Episode Transcript
[00:00:02] Speaker A: Welcome to your Cases on Hold, the JBJS podcast, hosted by Andrew Schoenfeld and Aisha Adkeen.
[00:00:08] Speaker B: Here we discuss the best of what each issue of JBJS has to offer with the usual dose of entertainment and pop culture.
[00:00:16] Speaker A: Take us with you in the gym, on the commute, and as ever, whenever your case is on hold.
Welcome back everyone, to your Case is on hold, episode 105. If you're listening online, the day we Release, this is May 5th for the May 6th issue, and I assure you that is correct. Ignore the Please again, forgive the mistake on the April episode. I am Andrew Schoenfeld, Associate Editor and also professor of Orthopedic Surgery at Harvard Medical School and Vice Chair for Education at Mass General Brigham. And I have with me as always,
[00:01:02] Speaker B: I'm the co host, Aisha Abdeen. I'm a Chief of Division of Hip and Knee Arthroplasty at Boston Medical center and Associate professor of Orthopedic Surgery at Boston University.
[00:01:13] Speaker A: Wonderful. As you have heard in the past, or if you're just listening to us for the first time, we have to share with you that these opinions that you will hear are our own and not those of the editorial board, the editor in chief of jbjs, the members of the board of trustees, the other editor in chief of the constituent journals, or the executive leadership of the organization. They're just our opinions. Sometimes they are hot. Sometimes that's intentional. We want to get the conversation started. We want to stimulate some thought and advancement. If we just tell you everything is great, that would be boring, right?
[00:01:54] Speaker B: That's right.
[00:01:55] Speaker A: It got into the journal. So I mean that's like your first signal that these, these articles are worthy. But we therein we can have gradations with that out of the way. This episode is sponsored by the Miller Review course.
You are listening right at the beginning of May. It is that time of year to start getting ready for the various orthopedic certification tests or just re familiarize yourself with what's new and exciting in the field of orthopedics. If you are listening to this podcast or you're a regular listener to this podcast, I think like Aisha and I, you are probably someone who just loves knowledge in the context and setting of orthopedic surgery, whether it's in your discipline or others. Some of the best way to inspire new research in your own subspecialty, I have found, is by reading research from other subspecialties or learning about research in other subspecialties.
So definitely sign up if you're so inclined. I think, you know they have limited seats and those are probably closing it at this juncture.
And with that we will get into the articles for this issue.
Top of the pile we have Robert E. Booth Jr. Maryland, 1945-2026. This is an obituary and is permanently free.
Robotic Assisted Reverse Shoulder Arthroplasty Rationale, Potential Challenges and Future Directions by Menendez. And this comes with a highlight or is an article highlight rather.
Then we have Pedagra by Allen Permanently Free Conceptualizing Professional Development through six Dimensions of Wellness by More MRI based Synthetic CT shows Promise as a radiation free Alternative to Conventional CT and Orthopedics by Stuart no Midterm Benefits of glucagon like peptide 1 receptor agonist following Total Joint Arthroplasty A Systematic Review by Leggieri and colleagues. This is the lead article for this issue with an infographic and it's also permanently free.
Then we have Autoclaving Effectively Sterilizes Contaminated Retained Cement in Orthopedic Surgical Trays by Thompson. This article is 30 days free and also has a comment.
So we'll now step into the headlines. What's new and exciting in orthopedics this month?
My article is the cost effectiveness of Enoxaparin Compared with Aspirin for Thromboprophylaxis in patients with Orthopedic trauma. This is by Levy and colleagues and is a study that was done in conjunction with the Major Extremity Trauma Research Consortium. I believe it's going to be one of two articles from this consortium that we're going to hear about on this episode.
This investigation is a cost effectiveness analysis that follows on a trial that was already done by this group and published previously.
The motivational premise is that aspirin, as I'm sure you're aware, given the nature of your practice, and as Antonia Chen and I had discussed on many episodes previously, aspirin is now or close to becoming the predominant choice. Their words, they say predominant. So we'll go with that predominant choice for VT prevention after elective hip and knee replacement surgery. And I would say the caveat there, and we're going to come back to that, is in the low risk patient, of course, and this practice provided the rationale for a recent trial in patients with an orthopedic trauma for which there were two they have two citations and a previous publication where the trial, the actual trial, demonstrated that aspirin was non inferior to enoxaparin for the primary outcome of all cause, mortality and showed comparable effectiveness in preventing pe.
