We’re back after our summer break! To kick off the new year of #JHSJC, we discussed “Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials” and “Selective Thumb Carpometacarpal Joint Denervation Versus Trapeziectomy and Ligament Reconstruction With Tendon Interposition for Painful Arthritis: A Prospective Study With 2 Years of Follow-Up,” both of which are leading articles from the September issue of JHS. We thank everyone who joined us and look forward to next month’s discussion!
Check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Brent Graham @BgTalkinman:
Welcome back to #jhsjc after our summertime hiatus! We are going without a chatroom now and hopefully that will make participation easier. Let’s start with the first article on complications after #VLP for #DRF https://jhandsurg.org/article/S0363-5023(23)00259-9/fulltext
RyanC @RPCalfeeSTL:
interesting to see the number of complications they found #jhsjc
Brent Graham @BgTalkinman:
This study sought to evaluate the occurrence of complications with volar locking plating (VLP) for distal radius fractures as reported by randomized trials. #jhsjc
Brent Graham @BgTalkinman:
On thing I’m noting is that posting takes longer than with our previous chatroom so be patient #jhsjc
Brent Graham @BgTalkinman:
Agree with @RPCalfeeSTL that the number of complications found is much higher than other papers published on this topic #jhsjc
Brent Graham @BgTalkinman:
The overall complication rate was approximately 31%. Major complications were defined as those requiring additional surgical intervention and were observed in 12.4%. #jhsjc
RyanC @RPCalfeeSTL:
estimates for incidence of complications depend on definition of complications but seemingly well done in this #jhsjc
Brent Graham @BgTalkinman:
Again, I agree with @RPCalfeeSTL that the definition of complications is key but appears entirely appropriate in this paper. #jhsjc
Brent Graham @BgTalkinman:
How does limiting the study to only those investigation that were randomized trials affect that, if at all? #jhsjc
Dafang Zhang @DafangZhang:
Great points @BgTalkinman @RPCalfeeSTL about definition of complications, agree well done in this study. RCTs f/u can be short, and tendon complications after DRF VLP can occur many years out. Scary to think that the reported complication rate might be underestimate! #jhsjc
Brent Graham @BgTalkinman:
I’m going to say that I think the complication rate has been underestimated in most other studies, especially when considering that many of these cases might not be done by hand surgeons. #jhsjc
RyanC @RPCalfeeSTL:
Good point about range of surgeons doing these in practice #jhsjc
Brent Graham @BgTalkinman:
I will answer my own question – I think limiting to RCTs probably means higher quality data and therefore a more accurate estimate of the true complication rate. #jhsjc
Brent Graham @BgTalkinman:
So, I conclude that this estimate of a much higher complication rate following #VLP than previously reported should be thought of an accurate #jhsjc
RyanC @RPCalfeeSTL:
Agree with this being more accurate than each of our own impressions
RyanC @RPCalfeeSTL:
Methods strong to just use RCT’s but based on each trial inclusion criteria may not apply to all distal radius fractures in clinic #jhsjc.
Brent Graham @BgTalkinman:
The complication rate was notably higher even though plate removal owing to patient preference or request, stiffness, or generalized pain was not considered a complication. #jhsjc
Brent Graham @BgTalkinman:
I agree with @RPCalfeeSTL that the generalizability of RCT findings is often less than would be hoped for, but I’m not sure that applies to this very common injury and treatment #jhsjc
Brent Graham @BgTalkinman:
Given that one of the advantages of VLP compared with other strategies like dorsal plating, is a lower rate of problems like tendon irritation, should these results give pause to the notion that VLP is better in this regard? #jhsjc
Rob Gray🧢 @robgraymd:
There is no world in which the flexor tendons, which are a mile away from a volar plate are more irritated than the extensors which lie directly on a dorsal plate #jhsjc
Brent Graham @BgTalkinman:
Maybe that’s true but the data in this study speaks for itself, especially with regard to the number of mishaps involving the implants, like intra-articular penetration. #jhsjc
Rob Gray🧢 @robgraymd:
I just can’t understand how anyone has reoperation rates over 10% on volar plating. If your rates are that high, please come do some labs w me so we can help you. Coaching helps all of us.
Brent Graham @BgTalkinman:
Good procedures are ones that everyone can do well. If a procedure is so difficult that it requires that much “coaching”, is it really that useful? I would say that it isn’t. #jhsjc
Rob Gray🧢 @robgraymd:
If it were easy, we’d let the spine surgeons do it. Hand has the most complex anatomy in the body. We go to school for a million years. This technique can certainly be taught to all of us, but we have to be willing to unlearn what we have learned #jhsjc
Brent Graham @BgTalkinman:
I think experience shows that that isn’t true. Not all surgeons are equally skilled and #VLP seems to be a procedure that a lot more people have trouble with than they are willing to admit. That is what this study shows. #jhsjc
rcoyle46 @rcoyle46:
Surgeons tend to be good at what we do a lot, and not so good at what we don’t do frequently. https://journals.lww.com/jaaos/abstract/2023/09150/fellowship_trained_orthopaedic_trauma_surgeons.10.aspx
Brent Graham @BgTalkinman:
I think that is true – and not just in our field. So when we read papers by experts about #VLP with small rates of complications, everyone who reads that thinks they will replicate those results. Evidence shows they can’t and that is why papers like this one are important #jhsjc
Brent Graham @BgTalkinman:
It’s also telling that the rate of implant removal linked to hardware complications was nearly 7% and included rates of between 0.5-1% each for intra-articular screw penetration, plate prominence, malunion and screw loosening. #jhsjc
Brent Graham @BgTalkinman:
It’s also telling that the rate of implant removal linked to hardware complications was nearly 7% and included rates of between 0.5-1% each for intra-articular screw penetration, plate prominence, malunion and screw loosening. #jhsjc
Dafang Zhang @DafangZhang:
Recent jhs article showed rate of intra-articular screws in VLP on CT can be shockingly high! https://www.jhandsurg.org/article/S0363-5023(23)00075-8/fulltext #jhsjc
again related to point about how complications are define and how hard you look for them
Brent Graham @BgTalkinman:
That’s why data from these RCTs should be taken seriously! #jhsjc
Brent Graham @BgTalkinman:
Those kind of serious implant-related complications are more likely to be accurately documented in the context of RCT, which is why these figures should be considered seriously #jhsjc
Avi Giladi @theaviram:
coming from RCTs adds notable legitimacy to these complication numbers
Brent Graham @BgTalkinman:
Disclaimer! I’ve never done a #VLP – none, zero – bc I’ve never believed that the complications were less than dorsal plating and biomechanically it doesn’t make sense to me, but that’s just me! #jhsjc
Rob Gray🧢 @robgraymd:
Try it. You’ll like it!
