Our #JHSJC discussion for April was stimulating and we thank all who attended! We discussed the following two articles from Volume 47, Issue 4 of The Journal of Hand Surgery:
- Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial (https://www.jhandsurg.org/article/S0363-5023(21)00802-9/fulltext)
- Cost Assessment of Plating Versus Tension Band Wiring Constructs for Treating Mayo Type 2A Olecranon Fractures (https://www.jhandsurg.org/article/S0363-5023(21)00804-2/fulltext)
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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 #JHSJC! Be sure to use the JHSJC hashtag or the TwChat platform http://twchat.com/hashtag/jhsjc We will discuss two articles tonight. Let’s start with the article on flexor tendon rehab
RyanC @RPCalfeeSTL:
Looking forward to everyone’s thoughts on these articles #jhsjc
Brent Graham @BgTalkinman:
The study by Chvalley et al compared a standard #Kleinert approach to rehab with an active/place& hold prgm #jhsjc
The authors mention the imprecise definitions used in the literature for “early active motion”. Is there agreement that their active motion group corresponds to what most people think of that comprising? #jhsjc
4-strand repair using non-absorbable suture and epitendinous suture was their repair which seems reasonable. Thoughts? #jhsjc
RyanC @RPCalfeeSTL:
Our early motion does involve place and hold but increasingly some early active flexion in a comfortable arc. Not sure how much we need to push the envelope. I feel like some doing WALANT seem to be using more aggressive rehab #jhsjc
Warren @whammert to @BgTalkinman:
I think definitions are less clear as some consider place and hold active, but not truly active, so I like their description #jhsjc
RyanC @RPCalfeeSTL:
Repairs done seem reasonable – 4 Strand + epiT. #jhsjc
Warren @whammert:
I now use predominantly short arc active motion with half fist and no resistance #jhsjc
Warren @whammert to @RPCalfeeSTL:
I agree the repair is at least strong enough for active without resistance. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Agreed ! I think that was very clear. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Specifically they alternated passive with place and hold and then actual active flexion in a limited arc. Does that seem like “early active motion” #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
This is what I’ve used my entire career. It seems in most studies to be considered strong enough for early active motion. #jhsjc
Brent Graham @BgTalkinman:
There were a lot more ruptures than I would have thought – 3 in each group. The authors attributed tsat to the close supervision pts in an #RCT usually have. Thoughts? #jhsjc
The main concern with early active motion is rupture – in my experience that is a disaster. If the rupture rate is equal in the two groups (whatever the reason for that was) but the results were the same, is the risk of early active motion worthwhile? #jhsjc
Warren @whammert to @BgTalkinman:
I was surprised by the ruptures as well. They happen, but I am not sure why they would be more or less common in RCT #jhsjc
David Ring @DrDavidRing:
How is a rupture diagnosed? Poor outcome, reoperation, unravelled suture? #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing:
It’s a good question. They say that they were discovered at a routine follow-up or that the pts noted something and contacted the surgeons. There could be inaccuracies there. #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
Totally agree. In my practice, not worth the risk without clear benefit. #jhsjc
RyanC @RPCalfeeSTL:
agree also – rupture is disaster. #jhsjc
Charles Goldfarb @Congenitalhand to @whammert:
4 strand + epitendinous. For me, 2 more strands… #jhsjc
Brent Graham @BgTalkinman to @whammert:
I think they felt that the patients see doctors and therapy frequently , maybe more so than when not in a trial, so they were more closely supervised and therefore more likely to be noted. #jhsjc
David Ring @DrDavidRing:
I’m not sure I’ve exprienced a person doing well after flexor tendon repair who suddenly loses ground dramatically. And how else would you know? #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing:
Agreed. I don’t think they describe exactly when they occurred. #jhsjc
To be honest, I’m guessing but I had the impression these were people in the early stages #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
It is the reason I haven’t moved to early active motion. Most of the studies haven’t been large enough to perhaps identify a meaningful rupture rate. They may be infrequent but disastrous. They might not be noted in a most small RCTs. #jhsjc
Charles Goldfarb @Congenitalhand to @BgTalkinman:
agreed but so many talk about using an active motion protocol. I don’t recall surveys describing relative preferences. #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