So we work off of the documents that we are given by the journal in terms of, you know, articles should be standalone articles.
So I'm presenting to you what I read in this article as its standalone element. I will say that I think it relies a little bit, maybe too much on. You have to go to what they have as reference 18, the actual publication of the trial, for some additional details.
And I don't think that that's like a burden that should be put on the reader. I think the reader should have everything that they need. So I'm giving you my impressions based off of what I read in this article. I didn't go and get Article 18 and I do believe I've read that trial previously, but I didn't read it in conjunction with this or as a side by side. So don't at me with like any comments that are relevant to the previous publication.
Suffice to say the, the motivational premise is that that study found aspirin was non inferior to enoxaparin for the primary outcome and now they want to do a cost effectiveness analysis.
So right there, off the bat, I'm kind of like, well, so obviously I think we know intuitively that enoxaparin is more expensive than aspirin. There's, there's hardly anything that's less expensive than aspirin.
And if we already know that enoxaparin is more expensive than aspirin and we have a trial that aspirin is better than enoxaparin, what do we intuitively think is going to come out of a cost effectiveness analysis? Exactly.
We need to cut like if enoxaparin was better than aspirin, then definitely you could be looking at a cost effectiveness analysis because it depends on the gradation of how good, how statistically better one may be than the other.
If it was a push and they were both kind of equally effective, then yes, I guess also you could be looking at cost effectiveness, but when the what is already known and widely accepted as the cheaper medication is better.
I don't know, I don't see where we get into really like a cost effective analysis is really needed in this context. I think we know what the results would be. It's kind of pretty plain and evident. And, and you know, if you had asked me when I started reading this, well, what do you think the study is going to find?
I would have told you exactly what they found there. There isn't a surprise, but there are some surprises. Okay, but wait, there's more there's, there's some surprises that I have to share with you here. Okay, so the first thing I was surprised about is that the cost.
This, this. I'll just say, you know, spoilers for later on this issue of JB js I had so many things that just blew my mind.
Every article I read to prepare for this presentation, I was like, whoa, am I reading this right? So if you ask me, like, what's going to be the difference between, you know, anoxaparin and aspirin in terms of the cost of care? I'd be like, it's going to be like several thousand, maybe $10,000. Right.
The cost for enoxaparin, total cost of care for enoxaparin was $35,301.
And I mean, that includes everything. Obviously. It's like, you know, out the door. Total cost of care for treatment for aspirin, it was $35,067.
[00:09:29] Speaker B: I know. Such a marginal difference, right?
[00:09:32] Speaker A: It's a difference of 2.
The overall health care costs were $234 higher with an oxy parent.
[00:09:39] Speaker B: Yeah. Who would have thought?
[00:09:41] Speaker A: Yeah, well, I'm just like, I mean, those come in like, you know, prepared syringes that you're.
So 200, $234, $1,000 is almost like rounding error. $234 is. That's nothing.
[00:09:57] Speaker B: I know.
[00:09:59] Speaker A: It's almost to the point where I would say that, like, you know, in terms of the cost, it's the same.
[00:10:04] Speaker B: Right, Exactly.
[00:10:05] Speaker A: And then we get into another kind of health policy econometric principle, which is that when events in the, that you're analyzing the events that change the quality adjusted life years are very rare or limited, it becomes the construct of the cost per quality adjusted life year become kind of anachronistic like that. You know, you can.
It's a met. It's a measure. Right. And, and we have the thresholds, but they become kind of silly when you have things that are very rare or that modify the quality adjusted life year by just a very small amount. And that's what we see here because their cost effectiveness ratio for an OX parent is $635,000 per quality. Which when you just write that out, you're like, oh, yeah, an oxaparin is ridiculously more expensive. Who would even pay? But it's not. It's actually $234 more expensive. And using that measure doesn't actually convey that different. Like if you just told someone, well, if you use an OX parent, it's $635,000 more expensive per quality adjusted life year versus enoxaparin is $234 more than aspirin. Right. One of these is accurate and one of these is not, you know, it's disingenuous in terms of its, and that's really because I think that the use of the quality adjusted life year, while standard in these kinds of conversations, we're not using aspirin or enoxaparin to improve a patient's quality of life.
