Despite times still being very uncertain for all of us, we had a great conversation during this month’s #JHSJC! The two articles we looked at from Volume 45, Issue 5 of The Journal of Hand Surgery were Borderline Nerve Conduction Velocities for Median Neuropathy at the Carpal Tunnel and Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost.
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).
J Hand Surg Am- ASSH @JHandSurg:
The new #JHSJC chat format will have numbered questions for each article, labeled Q1, Q2, Q3… Please tag your answers with A1, A2, A3… and as always, tweets should include hashtag #JHSJC. #HandSurgery #OrthoTwitter #MedTwitter
Access articles here: jhsfocus.org/jhsjc/
J Hand Surg Am- ASSH @JHandSurg:
Let’s get started!
Please tag your answers with A1, A2.. and use the hashtag #JHSJC
Welcome to #JHS Journal Club with Editor and Host @BgTalkinman!
J Hand Surg Am- ASSH @JHandSurg:
Discussion Article 1: Borderline Nerve Conduction Velocities for Median Neuropathy at the Carpal Tunnel. Kortlever and @DrDavidRing, May 2020 https://doi.org/10.1016/j.jhsa.2019.11.020 #OrthoTwitter #MedTwitter #HandSurgery #JHSJC
J Hand Surg Am- ASSH @JHandSurg:
Article 1 Q1: Some were sent by primary care providers and others were referred by specialist clinicians. Is this an appropriate sample for this study? #JHSJC #OrthoTwitter #MedTwitter #HandSurgery
Brent Graham @BgTalkinman:
Q1 Is the sample for this study biased or generalizable? #jhsjc
Q1 My point is that it is a high prevalence sample. Is that likely to have had an effect on the findings? #jhsjc
Brent Graham @BgTalkinman:
A1 I would say that it isn’t because the patients were sent for a variety of reasons – both to “confirm” and to “rule out”. #jhsjc
David Ring @DrDavidRing:
A1: It’s difficult to do a study of carpal tunnel syndrome that is retrospective / convenience without a high prevalence. #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
A1 I would say that the mixture of patients sent to “rule out” and others to “confirm” is probably like most labs, so I think the findings are generalizable. #jhsjc
David Ring @DrDavidRing:
A1: Montgomery et. al. had a good approach: ncbi.nlm.nih.gov/pubmed/32299690 #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I agree and I think most labs have high prevalence populations. #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @DrDavidRing:
prevalence impacts all CTS studies, and findings re: testing parameters. hard to avoid though #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
#OrthoTwitter #MedTwitter #HandSurgery
Q2: What biases might be inherent in using this sample? #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing:
The main issue there was that the examiners might not have been ideal. I thought that was ok. #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
#OrthoTwitter #MedTwitter #HandSurgery
Article 1- Q2: What biases might be inherent in using this sample? #JHSJC
David Ring @DrDavidRing:
A1: Non-ideal examiners is perfect. Pragmatic. Real life. The best studies reflect actual practice. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
In the end that was what I thought too. #jhsjc
Brent Graham @BgTalkinman to @JHandSurg:
Only that the clinical dx might have been mistaken, especially for the group of interest – those in the “nuance” area #jhsjc
David Ring @DrDavidRing:
Q1: I think the key issue for me is: clinical or electrodiagnostic, are you comfortable cutting when things are not clear? #jhsjc
Ray Raven MD, MHCI, MBA @RayRavenMD to @DrDavidRing:
Totally agree, David. It definitely helps to analyze data from both groups. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Q1 I agree that this is really the point – diagnostic uncertainty #jhsjc
Avi Giladi @theaviram to @DrDavidRing:
Q1 the struggle is whether to give up trying to get clarification on the “unclear” cases. #jhsjc
David Ring @DrDavidRing:
If the symptoms are unclear or the test is mild or unclear, no knife. #jhsjc
Brent Graham @BgTalkinman:
@DrDavidRing and I talk about diagnostic uncertainty in this month’s podcast: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/May2020.mp3 #jhsjc
David Ring @DrDavidRing
A1: Moderate carpal tunnel, waking at night, splint not as effective any more. Solution at hand. #jhsjc
A1: Severe, let’s talk. Mild, let’s wait. #jhsjc
Brent Graham @BgTalkinman to @theaviram and @DrDavidRing:
Q1: We may have different ideas re: weighting the EDS or clinical findings but the issue is managing uncertainty #jhsjc
David Ring @DrDavidRing to @theaviram:
Time is the great clarifier. And relationship builder. And self-healer. #jhsjc
A1: Never underestimate the value of time as a diagnostic and therapeutic intervention. #jhsjc
