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 1. Sign up for Twitter if you haven’t already. If you’re unfamiliar with Twitter, check out Twitter Guide: Getting Started.

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 jhs@assh.org.

 

December #JHSJC

Participate in the December JHS journal club!

Date: December 11, 2018
Time: 9:00 p.m. EST

Article #1:

Predicting Clinical Outcome After Surgical Treatment in Patients With Carpal Tunnel Syndrome
Prognostic, Level II
By M.C. Jansen, MSc, S. Evers, MD, H.P. Slijper, PhD, K.P. de Haas, MD, X. Smit, MD, PhD, S.E. Hovius, MD, PhD, and R.W. Selles, PhD
JHS December 2018: Volume 43, Issue 12, Pages 1098–1106.e1
Read the full article here: https://www.jhandsurg.org/article/S0363-5023(18)30650-6/fulltext

 Summary

The authors carried out a prospective study on 1,049 patients who underwent carpal tunnel release. All patients had an open carpal tunnel release and a brief course of post-operative hand therapy. A number of patient characteristics, comorbidities and the pre-treatment score on the BCTQ were the main variables used to predict the score on the BCTQ six months after treatment. Over 93% of the patients improved on the BCTQ after treatment. The variables found to predict less improvement on the BCTQ were: a low initial BCTQ score; a high BCTQ-FSS score; co-diagnoses in the same hand including ulnar nerve neuropathy, trigger finger, trapeziometacarpal joint osteoarthritis and “instability or arthrosis of the wrist”.

Points for discussion

  • There were over 2700 patients eligible for inclusion in the study but only 40% completed the study. Could the loss of 60% of the patients have had an impact on the findings?
  • Among other factors, a low score on the BCTQ at intake was associated with a smaller improvement on the same score at six months. Does this reflect the fact that those patients were less affected and therefore, had less to recover from, or does this indicate that the diagnosis might not have been CTS?
  • A high BCTQ-FSS score was also predictive of a lower improvement on the overall BCTQ score. A high score on the BCTQ-SSS score was predictive of larger improvement. How should that n=be interpreted in terms of predicting outcome?
  • There were other factors associated with a smaller recovery on the BCTQ at six months: co-diagnoses including trigger finger, ulnar nerve neuropathy, osteoarthritis of the trapeziometacarpal joint, and wrist pathology. What is the meaning of that? Are those patients less likely to report improvements because their CTS symptoms are not addressed or is that due to the outcome measure being affected by these co-existing conditions?
  • Altogether, the variables examined only predicted about 40% of the variance in the 6-month BCTQ scores. This implies that the majority of the variance remains unexplained by these factors. What other factors might have an impact on the observations?

 

Article #2:

Cost-Effective Management of Stenosing Tenosynovitis
Economic/Decision Analysis, Level III
By Andrea Halim, MD, Andrew D. Sobel, MD, Adam E.M. Eltorai, MS, Kaveh P. Mansuripur, MD, and Arnold-Peter C. Weiss, MD
JHS December 2018:  Volume 43, Issue 12, Pages 1085–1091
Read the full article here: https://www.jhandsurg.org/article/S0363-5023(17)30874-2/fulltext

 Summary

The authors conducted a prospective study of costs incurred by payers for the care of trigger finger. Patients who met the indications for non-operative treatment underwent a corticosteroid injection and were followed up every six months with either phone calls or office visits. If symptoms persisted, patients were offered the choice of another injection or surgical release. Eighty-two patients were enrolled, of whom 35 eventually underwent surgery. On the basis of their analysis, the authors concluded that, although there was decreasing success with each injection after the initial one, the cost to payers was less with up to 3 injections than it would have been with surgery after either 1 or 2 unsuccessful injections. The savings were $826 per finger over the cost of surgery when offering up to 3 injections, 43% of the overall costs of surgery for all patients without non-operative treatment.

 Points for discussion

  • One of the issues with this kind of costing study is that it only measures direct costs, and in this case only a component of those direct costs, i.e. those assigned to payers. While there is no doubt that this is important information, how would the conclusion that up to 3 injections is “cost-effective” change if all costs, including those incurred by patients in terms of time lost from work and activities, pain inconvenience etc. were included?
  • Another important point in this study was that patients were asked at each follow-up if they would prefer surgery to another injection in cases where the previous injection was unsuccessful. That allows for the inclusion of patient preference in managing this condition. Would a shared decision-making tool that indicated the probability of success with each injection versus surgery, have changed the results? In other words, would there be expected a proportion of patients who would have rather just had surgery earlier and avoided having prolonged persistent symptoms?
  • Diabetics in this study went on to surgery at a lower rate than non-diabetics (19% versus 54%). The authors acknowledge the counter-intuitive nature of that observation. Does it imply anything about the study sample in. terms of generalizability?
  • Do the payers costs reported by the authors appear generalizable? In other words, are these costs that could be expected in other geographic location and treatment settings?