We're using it to prevent ostensibly a catastrophic life threatening event.
Right, right.
[00:12:01] Speaker B: All things are disagreeable.
[00:12:02] Speaker A: Disagree. Right, right. But would you say all things are equal?
[00:12:05] Speaker B: Well, if all things are equal in terms of the outcome, then we do care about quality of life and price. Right. So they're making the assumption that it's equal in terms of clinical efficacy and therefore we can now argue the moot points of cost and quality of life, etc.
[00:12:22] Speaker A: Well, but, but I would say it's more that again you're, you know, and, and we're going back to what they present from the original trial, which is that their aspirin is still better than enoxaparin in terms of the, the outcome which they had for the original trial as mortality aspirin was or non inferior to parent for the primary outcome, rather not better, but non inferior toxic parent for the primary outcome of all cause mortality and showed comparable effectiveness in preventing pe.
Which again takes me back to my original premise because I was characterizing it as like if, you know, one is better and in this case the better is it's cheaper and it's not inferior. And again, this is not, this is just in an academic sense analyzing this within the universe of cost effectiveness analysis and quality adjusted life years.
Patients who unfortunately have a catastrophic life event and pass away, that you don't really, you don't measure them in the quality adjusted life years. So if someone has a DVT or they have a PE and you're able, yes, there's going to be more cost. Maybe for the first couple of months they might have some diminished quality, they're not able to mobilize as much or something like that. At the end of one year, if everything works out the way it's supposed to, they should be at the same place as somebody who didn't fare. Right, Right. And that's really why we're seeing this astounding dollar figure relative to what is the actual cost.
You know, the other thing that kind of threw me was in the study design they talk about the inclusion criteria of the Prevent Clot trial, which is the, you know, the foundational element for this work.
And they talk about the power calculation, they talk about the cost, they talk about the utilities, and they talk about the construct of the study, looking at the rates, which all is tantamount to describing the ability of the study to detect differences.
But then in the limitations, they tell you that the costs were.
First, they assumed that the thromboprophylaxis was indicated for all patients who are hospitalized for the surgical treatment of an extremity, pelvic or acetabular fracture, and then that the costs were estimated from the US healthcare perspective and all that is fine. But then they say if the cost is $200 less, then an ox parent would reach the willingness to pay threshold, which, I mean, kind of goes without saying because there's only a $200 difference.
[00:15:07] Speaker B: Yeah, exactly.
[00:15:08] Speaker A: And I would say that again, like, if, if that's the difference between going from $635,000, $200 gets you from 635,000 to 150,000.
You know, there's some fragility in the estimates there.
So I think it's, you know, the assumption that thromboprophylaxis is indicated for all patients who are hospitalized or that there's equipoise in terms of the thromboprophylaxis is also another thing.
And, you know, that gets to. One of the concepts that I was saying initially when I was thinking about this is that this would only really be for the low risk patient for whom aspirin would be considered inappropriate. And I'm all for aspirin. It's less expensive. You're not having somebody having to give themselves injections. It's easier to take. It's better for the patient, it's better for the health system, it's better for the, you know, stewardship of limited healthcare resources. So I'm all for the, the aspirin, but I think that, you know, in, in this context, one, the premise need for the cost effectiveness piece is so it seems like a little bit of a, of an academic exercise just for the sake of academic exercise. And then the second is, you know, if you have somebody on aspirin, and God forbid they did have some type of catastrophic life event justifying the use of aspirin by saying, well, it's more cost effective then I don't think that that sounds too good.
[00:16:41] Speaker B: No, exactly right.
It's irrelevant at that point. But you do make a good point about risk Stratification. Right. And so this probably gets back to the original paper, but the absence of risk stratification is one of the concerns I had here. Are we going to a more potent anticoagulation such as enoxaparin based on risk and there might be variation in risk. They didn't Discuss High Energy vs Low Energy Trauma and fractures and patient risk factors such as a geriatric trauma patient versus a pediatric patient, comorbidities and whatnot. So I think that would play a role as well in terms of the decision to use it. Of course, not on the cost effective side of it.
