May #JHSJC Transcript

For the May JHS event, we discussed an article titled “Magnitude, Direction, Temporal Patterns, and Frequency of Loss of Distal Radius Fracture Reduction in Women 50 Years and Older.” We also looked at at a second article titled “Cost-Utility Analysis of Thumb Carpometacarpal Resection Arthroplasty: A Health Economic Study Using Real-World Data.” We thank everyone who joined us for the conversation! We’ll have one more #JHSJC event before taking a short break for the summer.

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 May discussion! #jhsjc
Let’s start with our lead article on radiographic changes after non-op treatment of distal radius fracture #DRF #jhsjc
Please be sure to use the “jhsjc’ hashtag. #jhsjc

Brent Graham @BgTalkinman:
This was a study based on registry data including over 1100 women over 50 yrs old who were treated with cast immobilization. #DRF #jhsjc
The authors carefully followed the patients with standard radiographs 1, 2, 3, 6, 9, and 12 weeks after reduction and monitored for changes in the various indices thought to be important indicators of unacceptable reduction loss. #jhsjc
90% of patients had some loss of reduction including 50% in whom that loss was considered clinically relevant. Most of the changes occurred in the 1st 3 weeks after reduction. #jhsjc
The changes correlated with age and osteoporosis but not with bone mineral density overall. #jhsjc
Was the sample used in the study representative of the population in which this kind of non-operative treatment would be considered appropriate? In other words, should the findings be considered generalizable? #jhsjc
With the increasing trend in recent years of #ORIF as a frequent treatment for #DRF, we do not often see this kind of data relating to non-op treatment. #jhsjc

Rob Gray @robgraymd to @BgTalkinman:
Loaded Q. I think this is who often gets these injuries and therefore Nonop tx, but as the results show, I think they should get more operations if we think that alignment matters. #JHSJC

Brent Graham @BgTalkinman to @robgraymd:
It’s notable that the study wasn’t about treatment outcomes and obviously that is important but their findings definitely confirm my own bias and experience that small amounts of displacement that might be considered clinically relevant may not matter much. #jhsjc

Rob Gray @robgraymd to @BgTalkinman:
It’s a difficult issue. Is alignment a surrogate marker for a good outcome or is it the outcome in and of itself? No surrogate has 100% concordance, but I don’t think it can be ignored, esp in the absence of a better marker #jhsjc

Dafang Zhang @DafangZhang:
great point re generalizability, and important to note that patients who underwent operative treatment were excluded, which adds some selection to this cohort #jhsjc

Brent Graham @BgTalkinman to @DafangZhang:
Do you think that the sample that was included is representative of patients who incur this kind of fracture? #jhsjc

Dafang Zhang @DafangZhang to @BgTalkinMan:
I do ?, the caveat being that those pts with severe enough DRF to warrant surgery were selected out. I think it’s a useful study on risk factors for displacement when treating with casting #jhsjc

Brent Graham @BgTalkinman to @DafangZhang:
This is what I’m getting at because there seems little doubt that there are fractures that could be managed non-operatively who undergo #ORIF #jhsjc

Brent Graham @BgTalkinman @robgraymd:
I agree but there seem to have been a number of studies that show little correlation btw clinical results and radiographic outcomes suggesting that this kind of displacement is common maybe under measured in many instances. I’m not sure whether it really matters #jhsjc

Rob Gray @robgraymd to @BgTalkinman:
But does that mean there isn’t a difference, or our tools aren’t sophisticated enough to pick it up? Level 17 evidence, but I have had several patients wish they had done ORIF. I have had one who wished they had done Nonop. #jhsjc

Brent Graham @BgTalkinman:
The findings also seemed to show that not much displacement occurs after 3 weeks, suggesting that might be enough. Given that avoiding stiffness is often stated as a justification for #ORIF is the problem just that non-op treatment is continued for too long? #jhsjc

Brent Graham @BgTalkinman to @robgraymd:
No, I agree that there could still be a difference but the evidence for #ORIF under these circumstances isn’t very convincing. And there are some poor results with #ORIF, including stiffness. #jhsjc

Rob Gray? @robgraymd to @BgTalkinman:
I think this is a v interesting q. Orif has major advantages of improved alignment, faster mobilization, better early ROM. If we only casted 3w, I think it narrows the gap. I also think more would fall off, but I hope someone does the study! #jhsjc

