTQ didn’t change, seems somewhat incongruous. #jhsjc
Brent Graham @BgTalkinman to @ruudselles:
I think that is more easily understood as having more room for improvement even if a large amount of improvement still results in an outcome substantially less than “normal”. #jhsjc
Ruud Selles @ruudselles to @BgTalkinman:
I agree. It relates to the concepts of minimal clinical important difference (MCID) as something to achieve or the Patient Acceptable Symptom State (PASS) as something to achieve #jhsjc
Dominic Power @dominicpower1:
Comes back to my earlier point …. what should be the threshold of acceptability to determine stop/go on surgery. #jhsjc
Brent Graham @BgTalkinman:
The most common presentation of cubital tunnel syndrome is a sensory symptom and 8/11 items on the BCTQ symptom subscale are about “pain” or a sensory disturbance. It is hard to understand what the pts are satisfied with if that doesn’t change! Thoughts? #jhsjc
Brent Graham @BgTalkinman to @dominicpower1:
What should pts with mild symptoms be told based on these observations? #jhsjc
Brent Graham @BgTalkinman to @ruudselles:
Agreed, although I think of MCID as a measure of “noise” in the scale. An emerging (in hand surgery) concept you will be reading more about in @JHandSurg soon is “substantial clinical benefit”. #jhsjc
Ruud Selles @ruudselles to @BgTalkinman:
That sounds interesting. MCID should ideally be based on the change needed for patients to report satisfactory outcomes, not based on the test-retest reliability of an instrument #jhsjc
Dominic Power @dominicpower1 to @BgTalkinman:
The results can be used to frame the consent discussion. Non-operative measures I find of limited acceptability to patients – do we need better ones? Hard to not operate for the idividual with intrusive symptoms when the evidence demonstrates some benefit. #jhsjc
Brent Graham @BgTalkinman to @ruudselles and @NMendelaar:
The general assumption is that a change in status represents an “outcome” in the setting where treatment has been administered but there can also be spontaneous changes, especially in cubital tunnel syndrome. #jhsjc
Dominic Power @dominicpower1 to @BgTalkinman:
Who is to determine whether an improvement is substantial? #jhsjc
Brent Graham @BgTalkinman to @dominicpower1:
I completely agree – and I think simple decompression is very effective, but on the basis of these findings what do you tell a pt to expect? This is where the idea of BCTQ responsiveness is important. It doesn’t seem to measure the satisfaction pts report. #jhsjc
Ruud Selles @ruudselles:
I feel that in many outcome studies in hand surgery the differences in the response of patients to treatment are not given enough attention. So often you see a mean and an SE or SD but little more than that. Heterogeneity is almost always huge #jhsjc
Brent Graham @BgTalkinman to @ruudselles:
I agree. I think that is why we will see a move away from MCID (except for estimating sample size) toward an idea of “substantial clinical benefit”. #jhsjc
Ruud Selles @ruudselles to @BgTalkinman:
Agree; There is a lot to be learned there. There is also a trend to plot more individual patient data. That also helps. Not only averaging and counting the number of patients above and below some threshold
Brent Graham @BgTalkinman to @dominicpower1:
It can be done using anchor question-based methods, just like are used for establishing the MCID. There will papers coming out in #JHandSurg in the next few months showing that. #jhsjc
Brent Graham @BgTalkinman:
Whatever it is that the pts like about being treated for cubital tunnel syndrome using simple decompression, is there any role for ulnar nerve transposition as a primary treatment of that condition in 2022? #jhsjc
hank holliger GC4 Diva @HHolliger to @BgTalkinman:
Symptomatic subluxation
Mr Andy Hacker @BucksHandExpert to @BgTalkinman:
Only if they are unstable on presentation…. Otherwise, simple in situ decompression
nienke mendelaar @NMendelaar to @BgTalkinman:
I do not think that the results of our study can provide a definitive answer about whether or not to use ulnar transposition. This is because we excluded these patients; these patients may have even worse pre-op symptom severity. #JHSJC
Brent Graham @BgTalkinman @NMendelaar:
That is very reasonable. My sense is that there is a strong move away from ulnar nerve transposition in North America, a move I think is very justified personally. #jhsjc
Ruud Selles @ruudselles:
of course, we need to realize that we have no control group; who would dare something placebo-controlled? #jhsjc
Dominic Power @dominicpower1 to @BgTalkinman:
in my practice …no. @ryckiewade has shown in his network systematic review the risk profile is unacceptable. Are there better options in selected cases such as medial epicondylectomy or should simple decompression suffice for all, irrespective of stability? #jhsjc
Ryckie Wade @ryckiewade to @dominicpower1 and @BgTalkinman:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773396 future research should focus on the potential gains of endoscopic surgery and epicondylectomy, which appear to carry little (any?) additional risk #jhsjc
Dominic Power @dominicpower1 to @ryckiewade and @BgTalkinman:
A great paper and beautifully presented data!
Ruud Selles @ruudselles:
We have some transposition data in our sample but few. We might try to dive into it and do some comparison but there might be too many confounders for a fair comparison #jhsjc
Brent Graham @BgTalkinman to @dominicpower1:
I agree and it has been my longstanding belief that simple decompression is the starting point regardless of the clinical findings. That was the conclusion of an article I wrote in JHS(Eur) 15 years ago https://journals.sagepub.com/doi/full/10.1016/J.JHSE.2007.07.001 #jhsjc
Dominic Power @dominicpower1 to @ruudselles:
No problem with a construct where mild cases are randomised to SD/non-operative management. Similar was used in CTS with injection versus surgery but the attrition and cross-over was so high that the pilot study didn’t need to be extended to full RCT (INDICATE) #jhsjc
Brent Graham @BgTalkinman to @dominicpower1 and @ruudselles:
I agree that the comparator doesn’t have to be a placebo bc that is unlikely to be accepted by most ethics boards. In part that is bc the evidence that SD is effective is continually growing. #jhsjc
Brent Graham @BgTalkinman:
To summarize, how should a reader use this information to talk to a pt who has persistent but mild sensory symptoms and who has failed non-op treatment? #jhsjc
nienke mendelaar @NMendelaar:
The message for patients with mild complaints would be that there can be no guarantee that all symptoms will disappear, but that improvement does occur and patients have often reported being satisfied with this. #JHSJC
Dominic Power @dominicpower1 to @BgTalkinman:
If you want to wait until you have more severe symptoms then your satisfaction will be greater because you are starting from a worse position! BUT not all patients with severe symptoms and functional impairment return to baseline. #jhsjc
Ruud Selles @ruudselles:
Great to have your input and ideas on this study! #jhsjc
Brent Graham @BgTalkinman to @dominicpower1:
I wholeheartedly agree – and that’s why I would advise pts with mild symptoms that are persistent to have a SD and I will assume that they will do better than what might be predicted by the BCTQ isn aggregate of pts. #jhsjc
Dominic Power @dominicpower1 to @BgTalkinman and @NMendelaar:
Agree – however we are assuming that mild symptoms are best treated with SD alone – there may be a subgroup where ME confers advantages ~(detensioning / instability of the UN). Future study design? #jhsjc
Dominic Power @dominicpower1 to @BgTalkinman:
Thanks for selecting our paper. At least 3 new studies needed for further exploration! #jhsjc
Brent Graham @BgTalkinman:
Thanks to all for a truly stimulating discussion!
