#JHSJC

September #JHSJC Transcript

The #JHSJC is back! We took a brief summer break but returned this month to discuss two leading articles from the September 2022 issue of JHS, 1) “Volar Locking Plate Compared With Combined Plating of AO Type C Distal Radius Fractures: A Randomized Controlled Study of 150 Cases,” by Eva Lundqvist, MD, Per Fischer, MD, PhD, Per Wretenberg, MD, PhD, Kurt Pettersson, MD, PhD, Adolfo Lopez Personat, MD, and Marcus Sagerfors, MD, PhD, and 2) “A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures” by Michael B. Gottschalk, MD, Alexander Dawes, BS, John Hurt, BS, Corey Spencer, MD, Collier Campbell, MD, Roy Toston, BS, Kevin Farley, MD, Charles Daly, MD, and Eric R. Wagner, MD.

Thank you to everyone who joined! We’re looking forward to an equally fruitful conversation in October. As a reminder, we now use the TwChat platform for our event. Please review the information here on how to participate.

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 back after our summer hiatus! We are 1 week later than usual because I was away last week. Future sessions will be the 2nd Tues anjd the 2nd Wed (8 pm BST)of the month. #jhsjc

Brent DeGeorge @UVA_HandSurgery:
UVA is excited to have the #JHSJC back 😀😀😀! #jhsjc

Brent Graham @BgTalkinman:
The subject of both papers to be discussed tonight is treatment of distal radius fractures #DRF. #jhsjc
Let’s begin with our lead article, the #RCT evaluating two surgical strategies for intra articular fx of the distal radius #DRF #jhsjc

RyanC @RPCalfeeSTL:
Interested in hearing about peoples approach to the intra-articular fractures! #jhsjc

Brent Graham @BgTalkinman:
The study was a randomized trial comparing volar plating alone with combined volar and dorsal plating for treatment of AO Type C intra-articular fractures of the distal radius. What is your usual approach to this fracture? #jhsjc

hank holliger @HHolliger to @BgTalkinman:
Restore length, tilt, inclination and joint surface. Stabilize. Is there another approach?

Brent DeGeorge @UVA_HandSurgery:
Aaron and I are volar plating for many, however you have to recognize the limitations of volar plating and utilize other techniques such as dorsal bridge plating or fragment specific fixation when needed. #jhsjc

Brent Graham @BgTalkinman:
This is the type of injury I would have always approached dorsally, using bone graft to support depressed intra-articular fragments. I would only add a volar plate if the volar cortex was disrupted – I guess that is a combined approach for this study. #jhsjc

Brent DeGeorge @UVA_HandSurgery:
We found it interesting that the study randomizes to a TriMed volar plate, however the comparator utilizes a different volar plate in addition to the dorsal plating system? #JHSJC

Brent Graham @BgTalkinman to @UVA_HandSurgery:
There was no dorsal bridging plates in this study. #jhsjc

Chris Grandizio @ChrisGrandizio to @UVA_HandSurgery:
I give the authors a lot of credit for randomizing this decision. Everybody has their own threshold for when the fracture “needs something else” and there is so much variability between surgeons in terms of how they approach these DRFs. #jhsjc

Brent DeGeorge @UVA_HandSurgery to @BgTalkinman:
In this study, they used a different volar plate in the volar plate only group versus the combined group, no? #jhsjc

Brent Graham @BgTalkinman to @ChrisGrandizio:
It’s true that everyone has their own approach -which is why this kind of study is important. I will say that when I read #RCT addressing questions like this, often what is found is that the treatments are often approx equivalent. #jhsjc

Brent Graham @BgTalkinman:
While the aggregated mean radiographic scores for the groups were the same, there were more poor radiographic results in the volar plating group. What does that mean in the long-term, given that the study probably wasn’t long enough to know that based on data? #jhsjc

RyanC @RPCalfeeSTL:
I’m impressed by RCT. In practice some AO C fractures reduce well with traction and I volar plate. Some don’t and I would go dorsal. #jhsjc