Brent Graham @BgTalkinman to @robgraymd:
For what little it’s worth, my practice has always been to immobilize this kind of fx 3 wks and then begin movement with protective splinting for 3 wks. I haven’t specifically studied but I don’t think there have been many probs with that. #jhsjc

Rob Gray? @robgraymd to @BgTalkinman:
I think the problems often cited w ORIF come from low-quality surgeries. Perhaps I am doing low-quality Nonop! going to look into this. Thanks! #jhsjc

Dafang Zhang @DafangZhang:
this study also provides evidence to support the common practice of serial radiographs for ~3 weeks before “buying it” #jhsjc

Brent Graham @BgTalkinman to @DafangZhang:
Agreed. I see little point in getting additional radiographs after that time unless some problem crops up and I think this study supports that idea. #jhsjc

Brent Graham @BgTalkinman:
Let’s move on to the other study evaluating cost-effectiveness of 1st CMC reconstruction for OA. #jhsjc
In my view this was a very carefully performed costing study using “real-world” data from their clinical practices across the Netherlands. The analysis included modeling of time lost from work. #jhsjc
It’s important to note that the operations included any type of trapezial resection including oyrocarbo arthroplasty #jhsjc
The findings showed that while it is well-understood that the clinical results are very good, they are also cost-effective. #jhsjc
The authors conclude that returning patients to full work productivity is a key consideration in making the intervention cost-effective. Would that likely to be true in North America? #jhsjc

Rob Gray? @robgraymd to @BgTalkinman:
It is an interesting issue. Does it mean we need a higher pain threshold to operate on retired patients or SAHPs who are clinically identical? I find that unpalatable, but that doesn’t mean incorrect. #jhsjc

Brent Graham to @BgTalkinman to @robgraymd:
I would say that what it might mean is that for working age pts who are willing to have surgery maybe non-op mgmt should be de-emphasized. Or even abandoned? #jhsjc

Rob Gray? @robgraymd to @BgTalkinman:
most of my working CMC OA pts keep trying to DELAY surgery until retirement bc they don’t want to take time off. Perhaps representative of their work that they still CAN work w the OA. my 50yo laborer men are my happiest CMC pts. #jhsjc

Brent Graham @BgTalkinman to @robgraymd:
That is interesting but I wonder if it is more a measure of the divergent social circumstances between the US and just about everywhere else when it comes to issues of supports and insurance. #jhsjc

Brent Graham @BgTalkinman:
Let’s go further – for other common, elective hand conditions, like carpal tunnel syndrome should non-operative management be de-emphasized, if not abandoned, if working age people are willing to have surgery? #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
probably too far a leap — many conservative treatments are more than adequate for patients. can’t just abandon them. #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Of course, I don’t disagree! But I do think that the idea that non-op rx is always required before sx is considered for every hand condition is probably not really appropriate and more of a ritual. #jhsjc

Brent Graham @BgTalkinman:
Thanks to all for the great insights! We are back June 14 for our last session before a summertime hiatus. #jhsjc

Brent Graham @BgTalkinman:
Welcome to JHSJC for May, Eurozone edition! we are going to focus on the study by Grobet et al on cost-effectiveness of trapezial excision for OA of the 1st CMC joint. https://jhandsurg.org/article/S0363-5023(22)00055-7/fulltext #jhsjc
The comparison made in this study was reconstruction of the 1st CMC joint by a variety of methods with continued non-operative mgmt. #jhsjc
The study found a marked advantage to surgical treatment at a figure well below the threshold for cost-effectiveness established for most Western societies #jhsjc
The clinical results of these procedures are widely known to be very good and now this study also finds them to be cost-effective as well. #jhsjc
The study focused on “resection arthroplasty”, encompassing a wide variety of surgical procedures, the only common feature of which was removal of the trapezium. Pyrocarbon implant arthroplasty was also included. Does that affect the generalizability of these findings? #jhsjc
Obviously, patients choose their treatment, but does this mean that earlier surgery should be considered at least for working age patients? In other words, assuming patients are open to surgery as a treatment, is there actually a role for non-operative management? #jhsjc
Given the findings of this study, what does it say about other common, elective hand conditions, like carpal tunnel syndrome!? Does this mean that for working age patients who are willing to consider surgery, non-op mgmt for these conditions should be de-emphasized? #jhsjc
Has anyone a response to any of these 3 questions I’ve posed? #jhsjc
Maybe this topic doesn’t resonate!! We will leave off the discussion for now. We begin a summer hiatus now and will return on September 14 #jhsjc

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