Avi Giladi @theaviram to @DrDavidRing:
Q1 absolutely agree re: time and good relationships #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing and @theaviram:
I agree that time is an important factor – waiting when there is uncertainty #jhsjc
Brent Graham @BgTalkinman to @theaviram:
How do you manage the discussion of uncertainty? #jhsjc
David Ring @DrDavidRing to @Congenitalhand and @BgTalkinman:
A1: Diagnostic injection is over-valued. Injection is no better than simulated injection, so how can it be useful. #JHSJC
Avi Giladi @theaviram to @BgTalkinman:
Q1 sincerity in my own lack of clarity seems to help. I just don’t know and risk could be > reward. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing and @Congenitalhand:
I agree. I rarely do an injection. Splinting is a sufficient therapeutic trial. I learn more from that than EDS! #jhsjc
David Ring @DrDavidRing to @Congenitalhand and @BgTalkinman:
A1: And be careful using tests is low prevalence situations. Bayes’ theorem shows the flaws in even the best diagnostic tests. #JHSJC
J Hand Surg Am- ASSH @JHandSurg:
Q4: How should this information be presented to patients? #JHSJC #OrthoTwitter #MedTwitter #HandSurgery
Brent Graham @BgTalkinman to @theaviram:
Q1 That has always been my credo – be expert enough to say “I’m not sure”. #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Q4: How should this information be presented to patients? #JHSJC #OrthoTwitter #MedTwitter #HandSurgery
Robert Foster MD @RobertFosterMD1:
Waiting is never wrong. I find myself ordering more NCVs over past year b/c insurance denies surgery unless done, even severe/obvious #jhsjc
Brent Graham @BgTalkinman to @JHandSurg:
A4: I believe that uncertainty plays a role in just about everything we do. I explain things as probabilities sm, med, lg #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
A4: This is not an issue in a single payer system where the MDs are the experts, not the payer. #jhsjc
Warren @whammert to @BgTalkinman and @JHandSurg:
You have to do this cautiously as to some patients, uncertainty comes off as you are not competent. #jhsjc
David Ring @DrDavidRing to @RobertFosterMD1:
The result of our misdirection in part. I’m getting the same. #jhsjc
David Ring @DrDavidRing to @BgTalkinman and @Congenitalhand:
Splinting is the definitely the better diagnostic, therapeutic, relationship building trial #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing and @Congenitalhand:
Also, I’m too lazy to do an injection #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Let’s move on to Discussion Article 2: Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost. Kay et al, May 2020 https://doi.org/10.1016/j.jhsa.2019.12.010 #OrthoTwitter #MedTwitter #HandSurgery #JHSJC
Brent Graham @BgTalkinman to @whammert and @JHandSurg:
Nice profile pic! I agree. It requires confidence. I think stated the right way it builds a good rapport with most pts. #jhsjc
Ray Raven MD, MHCI, MBA @RayRavenMD to @whammert:
Thanks for joining in, Warren! Great profile pic! #jhsjc
Brent Graham @BgTalkinman:
We are on to the second article. #4CF vs #PRC … again. The old conundrum #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Q1: How might the lack of clinical granularity limit the findings of the study, if at all? #JHSJC #OrthoTwitter #MedTwitter #HandSurgery
David Ring @DrDavidRing to @whammert, @BgTalkinman, and @JHandSurg:
Communication strategies are key. Evidence show how to communicate uncertainty @uthealthcomm #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing @whammert and 3 others:
Absolutely agree with that #jhsjc
Warren @whammert to @JHandSurg:
big picture, but hard to get details – data out is only as good as data in #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
is it really a conundrum if we continue to see similar findings with group data? #jhsjc
Brent Graham @BgTalkinman:
There seems to be increasing evidence that when equally indicated #PRC should be preferred. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I guess that’s what I’m getting at – I don’t think so. #PRC seems to be best -in the aggregate — consistently. #jhsjc
Warren @whammert to @BgTalkinman:
starting to agree, but midcarpal fusion has more indications and hard to ever know if stage 3 where PRC not good #jhsjc
Ray Raven MD, MHCI, MBA @RayRavenMD to @BgTalkinman:
I had a CRNA come in today. 48 years old. Stage IV SLAC. I like the Eaton PRC with capsular interposition. #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
