For this discussion, we looked at Midterm Patient-Reported Outcomes in Wrist Denervation for Post-Traumatic Arthritis and Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study, both of which are from the November 2021 issue of JHS. We thank everyone who joined our debate, especially our colleagues from overseas!
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 first session for November! Remember to use the #jhsjc hashtag in your tweets. Let’s start with article 2 #tetraplegia recon
Was it appropriate to use the National Inpatient Sample database as the data source? #jhsjc
The assumption was that all of the cases would be done as an inpatient. Was that reasonable? #jhsjc
RyanC @RPCalfeeSTL:
I think the database choice was reasonable as most admitted at some point #JHSJC
Warren @whammert to @BgTalkinman:
I think it depends on how in patients are classified. I can see some having surgery and back to rehab the following day #jhsjc
and that qualifies as 23 hour stay, but not inpatient #jhsjc
Brent Graham @BgTalkinman:
Overall the findings make sense. Why would the cases be less likely to occur in private or investor-owned hospitals? #jhsjc
RyanC @RPCalfeeSTL:
does NIS capture one night stays? #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I don’t know, but I will assume it doesn’t. #jhsjc
Warren @whammert to @BgTalkinman:
thinking surgeons in those hospitals less likely to do this type of surgery #jhsjc
Brent Graham @BgTalkinman to @whammert:
Does that suggest that insurance type is less important than the nature of the surgeons at these hospitals? #jhsjc
The finding that urban hospitals, academic or non-academic, were more likely to do the cases would fit with that idea. #jhsjc
Warren @whammert to @BgTalkinman:
Personal opinion is these are not easy surgeries and the patients take a lot of work. and other surgery easier #jhsjc
Brent Graham @BgTalkinman to @whammert:
That would also be consistent with cases being done in academic centers. #jhsjc
Warren @whammert to @BgTalkinman:
agree. A lot more work than CTR, basal joint…and sometimes why surgeons choose to work where they do #jhsjc
Brent Graham @BgTalkinman:
Is it possible that these access issues have some aspects in common with those related to replant access? #jhsjc
Warren @whammert to @BgTalkinman:
I think there are similarities, but also a lot of differences as these are elective and require more hospital resources #jhsjc
Brent Graham @BgTalkinman:
If that is true, what is the way to address the issue of expertise maldistribution? #jhsjc
Warren @whammert to @BgTalkinman:
Regional Centers of excellence? #jhsjc
Brent Graham @BgTalkinman
In other words, is regionalization for the care of these cases a practical idea? #jhsjc
Brent Graham @BgTalkinman to @whammert:
I was typing that as you tweeted! #jhsjc
Brent Graham @BgTalkinman:
These cases are less common than amputations requiring replantation. Does that make the idera of regionalization easier or harder? #jhsjc
There are patient factors too. See https://www.jhandsurg.org/article/S0363-5023(16)31234-5/fulltext and listen to this: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/July_2017.mp3 #jhsjc
RyanC @RPCalfeeSTL:
hard to know. I think fewer surgeons are doing this than even replants #jhsjc
Warren @whammert to @RPCalfeeSTL:
Agree. I think the hand surgeons needs to be part of the team, but the leader is probably better to be a rehab doc #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Do insurers have any motivation to send #tetraplegia pts out of network for a center of excellence? #jhsjc
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
Not if it costs them money. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Canada is smaller, less fragmented healthcare system but almost all of these cases would be seen in a regional center. #jhsjc
Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
That fits with the finding that the combo of hand surg and specialist physiatrists distribution was important. #jhsjc
Brent Graham @BgTalkinman:
Last word on the #tetraplegia paper. Take a listen to the podcast: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/November_2021.mp3 #jhsjc
Brent Graham @BgTalkinman:
Let’s move on the other article-wrist denervation for OA #jhsjc
This is a small series that is level IV evidence. #jhsjc
Overall the results were good at least for 2 years. The sample was too small to allow any strification for severity. #jhsjc
Would the results stand up if there was a predominance of higher grades of #SLAC wrist? #jhsjc