And then just practicality in their discussion, they do mention the potential use of enoxaparin while the patient's in hospital and then sending them out on PO aspirin post op or once they're discharged.
And you know, there might be the concerns of the multi trauma patients that are intubated and just the practicality of receiving aspirin at that time until they're able to take, you know, intake. So some of the practicalities I think need to be considered.
[00:17:45] Speaker A: Would this change your practice from a. I don't know if you take trauma
[00:17:49] Speaker B: call or not, but I do take trauma call.
It may change my practice if I delve into sort of the, again, the unilateral one extremity trauma, not the multi trauma patient to consider based on this evidence and the paper that preceded it to change to aspirin. Yes. How about yours?
[00:18:08] Speaker A: I don't take trauma call, so I don't feel I am in the right to weigh in on this domain.
I think using aspirin is well justified though. For sure.
[00:18:22] Speaker B: Definitely.
[00:18:23] Speaker A: And again with the caveats that like you said, it's low risk patient based on background, sociodemographic, medical characteristics, comorbidities and injury pattern.
[00:18:35] Speaker B: Exactly.
[00:18:36] Speaker A: Yep.
All right, so we're going to move into your headline, which is comparison of highly cross linked and conventional polyethylene during simultaneous bilateral cross cruciate retaining total knee arthroplasties results at a minimum follow up of 15 years. This is by Kim and colleagues and does come with a comment.
[00:18:58] Speaker B: Right. So unlike in total hip arthroplasty, the benefits of highly cross linked polyethylene and total knee replacements are not well established.
Highly cross linked poly tibial inserts have been developed for the use in total knee arthroplasty to address the issue of wear of the conventional poly bearings. However, multicenter and registry data suggest similar intermediate clinical and survival outcomes.
Most studies have focused on posterior stabilized inserts and have other limitations such as multiple surgeons and include multiple or a wide range of prostheses in one given study. But this study aimed to compare longer term results at 15 year minimal follow up clinical and radiographic results and looking at revision rates as well as survivorship between highly cross linked polyethylene and conventional polyethylene bearings among patients undergoing cruciate retaining total knee arthroplasty is performed by a single surgeon.
The cases were performed between 2006 and 2010 and they had 894 bilateral primary total knee arthroplasties performed during the same anesthetic session in 444 patients. Patients were less than or equal to 65 years of age.
Ten patients were excluded or 20 knees because they declined to participate.
In the end there were 410 patients that were available for follow up at a median or a mean time rather of 17 and a half years.
So really long term follow up. This is an excellent design where you have an internal control construct where each patient received either the conventional polyethylene or the highly cross linked polyethylene using the same implant manufacturer and it was a cruciate retaining high flexion design. The next gen implant by Zimmer Biomet so each patient received the highly cross linked polyethylene on one side and a conventional poly on the other side. The order of insertion of the two prosthesis was alternated between sides in consecutive patients and patients were blinded as to which knee received which type of polyethylene bearing.
All of the patients in the study were Korean. The study was performed in Korea and 164 patients were men, 246 were women.
The surgical technique was the same for all procedures and the patella was resurfaced in all cases and the poly type of the patella used matched the poly of the bearing.
The Knee Society score, the Western Ontario McMaster University's Osteoarthritis Index or the Womack score as well as the University of California Los Angeles UCLA activity score were collected preoperatively and and then again at three months, one year and every three to five years postoperatively. The active range of motion of each knee was measured before surgery and at each follow up.
The authors contend patients were able to distinguish the degree of pain in each knee, although that can be kind of difficult.
It was somewhat difficult for patients to differentiate the degree of functional impairment between knees.
However they contend with careful questioning they were able to specify which knee bothered them more and a visual analog scale from 0 to 10 was used for satisfaction. Patients were also asked which knee they thought was better post op. X rays were assessed for alignment and posterior slope as well as posterior femoral offset and a CAT scan was done for evaluation of component rotational positioning and presence of osteolysis. At the latest follow up the authors found no significant advantage was observed for the highly cross linked polyethylene bearing over the conventional poly however and there was no difference in knee society score or pain or range of motion between groups. There was no difference in improvement in the Womack post op and no difference in the UCLA activity score. Patient satisfaction was similar in both groups at approximately 80%.