I have to say that that would be a pt in which I would always do a #4CF. Its the early pre-collapse pt that is less clear #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Discretion should be used in assessing the pt in front of you, but all of these large studies point to the same conclusion #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Article 2- Q2: If a more comprehensive costing were carried out over a clinically relevant time horizon, so that costs of complications, time lost from activities/work, out-of-pocket expenses etc., were modeled, would it be likely that the findings would be different? #JHSJC
Robert Foster MD @RobertFosterMD1:
I can’t think of a reason to choose #4cf over #PRC if capitate suitable #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
always use discretion, but as more data are available must ?? the validity of the “indications” used #jhsjc
Brent Graham @BgTalkinman to @Congenitalhand:
If there is any DISI – even a little – I rec #4CF but if the changes are only periscaphoid I go with #PRC and that has always been my approach. Data seems to support liberal use of #PRC for that pt #jhsjc
Ray Raven MD, MHCI, MBA @RayRavenMD to @RobertFosterMD1:
what if the capitate isn’t “suitable”? have you tried Eaton capsular interposition with #PRC? Works well in my hands. #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
Agreed! Any DISI makes me wonder about capitate cartilage health so low threshold for #4CF but #PRC is default #jhsjc
Robert Foster MD @RobertFosterMD1:
Conversion rate very low for both in this study, consistent w/ my experience #jhsjc
Anyone ever leave decision for intraop between PRC and 4CF? #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
You prob have the correct indications. My failures have been with my indications not the #PRC procedure itself #jhsjc
I do not. #jhsjc
Warren @whammert to @RobertFosterMD1:
quite often – I explain both and give my thoughts, but always indicate I may change if other procedure is better #jhsjc
Brent Graham @BgTalkinman:
Q2 is about the time horizon – would costs be higher for PRC over a longer time? OOP etc. #jhsjc
Robert Foster MD @RobertFosterMD1:
I have on a few occasions, patients understand I prefer PRC if cartilage warrants. I don’t like OR prep for both, hardware vs none, but rather leave OR knowing indications present were best #jhsjc
Brent Graham @BgTalkinman:
Q2 The costs were strictly direct costs, not time lost from work etc. #jhsjc
Ray Raven MD, MHCI, MBA @RayRavenMD to @BgTalkinman:
I belive that #PRC is the more cost-effective procedure in most cases. #jhsjc
Robert Foster MD @RobertFosterMD1:
I perceive PRC costs to be lower. No HW, no repeated XR looking for fusion #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
That is what these studies – 2 now in JHS — have shown. Also less conversion to wrist fusion. #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Article 2- Q3: However, if those cases in which either procedure is indicated, does the accumulated evidence show that PRC should be the preferred intervention? #JHSJC #OrthoTwitter #MedTwitter #HandSurgery
Robert Foster MD @RobertFosterMD1:
PRC less time to RTW and less time until discharge from clinic #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
The concern is the risk of wrist fusion but that seems less with 4CF – not the conventional wisdom until now. #jhsjc
Brent Graham @BgTalkinman:
The role of administrative data has been important here. These are insights that couldn’t be had from single institution studies/RCT. #jhsjc
Robert Foster MD @RobertFosterMD1:
Have converted 1 PRC in 23 years, 16 yrs after index. No 4CFs. I don’t do many wrist fusions #jhsjc
Increase in frequency of both seen in study likely inverse to decreased total fusions #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
I misspoke there – risk of wrist fusion is less with #PRC – that hasn’t been the conventional wisdom. #jhsjc
Robert Foster MD @RobertFosterMD1:
study noted increased frequency of the studied procedure over time as well, which I meant to say #jhsjc
Brent Graham @BgTalkinman:
I’m not sure if we will be seeing many more studies comparing #PRC and #4CF bc the answer seems to getting clearer #jhsjc
Robert Foster MD @RobertFosterMD1:
Looks like group agrees on PRC preference. Not much controversy, and article supports. #jhsjc
Brent Graham @BgTalkinman to @RobertFosterMD1:
Agreed! #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Check this link next week for transcripts! jhsfocus.org/jhsjc
Great discussion! Thank you for participating in the May #JHSJC!
Robert Foster MD @RobertFosterMD1:
Thanks for hosting! Most enjoyable activity. See ya next month. #jhsjc
Brent Graham @BgTalkinman:
Great discussion! Thanks for participating! One more session before we take a break for the summer. Back here June 9. #jhsjc