Brent Graham @BgTalkinman:
Lol!! I’m not sure I would! It’s too late anyway – I’ve stopped operating. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other paper on #denervation for #OA of the #1stCMC joint #jhsjc https://x.com/BgTalkinman/status/1701770368321532012?s=20
Brent Graham @BgTalkinman:
The study compared outcomes following treatment of osteoarthritis using either selective denervation of the trapeziometacarpal joint or #LRTI #jhsjc
RyanC @RPCalfeeSTL:
I certainly see this article as a conversation starter #jhsjc
Brent Graham @BgTalkinman:
Does the fact that the cases were not randomized matter to the findings? #jhsjc
Avi Giladi @theaviram:
yes!
Homo mediocritus @homomediocritus:
it does hugely – case selection has huge impact on outcomes, doing nothing would result in big ‘improvements’ in many patients due to non-specific treatment effects…….
Homo mediocritus @homomediocritus:
without randomisation, one has no idea which intervention is better and without a control, one doesn’t really know if either intervention is that effective……as what is the natural history……
Brent Graham @BgTalkinman:
At the end of the follow-up period, most of the outcomes were similar in the two groups. Pain was slightly higher in the denervation group. Should that be expected to be a static situation or is it likely that pain would be greater with longer follow-up? #jhsjc
RyanC @RPCalfeeSTL:
No idea about pain in long term. Would love to know from those experienced in cmc denervation #jhsjc
Rob Gray🧢 @robgraymd:
I would expect that to increase, but neurectomy is a stopgap procedure. You trade less durability of pain relief for rapid recovery.
Brent Graham @BgTalkinman:
The failure rate of the denervation procedure was 9%. Given the additional potential for morbidity, cost, and time away from activities for the patients who require conversion to arthroplasty, what should be considered an acceptable failure rate for this procedure? #jhsjc
Brent Graham @BgTalkinman:
In other words, patient choice notwithstanding, is there value in the intervention if a substantial proportion eventually require two procedures, or is a better strategy to offer the bigger, but more definitive procedure. #jhsjc
Rob Gray🧢 @robgraymd:
That’s patient dependent. Some want one and done. Some need a stepping stone. Both are reasonable as long as the patient knows what they’ve buying. #jhsjc
Brent Graham @BgTalkinman:
A time is coming when it won’t be what a pt is “buying”, it will the overall costs to a system and patient choice won’t have the prominent role it does now. That is a luxury a future system might not be able to bear. That’s why I ask the question. #jhsjc
Rob Gray🧢 @robgraymd:
I think you are right, unfortunately. A sad development for patient autonomy. #jhsjc
Brent Graham @BgTalkinman:
When it gets down to cost – and I mean pt costs, system costs, time lost from activities/work etc – will denervation be a viable option? #jhsjc
Dafang Zhang @DafangZhang:
I find denervation sometimes creeps into my counseling precisely due to shorter time off work. Some patients can’t commit to length of recovery from CMC arthroplasty. #jhsjc
Brent Graham @BgTalkinman:
I get that circumstances vary for individual pts but as a best practices approach, if #denervation fails in 10% and a 2nd procedure is required the overall best strategy could well be the larger, more definitive procedure and the pts should know that #jhsjc
Dafang Zhang @DafangZhang:
I think it’s a good point and unanswered question. I would agree that denervation is not going to replace arthroplasty in my practice lol. I wonder if denervation is an appropriate option for some patients, not all. #jhsjc
Dafang Zhang @DafangZhang:
for young pt with thumb CMC oa refractory to nonop tx, options have ranged from extension osteotomy, CMC arthroscopy, and now denervation enters the mix! #jhsjc
RyanC @RPCalfeeSTL:
I agree when patients can’t do longer post op restrictions but I am at mentioning stage as opposed to lots of experience with it #jhsjc
Dafang Zhang @DafangZhang:
Agreed @RPCalfeeSTL, I don’t have these authors’ experience but cite their experience as I mention this newer option for select few patients #jhsjc
Rob Gray🧢 @robgraymd:
I’m doing more and more. The patients really like them, especially the fast recovery. I tell them it works like a really good steroid shot. 70% chance of 70% pain diminution for 2 to 5 years. #jhsjc
Brent Graham @BgTalkinman:
Thanks to all for the great insights! We return October 10 but before then I look forward to seeing you in my home of Toronto at the annual @HandSociety meeting! #jhsjc