There were no significant differences between the two groups with regard to radiographic parameters including knee alignment, component position, joint line level, posterior femoral osteoarthritis, condylar offset and radiolucent lines.
Revision rate was 2.0% in the highly crosslinked polyethylene group and 2.2% in the conventional polyethylene group with revision or loosening as endpoint. The Kaplan Meier survivorship analysis showed a survival rate of 98.0% for the highly cross linked bearing group and 97.8% for the conventional poly bearing group at 17 and a half years postoperatively so no difference in survival.
This was a commendable study due to its prospective design, its blinding, its internal patient controls as well as a bona fide long term follow up in the arthroplasty world which is 15 to 19 years with a mean follow up of 17 and a half years. There were no differences in osteolysis or survival between highly cross linked polyethylene and conventional poly in the CR group or the CR total knees. In all the cases the study allays some concerns that highly cross linked polyethylene may generate smaller wear particles than conventional poly resulting in increased biologic activity.
There may be reduced resistance to wear crack fatigue propagation rather in highly cross linked polyethylene because it can potentially be less resistant to crack propagation and fracture. However that did not bear out in the study either so there were no differences and more importantly the equivalence in outcome suggests that the recent move towards highly cross linked polyethylene and total knee arthroplasty may not actually be worth the significant cost which can be up to four times the cost.
It's interesting because this is yet another study that's adding to the data that really there doesn't seem to be a tremendous benefit in using highly cross linked polyethylene and Total knee arthroplasty, unlike what we've seen in the total hip arthroplasty space.
Andrew, what were your thoughts on this paper?
[00:24:50] Speaker A: Yeah, this was the only one of all the ones that were presenting that I didn't have my mind blown by some statistic or figure. It's great to have the, you know, really long term follow up.
My, my esteem goes out to, to those surgeons to, you know, to be able to follow these patients, such a large number of patients, 15 years.
Really good insights on that front.
We'll now move on to pain outcomes following modern external ring fixation compared with internal fixation for severe open tibial fractures. A secondary analysis of a prospective randomized trial, the Fix it trial. This is our your case is on hold featurette. This article is by Hsu and colleagues with a comment visual summary. It is a highlight for this issue and 30 days free.
So we have the perfecta on that, on this, on this paper. But this paper is far from perfect, I think.
Also I saw that your chair, Dr. Tornetta, is a. He's not the first senior author, but he's in the author mix there.
[00:26:03] Speaker B: That's right.
[00:26:04] Speaker A: We have to tread carefully.
[00:26:06] Speaker B: Exactly right.
[00:26:08] Speaker A: Oh, I'm sorry. I'm gonna get you in trouble.
[00:26:10] Speaker B: Not that we ever really do though. Right.
[00:26:15] Speaker A: All right, well, let's, you know, let's get into it here. So this is a secondary analysis, which again, even going back to. And this is also a met. I don't know if they call it metric or metric is how I pronounce it, but maybe they want to be met. Rc, The Major Extremity.
Major Extremity Trauma Research Consortium.
This is another study that came out of that group.
It is a secondary analysis of the previously published Fix it clinical trial which was conducted in 20 US trauma centers and has a separate protocol.
And that trial has already been published.
The again, don't at me about something that I mentioned about the original Fix it as how I'm interpreting it here based on what was presented for me to read in the context of this paper, which should exist as a standalone paper. When you say secondary analysis, that typically to my mind means that you're taking data that was collected for an RCT or for other purposes for they had their own reasons what they were doing. It was powered for certain things and now you're looking at some other things. I think that's different when you have, you know, the primary outcome from the RCT and you know that takes up 3,000 words. So you publish that and then There's a secondary outcome for which you are also adequately powered for. It was an intentional planned outcome that was in the protocol. That's different.
But sometimes people use those words interchangeably. And reading this, I wasn't sure. Initially I took it to mean that this was a secondary outcome, but a planned outcome. But actually I don't think it is that way. And then it gets a little bit more confusing for me because in the method section they're talking about primary outcomes and secondary outcomes. But those are unique, I think, to this actual study and not to the Fix IT trial.
