JHS Journal Club
Created in 2018, the JHS Journal Club is a Twitter-based journal club that allows you to interact with other Journal of Hand Surgery readers and discuss interesting articles in JHS. You’ll participate in live meetings via Twitter, sharing thoughts with readers from around the world.
How to Participate
Step 2. Join the conversation
Using the actual Twitter website or app is not the best option for participating, as you will be required to continually refresh your feed to follow the conversation. Try one of these easy alternatives:
- Option 1 (highly recommended): Visit tchat.io and enter the hashtag #JHSJC to follow the conversation in real-time. The site will automatically add the #JHSJC hashtag to each of your tweets and make it easier for you to participate. An alternative to tchat.io is tweetchat.com. Be sure to allow access your Twitter account.
- Option 2: Follow the #JHSJC hashtag as a saved search in a Twitter client such as Tweetbot (download for Mac, iPhone or iPad), which has the ability to continually stream when you are connected.
Step 3. Participate
Speak your mind!
- If you’re following options 1 or 2 above, the #JHSJC hashtag will automatically be added to your tweets, so there’s nothing else you need to do.
- If you’re using the Twitter website or app, be sure to include @JHandSurg and #JHSJC to your Tweets.
Questions? Contact us at firstname.lastname@example.org.
Participate in the August JHS journal club! (Please note that there are two times provided to accommodate participants around the globe.)
Date: August 14
Time: 9 pm EDT
Date: August 15
Time: 8 pm GMT (4 pm EDT)
Article #1: Mulders et al; “Association Between Radiological and Patient-Reported Outcome in Adults With a Displaced Distal Radius Fracture: A Systematic Review and Meta-Analysis”
The objective of the study was to evaluate the outcome of distal radius fracture by radiologic alignment and patient-reported outcomes, in a meta-analysis. The authors identified 16 studies that reported these outcomes in 1,961 patients. They defined radiologic outcomes as either “acceptable” or “unacceptable” on the basis of criteria previously published in the literature. The patient-reported outcomes were either the DASH (or QuickDASH) or the PRWE. These were standardized so that they could be combined. The main findings were that there was a small difference of about 4 points favoring an “acceptable” reduction. The most important factors leading to a better patient-reported outcome were an “acceptable” reduction in terms of dorsal angulation and ulnar variance. However, despite the presence of a statistically significant difference in the patient-reported outcomes for an “acceptable”, versus an “unacceptable” radiologic outcome, the size of the difference was below the minimally-clinically important difference for the outcome measures studied. The authors conclude that these differences “were unlikely to be clinically important”.
Points for discussion
- Was the approach taken to identifying the appropriate articles adequate?
- Were the definitions for what comprised an “acceptable” alignment appropriate?
- How was the study limited in terms of identifying patient subgroups? In other words, are these results generalizable to all patients or only to certain groups, like those above or below a certain age?
- There was no consideration of the immediate post-treatment period in terms of a more rapid, or slower, return to activities. Also, there was no consideration of complications associated with the various forms of treatment? How do those considerations affect the observations and conclusions?
- There has been a moderate amount of evidence suggesting that, for many distal radius fractures, the main advantages of an aggressive approach to treatment, using ORIF for example, are in the first few months and that within 12 months, the results of operative and non-operative treatment are about the same. Assuming that operative treatment is more likely to result in an “acceptable” radiologic alignment, how should these findings be interpreted in terms of the indications for ORIF?
Article #2: Huetteman et al; “Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments”
The authors used the Truven MarketScan database to evaluate cost associated with surgical treatment of distal radius fractures. The goal was to estimate costs that might be included in a bundled payment under various assumptions. Specifically, the effects of surgery type, time periods to be included and the types of services included were assessed. The sample included 23,453 cases of which 15% were patients older than 65 years of age. The most commonly performed procedure was open reduction/internal fixation, which was done in 88% of cases. There were large variations in cost and the largest single component of the cost was the surgical procedure itself, which accounted for 61%-91% of the total costs. There was also substantial variation in costs depending on the definition of what encompassed an “episode of care”. The authors concluded that the best strategy to maximizing cost reduction was to have what they considered to be a “narrow” definition for the scope of the bundled care, which included only those services directly related to the cost of the fracture care and was long enough to capture costs related to therapy and imaging.
Points for discussion
- Is the Truven MarketScan a good model for studying these costs?
- The authors’ four models related to whether the care was “comprehensive”, by which they meant inclusive of all aspects of a person’s medical needs, or related strictly to the fracture and defined by the period of coverage: either 30 or 90 days. Are those realistic parameters for making these estimates?
- What components of the care were left out by the investigators? Were there any aspects that should not have been included?
- The specific costs obviously will vary a lot for readers working in various settings both inside the United States and across the world but the finding that those costs are variable, even within a specific payment scheme, seems to be a constant. How does that effect outcomes?
- Previous studies have shown that surgeon selection of implants used for treatment of distal radius fractures varies very substantially – there have been two studies in JHS demonstrating this. In the absence of any actual evidence showing one implant to be superior to another – in other words without any proof that, appropriately performed, it is the intervention of ORIF that matters much more than the implant used, how can this variation be eliminated?