We kicked off our springtime #JHSJC with a great conversation about two leading articles from the April issue of JHS: “A Prospective Clinical Trial Comparing Denervation With Suspension Arthroplasty for Treatment of Carpometacarpal Arthritis of the Thumb” (https://www.jhandsurg.org/article/S0363-5023(22)00723-7/fulltext) and “Correlation of Carpal Tunnel Syndrome 6 Score and Physical Exam Maneuvers With Electrodiagnostic Test Severity in Carpal Tunnel Syndrome: A Blinded Prospective Cohort Study” (https://www.jhandsurg.org/article/S0363-5023(22)00722-5/fulltext).
We thank all of those who joined us and encourage you to keep the conversation going below in the comments! Please plan to join us next month. You can find the instructions for using the TwChat platform here.
Check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Brent Graham @BgTalkinman:
Welcome to the April session! remember to use the #JHSJC hashtag; go to https://t.co/eFYcHSC4fv to find article summaries.
Let’s start with the article comparing results of #CMC denervation and #LRTI; https://t.co/363zc76jaR #jhsjc https://t.co/dtI31TPXRo
I misspoke and the visual abstract is slightly incorrect too – the comparison was not to #LRTI but to suture suspensionplasty #jhsjc
RyanC @RPCalfeeSTL:
denervation is intriguing and seems to be gaining in attention #jhsjc
Brent Graham @BgTalkinman:
The study design was a prospective cohort, but the patients were not randomized – each patient chose the treatment they preferred; outcomes measures: Michigan Hand Outcomes (MHQ); visual analog scale for pain. A total of 48 pts – 34 #denervation, 14 arthroplasty. #jhsjc
Outcomes were similar in the two groups, but not unexpectedly, those undergoing #denervation returned to their activities much more quickly. #jhsjc
Randomization would have made for a better study, especially since the focus was on patient-reported outcomes. Is there a risk of confirmation or recall bias by the patients reporting their outcomes, sufficient to affect the observations? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
Yes, randomization nearly always seems preferred from a scientific standpoint although markedly harder in practice #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Agreed. Personally I accept this as a feasible strategy that may not introduce a concerning amount of bias. It is something just to keep in mind when looking at patient reports. #jhsjc
Brent Graham @BgTalkinman:
The authors indicate that while the early results are about the same the earlier return to activities is the main advantage. But, what proportion of patients eventually requiring a second intervention to perform an arthroplasty would make that early advantage irrelevant? #jhsjc
David Ring @DrDavidRing:
All treatment interventions have nonspecific effects. This study design does not ensure there are specific effects that balance the inherent harms of surgery. Surgery for pain is always discretionary, never required. I need a sham surgery control.
RyanC @RPCalfeeSTL to @BgTalkinman:
I’m not sure on percentage. But, I would think that if preponderance of denervation patients never proceed to second surgery that would be worth it. #jhsjc
Brent Graham @BgTalkinman:
This is always the issue with small interventions that could be seen as stopgap measures – think CCH for example. The upfront advantages may look better than is the overall effect in the longer term. It’s something that could be amenable to a decision analysis model #jhsjc
There are no studies with long follow-up, so the longer-term results of the procedure are unknown. If the objective is to denervate the joint, should it be expected that neuropathic changes will eventually occur? Does that complicate revision to conventional arthroplasty? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
all unknown as far as I know. I would be hoping for long term relief and may just not be aware of this causing neuropathic degeneration of joint at cmc or wrist or small joints in fingers #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I agree it is unknown – more a theoretical consideration. #jhsjc
Brent Graham @BgTalkinman:
What should be the place of this in the approach to 1st #CMC #OA? Is this something for all early cases? Does it replace splinting? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
for me this is still surgery so not replacing any nonop treatment. I would consider for those unable/unwilling to take necessary downtime with trapezium removal or those that we have concern for issues if remove trapezium #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
For patients who fail non-op tx? #jhsjc
David Ring @DrDavidRing:
Subjective outcomes need adequate controls to be sure the improvement are specific to the intervention. I suspect these are all nonspecific effects and we could skip surgery and achieve them. Surgery for discomfort is never necessary/required. Always discretionary. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Understood – we need RCTs studying this. These are preliminary findings, which I don’t think the authors overstate. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman and @DrDavidRing:
I think Dr. Ring would say avoid saying “fail” non op. But, I would say for those with symptoms that persist that they feel are not tolerable or bothersome enough that they feel risks/recovery of surgery reasonable #jhsjc
RyanC @RPCalfeeSTL to @DrDavidRing:
Agree #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL and @DrDavidRing:
I agree “fail” is a strong word! #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other paper – the ability of clinical evaluations to assess #CTS severity; article:https://jhandsurg.org/article/S0363-5023(22)00722-5/fulltext; podcast: https://jhandsurg.org/audio-do/jhs-podcast-episode-85 #jhsjc
The objective of the study was to assess the correlation between #CTS6 score, Semmes Weinstein testing, and a single physical examination maneuver not included in the CTS-6, the Durkan test, with electrodiagnostic testing (EDT) as the reference standard for CTS severity. #jhsjc