There have been RCTs that seem to show better motion but they haven’t been large enough to identify a true rupture rate – they usually don’t report ANY rupture and that cannot be true. #jhsjc
Those RCTs seem to have been influential even if they are probably not truly level I evidence. That is what I find interesting about this study – it doesn;t show a clear advantage so I would opt for the safer option. #jhsjc
Warren @whammert to @BgTalkinman:
This is where one could make the argument for doing repair under straight local to be sure there is not catching at the pulley or gapping #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree that this is one area where #WALANT may be an important consideration. #jhsjc
Brent Graham @BgTalkinman:
The risks are: early active motion – rupture; passive motion – adhesions. Which is best? #jhsjc
… or do we know? #jhsjc
RyanC @RPCalfeeSTL:
I don’t think we know. Certainly some variable rehab for me based on injury/repair quality and how stiff or mobile people seem during follow up #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Yes! I have always been more cautious in those with great flexibility. They seem like limited scar formers and also at low risk for adhesions so I feel comfortable with passive motion. #jhsjc
Warren @whammert to @BgTalkinman:
If my surgeon was confident in the repair – I would use active motion on my hand #jhsjc
Brent Graham @BgTalkinman:
Lets’s move on to the other study – costs of ORIF of Mayo2A #olecranon fractures. https://t.co/IXw28Duz65; https://t.co/NzqqsG2wvO #jhsjc
The focus was just on direct costs alone. The question was essentially if the extra expense associated with plate/screws ORIF is justified by a lower rate of needing a 2nd procedure for implant removal. #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @RPCalfeeSTL:
hard to account for all of those situational “variations” even in a nicely designed study like this one. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Agreed. Its efficacy vs effectiveness but still compelling as an essentially negative results study. #jhsjc
Brent Graham @BgTalkinman:
The premise of the costing study was that the results of the two strategies for internal fixation were equivalent. Does everyone agree that is true? #jhsjc
Warren @whammert to @BgTalkinman:
From a cost stand point, hard to justify the plates, but I don’t think this will change behavior/ surgical decisions #jhsjc
Brent Graham @BgTalkinman to @whammert:
Why not? In my era of training all of these cases were treated with tension band wiring. #jhsjc
Warren @whammert to @BgTalkinman:
Tension bands clearly work, but are not as sexy , not AO, and just my opinion that hard to convince many to make a change. #jhsjc
Brent Graham @BgTalkinman to @whammert:
It is this recurring theme that we seem to arrive at almost every time we discuss this in this venue. Why ignore the evidence? It WILL change once there is bundled payments. #jhsjc
Warren @whammert to @BgTalkinman:
I agree bundled payments can make a difference – but hospitals and physicians have to be more aligned and to this point, not many are. #jhsjc
Warren @whammert:
Also, seems to be more interest in changing based on TV commercial and company marketing than a RCT – unfortunately #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree and it’s a shame that it takes a dramatic change like bundled payments to get people to practice according to evidence but I guess it has something to do with human nature. #jhsjc
Brent Graham @BgTalkinman:
It wasn’t a part of their costing analysis but they noted that the removal rate was actually the same for both groups. Is that the experience of people here? #jhsjc
RyanC @RPCalfeeSTL:
I don’t get a lot of these. I certainly have removed both tension bands and plates for discomfort. #jhsjc
Brent Graham @BgTalkinman:
How convincing was their sensitivity analysis where they assumed ALL the tension bands were removed and NONE of the plates were? #jhsjc
Brent Graham @BgTalkinman:
Is it likely that the results would have been materially different had out of pocket expenses been considered? #jhsjc
I’m getting at patient expenses like time off work etc. #jhsjc
Warren @whammert to @BgTalkinman:
I think it would need to be w direct expense out of patients pocket and even then, likely dependent on how MD presents options #jhsjc
Brent Graham @BgTalkinman to @whammert:
I’m sure that is true. #jhsjc
Brent Graham @BgTalkinman:
In the podcast, I discussed the subject of surgeon reimbursement for the two procedures with Dr. Kazmers, and he indicated that, being based on CPT code, it should be the same. Is that true in your institutions? #jhsjc
Warren @whammert to @BgTalkinman:
That should be the same throughout the US for surgical billing – based on code for ORIF regardless of what is used. Different on the surgery center side for expenses #jhsjc
Brent Graham @BgTalkinman to @whammert:
Is there a conflict of interest there for surgeon owners of surgical centers? #jhsjc