RyanC @RPCalfeeSTL:
I think implication of radiographic reduction over time depends on patient age. #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Do you mean combined plating or dorsal alone? #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
Usually just dorsal for me. Combo only if need dorsal intra-artic reduction but part of issue is volar displacement of articular surface in which case I like to buttress from volar #jhsjc

Brent Graham @BgTalkinman:
I agree that it was a well-planned #RCT but I’m not sure that is addresses all types of intra-articular fracture, like @RPCalfeeSTL implied. We went into that in the podcast interviewing the authors: https://www.jhandsurg.org/audio-do/jhs-podcast-episode-78 #jhsjc

DrAmberLeis @DrAmberLeis to @RPCalfeeSTL:
good point! The younger patients are the ones I worry more about. #JHSJC

Chris Grandizio @ChrisGrandizio:
I would be interested know which component(s) of the Batra score resulted in the poor radiographic outcomes in the volar plate only group. #jhsjc

Brent Graham @BgTalkinman to @DrAmberLeis:
I agree! The study wasn’t long enough to address that point – and a study like that will be unlikely bc of feasibility issues. It would be good to follow these pots in a few years #jhsjc

Brent Graham @BgTalkinman:
In some ways the classification system used may not have been specific enough to allow the kind of stratification that might separate the requirement for volar or combined plating #jhsjc
There were many more implant removals in the combined group – 10% vs 31% – but is that surprising given that that, by definition, there are more implants that could possibly cause problems in the combined group? #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
I dont think the total number of implants is the issue there…but I would like to know what criteria (if any) were used for implant removal. #jhsjc

Brent DeGeorge @UVA_HandSurgery to @BgTalkinman:
Is it that or that dorsal plating is associated with higher rates of hardware removal and tendon-related issues? #JHSJC

Brent Graham @BgTalkinman:
If the findings that the clinical and radiographic results were, overall, essentially the same does that mean the treatments are interchangeable? Or does it mean that the study doesn’t really answer the most important question regarding treatment choice? #jhsjc

Brent DeGeorge @UVA_HandSurgery:
They commented that a study investigating patients managed with combined plating (dorsal) followed for 7 years reported a frequency of hardware removal of 51%…if the combined group here was followed longer i wonder if they’d find similar outcomes? #jhsjc

Brent Graham @BgTalkinman to the @theaviram:
The paper does not mention the specific indications – I assumed it was pain. They didn’t have any tendon ruptures. #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
yeah that’s a somewhat soft indication, especially if we dont know when the decision was made. would be nice to have more info there, especially since it’s the main “difference” between techniques, and is essentially a clinician decision #jhsjc

Brent Graham @BgTalkinman to @theaviram:
I agree – sort of! More info is always good but I don’t consider pain a soft indication for implant removal. Isn’t that the usual indication? #jhsjc

Brent Graham @BgTalkinman:
These are some good points! Let’s move on to the other study about methylprednisolone taper after surgery for #DRF. #jhsjc

RyanC @RPCalfeeSTL:
For paper 2: Another great effort and fascinating RCT. #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
I agree although it isn’t something that would ever have occurred to me. #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
If it’s painful at 4 months, does hardware need to come out? we dont know when it happened. and some take plates out prophylactically if they worry too prominent — how do we know that wasnt the case here? hard to know why 30% vs 10% #jhsjc

Brent Graham @BgTalkinman to @theaviram:
That’s true. My personal practice was almost always to wait 12 months before any implant removal unless there was clear radiographic evidence of healing earlier. That might be a little conservative. #jhsjc

Brent Graham @BgTalkinman:
The primary outcomes were pain reports kept in a pain journal by the patients and MME consumed. The patients were not blinded. Is that satisfactory? Could they have done anything differently? #jhsjc
…and there was a potentially important co-intervention bc all the patients also received #dexamethasone, which was something I had never previously encountered. #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
Agree, have never given steroid like this even as given in control group #jhsjc