The study was a double-blinded design – the hand surgeons conducting the clinical evaluation did not know the results of the EDT and the EDT technicians did not have access to the clinical evaluation. The EDT severity was graded using a previously published classification. #jhsjc
There were 105 patients studied. There was a weak correlation between the CTS-6 score and EDT severity. The SWMT also correlated with both the CTS-6 score and the EDT severity. The Durkan test showed no correlation. #jhsjc
The authors conclude that clinical evaluations like the CTS-6 and SWMT can indicate the severity of CTS. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I like the blinded design a lot. Always some limitation in using nerve conduction testing as reference standard when we know that has performance limitations itself #jhsjc
David Ring @DrDavidRing:
The mean CTS-6 score based on EDT grading were the following: (1) 14.8 (grade 0), (2) 16.0 (grade 1), (3) 14.8 (grade 2), (4) 16.7 (grade 3), (5) 18.7 (grade 4), (6) 18.3 (grade 5), and (7) 22.4 (grade 6). It doesn’t really go up until grade 4. #jhsjc
In other words, CTS6 will pick up more severe median neuropathy, but not mild. #jhsjc
Avi Giladi @theaviram to @DrDavidRing:
that was my take on the results as well. and not a necessarily surprising finding. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
That’s what was shown but grade 0 is “normal”, grade 1 is “very mild” and grade 2 is “mild”. Those gradations may not be practical in clinical practice. If the categories are collapsed to just “mild, moderate, severe”, the correlation would surely be higher. #jhsjc
David Ring @DrDavidRing:
I don’t think hand surgeons struggle with the diagnosis of severe median neuropathy at the carpal tunnel. We should put that aside. What we debate is the diagnosis of mild/moderate vs. normal median nerve. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I agree but the common justification for #EDT is to measure severity. This seems to show that it isn’t required to understand severity. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
I like that. We don’t need EDx to document severe median neuropathy. If we can agree that mild median neuropathy is treated nonoperatively, the EDx is not needed. Just stay away from “a little median neuropathy” and all is well.
Brent Graham @BgTalkinman:
The sample excluded workers’ compensation cases. In the podcast interview, the authors stated that they did not see any reason why these results wouldn’t be generalizable to that group. Is that a reasonable assumption? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
do you think grouping 1+2, 3+4, and 5+6 would markedly change the results? #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I do. The correlation isn’t striog for those lower levels. I would say that your grouping make more sense – grade 0 should perhaps have been left out. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
but the grade 0 had symptoms and scored on the CTS-6, cant really exclude them. that’s the most troubling group for some to sort through clinically #jhsjc
Brent Graham @BgTalkinman to @theaviram:
To me, that is a false negative for #EDT, which is another reason why it isn’t a great reference standard even if this setting. #jhsjc
Brent Graham @BgTalkinman:
In Oct we published a paper of which @RPCalfeeSTL was an author (https://jhandsurg.org/article/S0363-5023(22)00384-7/fulltext) that showed no correlation between the pre-operative CTS-6 and outcome, as measured by the Boston Carpal Tunnel Questionnaire (BCTQ). What is the reason for that discrepancy? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
The reason for limited correlation between pre-op disease severity and post-operative discomfort and incapability may be the strong association of mindsets with symptom intensity. Mindsets account for the discrepancies. Mindsets are a key aspect of health.
Brent Graham @BgTalkinman to @DrDavidRing:
Whether it’s mindsets or something else, the point is that this just shows that #EDT are probably not required to assess severity as many surgeons think. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I think our attempts to correlate preoperative data with postoperative change/outcomes just haven’t proven successful. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
I do appreciate that these results support the notion that if the diagnosis of CTS is clear and CTS-6 score is severe that EDT result will likely support the severity. But even at level 6 the variation in CTS-6 score is notable #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Maybe the right groupings should have been grade 0-2 – “mild”, 3-4 “moderate”, 5-6 “severe”. #jhsjc
I agree that it isn’t perfect but if the goal is to stratify severity to prognosticate it seems as if it does that reasonably well – if we are going to accept that #EDT is a reasonable measure of severity. #jhsjc
RyanC @RPCalfeeSTL:
in regards to studies when no perfect diagnostic standards, John Fowler and others have done some elegant work using latent class analysis #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I bring it up because it might be expected that severity and prognosis would be linked – but it doesn’t seem true here. It may be that a #CTR solves the problem even if it is severe. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
so ultimately I am not sure these results change the minds of those that still like EDT for various reasons. Too much system noise. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
My response to that would be that if it appears to be good enough to generally predict severity, it’s another reason why the cost, discomfort and delay of #EDT isn’t justified. #jhsjc
Brent Graham @BgTalkinman:
Great discussion! We return May 9. #jhsjc