RyanC @RPCalfeeSTL to @whammert:
agreed. I believe just code for ORIF olecranon. #jhsjc
Avi Giladi @theaviram to @whammert and @bgtalkinman:
the reimbursement being the same makes this study more impactful, as opposed to the trapeziectomy/LRTI debate or others in hand surgery where $$ to surgeons varies #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I admit that makes me feel better – to know that there is no risk that the focus on plates has any link to surgeon reimbursement. #jhsjc
Warren @whammert to @BgTalkinman:
Only conflict is they now share in expense and profit, so better for the to keep costs down – ie tension band #jhsjc
Brent Graham @BgTalkinman to @whammert:
Good insight! Thanks for clarifying! #jhsjc
Brent Graham @BgTalkinman:
Maybe that is a good note on which to conclude. As usual, thanks to all who contributed to another stimulating discussion! We are back tomorrow 4 pm EDT and then May 9/10. #jhsjc
Brent Graham @BgTalkinman:
Welcome to April JHSJC round 2! #jhsjc
Ryckie Wade @ryckiewade:
Hello all & welcome to the eurozone JHS journal club! Be sure to use #JHSJC or the TwChat platform
Today, we are discussing Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial https://doi.org/10.1016/j.jhsa.2021.11.031 #jhsjc
Brent Graham @BgTalkinman:
I am currently in a car driving on the highway in rural Ontario which may limit my communication. @ryckiewade is here to co-host. #jhsjc
Let’s start with the methods. This was a well-performed RCT – level I evidence. The paper talks about the definition of “early active motion” how does their definition correspond to how all of you think of that? #jhsjc
Ryckie Wade @ryckiewade:
Is anyone in the UK / Europe NOT using early active mobilisation after flexor tendon repair????? Recently published work suggests that across the pond (in the UK at least), we are all early active movers… https://doi.org/10.1177/17589983221089654 #jhsjc
Brent Graham @BgTalkinman to @ryckiewade:
I think it has been broadly adopted in North America, although I haven’t been an advocate personally. #jhsjc
Brent Graham @BgTalkinman:
Is place-and-hold with alternating active flexion within the confines of a splint qualify as early active motion? #jhsjc
Ryckie Wade @ryckiewade:
Echo that @BgTalkinman – this is a nicely designed and executed RCT. We need more of these in hand surgery. I was surprised to see (based on seemingly adequate power for the primary analysis) no meaningful objective differences between groups ? #jhsjc
Brent Graham @BgTalkinman:
Most participants in the N Amer discussion felt this was a satisfactory approach to early active motion. #jhsjc
Does the loss of patients make a notable difference in the power of the study sample given that most of the findings showed no difference btw the groups? #jhsjc
Ryckie Wade @ryckiewade to @BgTalkinman:
It doesn’t look like they inflated the planned sample for expected attrition? Equally, I was pleasantly surprised to see so only 2/64 drop out! @StirlingOrtho how good is this retention rate for a hand trauma trial!? #jhsjc
Brent Graham @BgTalkinman:
As I see it, the main risk/concern with early active motion is rupture. If the results are the same as with a more conservative approach to rehab, is that a necessary risk? #jhsjc
Brent Graham @BgTalkinman to @ryckiewade:
I agree that they didn’t add to the sample but the results were so similar that even if the sample is underpowered, I can’t see that there would be qualitative differences even fully powered. Thoughts? #jhsjc
Brent Graham @BgTalkinman:
I found the rupture rate to be higher than I would have expected. Did anyone else find that surprising? #jhsjc
The authors attributed that to the close supervision pts in an RCT receive. I find that a reasonable explanation. Thoughts? #jhsjc
Was the method of tendon repair – 4-strand non-absorbable suture with epitendinous repair – generalizable? #jhsjc
Ryckie Wade @ryckiewade to @BgTalkinman:
100% echo this – a well described phenomena that prospective studies capture higher prevalence of adverse events / complications than retrospective / otherwise! Blowing the RCT trumpet #jhsjc
Brent Graham @BgTalkinman to @ryckiewade:
Exactly! I agree. In this instance I expect that the rupture rate is probably accurate and actually underestimated in non-RCT studies. #jhsjc
Brent Graham @BgTalkinman:
Any thoughts from others about the meaning or importance of this study? #jhsjc
Well, I will say this: I am persuaded that early active motion may not be neccesary because this study shows that the results may be no better than a more conservative approach that is safer. Agree or not? #jhsjc
and I will add that I think the risk of rupture via poor patient compliance is greater for early active motion. #jhsjc
Paul Stirling @StirlingOrtho to @ryckiewade and @BgTalkinman:
Anecdotally this is surprisingly low but in reality the majority of recent reports in recent years have had rates <10% #jhsjc