Brent Graham @BgTalkinman:
When I say “co-intervention” my concern would be if there was a specific additive effect of the two steroids together that wouldn’t be present if only the methylprednisolone was given. #jhsjc
The basis for the methylprednisolone taper was an earlier study in JHS showing a positive effect in terrible triad elbow injuries, but I don’t know of any precedent for the routine dexamethasone. #jhsjc

Brent DeGeorge @UVA_HandSurgery:
50% reduction in opioid MMEs seems impressive to me! Many programs include multimodal anesthesia as a component of early recovery programs, which commonly include steroids? #jhsjc

Brent Graham @BgTalkinman to @UVA_HandSurgery:
Agreed, although the reduction was only between days 2 and 7. I would be interested if that result was better than a mutli-modal program and nobody received dexamethasone bc that might be more generalizable. #jhsjc

Brent Graham @BgTalkinman:
The authors conclude “With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain”. Is the study design appropriate to allow a conclusion related to safety? #jhsjc

DrAmberLeis @DrAmberLeis to @BgTalkinman:
I suspect my anesthesia colleagues may have provided dexamethasone to some of my operative cases without me realizing it… would be interesting to see how many of my radius fractures are already getting this! #JHSJC

Brent Graham @BgTalkinman to @DrAmberLeis:
Yes that would be interesting, although I suspect that it isn’t a widespread practice. Has anyone else routinely used dexamethasone in this setting? #jhsjc

Brent Graham @BgTalkinman:
I admit to being old enough to have been trained in an era that was extremely wary of any steroid treatment for anything because of the risk – possibly idiosyncratic – of femoral head AVN. #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
I think my concerns with steroid would be wound/bone healing or infection. At least they showed that these weren’t common when used in this population #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Agreed, although if I’m being critical, I would say that the study might be too small to really know that – fewer than 60 patients. #jhsjc

Dafang Zhang @DafangZhang to @RPCalfeeSTL and @BgTalkinman:
I agree! I do also worry about other systemic effects of corticosteroids. I think the authors wisely excluded poorly controlled diabetic patients. #jhsjc

Brent Graham @BgTalkinman:
So, should this finding be used more widely? #jhsjc

Avi Giladi @theaviram to @RPCalfeeSTL:
I worry also about the DVT risk; likely too small a cohort to see the complications show up, but they’re widely published elsewhere #jhsjc

RyanC @RPCalfeeSTL to @theaviram:
good thought also #jhsjc

Brent Graham @BgTalkinman to @theaviram:
I agree that is important. #jhsjc

RyanC @RPCalfeeSTL to @DafangZhang, @BgTalkinman, and @DrAmberLeis:
All great points. This isn’t the definitive study for all to change practice but certainly something to consider #jhsjc

Brent DeGeorge @UVA_HandSurgery:
This seems like an excellent opportunity as suggested by @RPCalfeeSTL for a multi-center clinical trial! #JHSJC

Chris Grandizio @ChrisGrandizio to @BgTalkinman:
I have used this steroid protocol for TT since they published that paper and started using it for some distal radius. I had concerns about steroids but most of our anesthesia staff were giving close to 5mg of Dec years prior to that. #jhsjc

Brent Graham @BgTalkinman to @ChrisGrandizio:
A replication study is in order! Do it without dexamethasone re: generalizability. #jhsjc

Brent Graham @BgTalkinman to @UVA_HandSurgery:
Yes! See my response to @ChrisGrandizio #jhsjc

Chris Grandizio @ChrisGrandizio to @UVA_HandSurgery and @RPCalfeeSTL:
great idea ! #jhsjc

Brent Graham @BgTalkinman:
Thanks to all for your thoughts! If you’re interested,this 2nd paper will be discussed with our Eurozone colleagues at 3 pm EDT tomorrow. We are back here Oct 11. I hope to see all of you in Boston! #jhsjc

DrAmberLeis @DrAmberLeis:
Great discussion, thank you all for sharing! #JHSJC #handsurgery #journalclub


Brent Graham @BgTalkinman:
Welcome back to JHSJC after a summer hiatus! Ive just returned myself from settling my son @UEA in Norwich, which is why the session has been delayed a week. We will return to our usual time, 2nd Wednesday of the month, next time. #jhsjc