The improvements were close to the #MCID for the main outcomes #DASH and #PRWE. Is it a reasonable strategy? #jhsjc
RyanC @RPCalfeeSTL:
I thought most were grade 3 so pretty advanced SLAC #jhsjc
Warren @whammert to @BgTalkinman:
I am not sure grade of arthritis matters for this – you are not treating the arthritis – just trying to decrease pain #jhsjc
Brent Graham @BgTalkinman to @whammert:
That’s a very good point but it suggests that the magnitude of the pain might not be related to the severity of disease. #jhsjc
RyanC @RPCalfeeSTL:
outcomes I thought convincing for improvement but still residual issues given scores. PRWE good outcome when wrist pain key thing #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Is it enough improvement to merit the effort? #jhsjc
RyanC @RPCalfeeSTL:
I think enough improvement. Seems like few returned for more surgery and no major rehab #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That’s true but it is a small series and short FU so hard to know if additional surgery isn’t inevitable. #jhsjc
Warren @whammert to @BgTalkinman:
Similar to thumb CMC arthritis – pain no direct correlation to stage of condition #jhsjc
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
I think it maintains motion, which is the reason my patients will occasionally choose this #jhsjc
Brent Graham @BgTalkinman:
What is the place of this strategy in the care of grade 3 and above #SLAC? #jhsjc
RyanC @RPCalfeeSTL:
how are results for others? I have only done this extensive denervation once and patient with advanced arthritis thrilled. I just haven’t been confident to do it consistently #JHSJC
Warren @whammert to @RPCalfeeSTL:
I have only done AIN/ PIN and not the more extensive denervation reported here, but my results are not as good #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I have never done it. I admit that #PRC or #4CF have worked so well for me that I haven’t considered other SX. #jhsjc
Brent Graham @BgTalkinman:
Does it have a role? Done like described in the paper, should it be an option before something bigger? #jhsjc
…or does it just waste time? #jhsjc
RyanC @RPCalfeeSTL:
if everyone went on to bony surgery later then I would question value but at least few did over 2 years #jhsjc
Brent Graham @BgTalkinman:
If it is considered, what should pts be told to expect? Like in this paper – small but measurable improvement that lasts? #jhsjc
Brent Graham @BgTalkinman:
There seem to be good results with this strategy in other hand conditions: https://www.jhandsurg.org/article/S0363-5023(21)00450-0/fulltext #jhsjc
Warren @whammert to @BgTalkinman:
IT might help and small risk, but minimal downtime and motion maintained. #jhsjc
Warren @whammert to @BgTalkinman:
I always wonder about this, but have not done it for thumb or other joints #jhsjc
RyanC @RPCalfeeSTL:
that seems fair although if asked I’m even more conservative saying it could help but maybe not predictable for me #jhsjc
Brent Graham @BgTalkinman:
And these: https://www.jhandsurg.org/article/S0363-5023(17)30905-X/fulltext AND https://www.jhandsurg.org/article/S0363-5023(17)31696-9/fulltext
Brent Graham @BgTalkinman:
There seems to be a lot of interest in this paper from our European colleagues. Join the discussion tomorrow at 4 pm EST. #jhsjc
Brent Graham @BgTalkinman:
Thanks for the insights! We are back here December 14. #jhsjc
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Brent Graham @BgTalkinman:
It’s the #JHSJC redux! Today 8 pm UK time (3 pm EST, 2 CST). Topic for discussion: #wrist #denervation for #OA #SLAC. Join in the discussion! Details at jhsfocus.org/jhsjc
Brent Graham @BgTalkinman:
Are we ready for our discussion? #jhsjc
Ryckie Wade @ryckiewade:
Evening everyone – welcome to Nov #JHSJC. Visit tchat.io and enter #jshjc – it’s the best way to participate #jhsjc
Or if you’re Tweeting in the app, then drop this hashtag #jhsjc so we can keep track
Ryckie Wade @ryckiewade to @hand_specialist and @homomediocritus:
would you like to get the debate started on this paper? https://www.jhandsurg.org/article/S0363-5023(21)00134-9/fulltext
Brent Graham @BgTalkinman
Let’s start with this: it’s level IV evidence. How convincing is it? #jhsjc
Is joint denervation frequently practiced in Europe? #jhsjc
There have been a number of studies in @JHandSurg on this strategy #jhsjc
Ryckie Wade @ryckiewade to @ruudselles:
you’ve published on the topic of wrist #OA this month (albeit an SR of SR of #PRC vs #4CF) – do you denervate prior / at the same time? What’s your view on the trajectory of PROMs following this procedure
Nicholas Riley @hand_specialist:
joint denervation is widely practiced in the uk. I think its a good option. Doesn’t change the skeleton. Also “failures” appear to be before two years so unlikely to miss a surgical option by delaying skeleton changing surgery #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
Agreed it doesn’t burn bridges Is it effective enough to be considered helpful or does it just delay the inevitable? #jhsjc
It’s very popular in N Amer as evidenced by the many publications in @jhandSurg. I’ve never done it personally. #jhsjc
Nicholas Riley @hand_specialist:
“majority” of people who are working it is a good option – I don’t think it delays the inevitable @bgtalikinman #jhsjc
Minimal down time – easy return to work – can be combined with radial styloidectomy if radial impingement pain @BgTalkinman #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
The follow-up in this study was 2-4 years. How long do you think it is before a more definitive Sx is required? #jhsjc
Brent Graham @BgTalkinman:
11/30 of these pts had SLAC grade II or less. What should be expected in more severe involvement? Is this for early SLAC only? #jhsjc
Nicholas Riley @hand_specialist:
The mayo mid term results show that revisions tend to occur within 2 years – beyond that it appears durable @BgTalkinman #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
Would you say that it is for mild involvement or all grades? #jhsjc
Nicholas Riley @hand_specialist to @BgTalkinman:
good question – i don’t know – later SLAC more likely to need bigger riskier surgery so denervation is a logical “try” #jhsjc
Brent Graham @BgTalkinman:
The improvements on the PROMs were very close to the MCID-actually lower than the higher estimates. How should that be interpreted? #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
Is that part of your approach to all patients: non-op -> denervation -> PRC/SLAC? #jhsjc
Nicholas Riley @hand_specialist to @BgTalkinman:
Yes – caveats tho, i think denervation is better for background pain, not great for painful clicking #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
What do you tell them to expect from #denervation – more surgery in the future? #jhsjc
Ryckie Wade @ryckiewade to @hand_specialist, @valehandsurgery, and @BgTalkinman:
Ryan, what’s your approach? Same/different to this ?/ Nick’s?
Nicholas Riley @hand_specialist to @BgTalkinman:
I say the aim is to avoid bigger surgery. In the worker my aim is to get them to retirement – often symptoms settle then #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
That seems reasonable. Same approach for the 40 yr old with SNAC? #jhsjc
Nicholas Riley @hand_specialistto @BgTalkinman:
Yes – #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
What I’m getting at is whether this is worthwhile if it provides minimum + on PROMS and eventually fails #jhsjc
Nicholas Riley @hand_specialist to @BgTalkinman:
Agree-this is tricky. Is this a low n= problem? issue with denervation is differing techniques- tricky to compare in SR #jhsjc
if it fails, seems to fail early (<2years) if patients get beyond seems durable – hence i don’t think we miss a boat.. #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
I don’t think SNAC is a low n prob. It’s common in N Amer. #jhsjc
That is a valid pt. It doesn’t burn bridges. Studies with longer FU are obviously required #jhsjc
Nicholas Riley @hand_specialist:
Sorry, the low n= Was in ref to the denervation studies demonstrating arguable MCID – might not be replying to the correct messages!! #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
Understood! #jhsjc
Nicholas Riley @hand_specialist:
IMHO we need a trial of non-surg .v. Denervation with at least 5 year follow up. But non-surg needs to be monitored treatment #jhsjc
Anyone up for a placebo .v. denervation trial? Only person to know will be the surgeon. Therapist and patient are easily blinded #jhsjc
Brent Graham @BgTalkinman to @hand_specialist:
I guarantee that gets published. My prediction? No differences. #jhsjc
Brent Graham @BgTalkinman:
Thanks for you insighjts Mr Riley @hand_specialist! We return on Dec 15. Let me know what we can do to make the discussion richer. #jhsjc
Nicholas Riley @hand_specialist:
Absolute pleasure – really enjoyed the discussion. #jhsjc
Ryckie Wade @ryckiewade:
Many thanks Nick @hand_specialist for your input. Look 4ward to seeing your RCT! #jhsjc