Ryckie Wade @ryckiewade:
Welcome to the Eurozone edition of #JHSJC. Above is the article that we are discussing & a guide for how to chip in. Over to you @BgTalkinman 🚨 Please use the #JHSJC hashtag if you’re Tweeting outside the chatroom

Brent Graham @BgTalkinman:
Our discussion last night with the North American group was on 2 papers about #DRF, from the Sept issue of @JHandSurg. As per @ryckiewade, for this session we will focus on the #RCT about post-op opioid and methylprednisolone. #jhsjc
This was an #RCT which looked at the effect of a tapered course of methylprednisolone in the post -op period. The control group didn’t receive this treatment. The outcome measures were opioid consumption documented in a pain journal and MME used. #jhsjc
Is this a common practice in Europe? #jhsjc
All patients in the study also received dexamethasone, based on a previous study showing that was effective in improving immediate post-op outcomes with serious elbow injuries. In this study, does that represent a co-intervention that might confound the observations? #jhsjc
I haven’t had any personal experience with that – maybe none of you haven’t either – but seemingly it could have some merit? Thoughts? #jhsjc

Brent Graham @BgTalkinman:
@OrthopodReg @ryckiewade @jennifercelane @Sohail_Orthopod @StirlingOrtho @Ryan_L_K @valehandsurgery @The_Pulvertaft @bota_uk @orthocollab @DgwHolmes @Draft3C @ndorms They didn’t have any complications but the study was probably too small and short in terms of FU to make any conclusion in that regard. #JHSJC
The focus of the study was whether this strategy resulted in less post-op opioid use. It did but I agree that there might be many ways to achieve that. #jhsjc
Is dexamethasone a co-intervention? There was an effect of the intervention, the methylprednisolone taper, even though all patients, in the control and test groups, received the dexa. #jhsjc
Patient reports were the main source of the data that was collected. Given that the patients were not blinded, is there a risk of bias sufficient to have influenced the findings? #jhsjc

Brent Graham @BgTalkinman to @OrthopodReg, @ryckiewade, and others:
Do you mean the other #RCT comparing methods of ORIF for intra-articular #DRF? #JHSJC

Brent Graham @BgTalkinman:
We just touched on this outside the chat. The authors conclude “With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain”. Is the study design appropriate to allow a conclusion related to safety? #jhsjc

Brent Graham @BgTalkinman to @OrthopodReg, @ryckiewade, and others:
I see no reason why they wouldn’t. All authors have to sign a declaration regarding providing data if requested. #jhsjc

Brent Graham @BgTalkinman:
Is steroid treatment likely to be a viable adjunct to surgical treatment for distal radius fracture? #jhsjc

Ryckie Wade @ryckiewade to @OrthopodReg, @BgTalkinman, and others:
This sounds like something the @Surgery_Trials and @bota_uk could work together on… Trainee led big data exercise. We have some data on which to plan/power #JHSJC’

Brent Graham @BgTalkinman to @OrthopodReg, @ryckiewade, and others:
I agree that this could be a concern although non-union of a #DRF is a rare event no matter the circumstances. In 30 years of practice I think I saw that once. #jhsjc
Studies on this topic in @JHandSurg are among our most heavily cited although I think it is a topic that has been largely brought under better control in recent years – using much the same approach you describe #jhsjc

Brent Graham @BgTalkinman:
I think the discrepancy here is very regional. Surgeons in the US have a lot of concerns about opioid use – hence this study and many others like it. It seems a smaller concern in the UK and maybe elsewhere in Europe too. #jhsjc
Ok! I think that does it for this month. Thanks for the comments. If there are suggestions on papers that are of greater interest to European surgeons please let me know! #jhsjc

Ryckie Wade @ryckiewade:
Thanks to everyone who joined in this evening. It’s great to see #RCTs hitting the stage. Major kudos to the authors – pulling off a trial is a massive undertaking and just what #HandSurgery needs! #JHSJC

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