So, you know, it, it got a little bit challenging for me to figure things out in terms of what is exactly inherent and unique to this paper versus what's coming. Because when I read the sample size calculation that they provide, I thought they were talking about for this secondary analysis.
But then they say in their limitations, they state that.
I don't want to misquote it first. The Fix it study was not designed to assess pain outcomes.
When this is a study about pain outcomes, the sample size that they're presenting I think is not entirely related to the.
This is where some of the confusion arises.
It was hard to work through in that sense for me. But essentially they took the fix IT data. They have adults with severe open tibial fractures randomized to undergo definitive modern external ring fixation 122 patients, or internal fixation 132 patients. The primary outcomes were pain intensity and interference.
That's for this study at 6 and 12 months measured by the brief pain inventory. Then the secondary outcomes were the numeric pain rating scale scores and the incidence of moderate to severe pain.
Then they talk about a post hoc sub analysis which again it's like. But this is already. There's just too many uses of the words like analysis, analysis of primary, secondary. But so you know, I wish that that was like a little bit clear or that there was better clarity on that front. Essentially, you know, the study showed that six months pain intensity did not differ significantly between the external fixation group and the internal fixation group. But patients who underwent external fixation had greater median pain interference than patients who underwent internal fixation at 12 months. Pain intensity, pain interference and the numerics rating scale did not differ by treatment type. But the overall incidence of moderate to severe pain was fairly high. 33% at six months, 35% at 12 months.
At six months. And this is only inherent to one group. The pin site infections were associated with greater pain intensity. Only one group can have pin site infections, certainly at six Months.
Their conclusion is that patients treated with modern external ring fixation had greater pain interference than patients treated with internal fixation.
And this is partly due to the pin site infections.
Then they say that this highlights that persistent pain is common regardless of treatment type. And the findings can guide surgeons in choosing ring external fixation or internal fixation for these fractures.
That, to me, is a total Sopranos ending paradigm. Like, it's a secondary analysis of a level one trial. You've got large number of patients and, you know, again, we talk about some of these things philosophically, and I do think it's fascinating, you know, how like, group dynamics work and things like that. And I'm not saying that I know that this is how it happened. I don't, obviously.
I mean, you know, I may have some passing relationships. I have better relationships with some people who I know contribute to the Met rc, but I don't know anyone on this author list especially well at all. So I didn't ask anybody. But I can see that there might be somebody who likes to use the pin external fixators.
And they look at this data and they're like, oh, well, we don't really know.
And it's like, oh, we don't really know. Right.
So my overarching comments are, I think, as a, as a natural history study or as something that you can share with patients in terms of what expectations are after these types of very severe traumas. I think this is great.
They're talking about outcomes related to the pin site infections. But as this is a randomized trial, and this is part of the problem, when you're using randomized trial data to do secondary analysis, that's just 11 patients. Only 11 patients had. Right. So you're making a statement that's supposed to be clinically informative just based on the experience of 11 individuals. And I don't think that that's likely to hold up in a. In a bigger context, but we'll put pause on that for a second because I think there's a bigger underlying point.
This is the part where this is number two of Andrew's mind was just exploded.
There were 20 patients who underwent external fixation and still had external fixation in place at 12.
[00:33:26] Speaker B: Right. I know that's astounding.
[00:33:30] Speaker A: What.
And this is, you know, maybe this goes back to their original trial and part of the challenge for me, and not having that piece immediately accessible, because I don't think, you know, you could say, well, why didn't you have them side by side? Because that's not the way you're supposed to read the articles like, but if you're doing the internal fixation and not having a whole bunch of patients fail and get revisions and stuff like that, and you have 20 patients who are still having the external fixation in place at one year and haven't completed the treatment, is that not a marker of like, which one of these is better?
[00:34:04] Speaker B: Agree, agree. But I suppose their, their side is the patients feel well and their pain is equal and they're not looking at the outcome of the fracture treatment so much as the pain treatment in this.
[00:34:15] Speaker A: Yeah, but you can't consider those things in like separate, like we're just going to ignore the fact that they're still people who are spending, I mean, and everything that goes into the care and management of those devices, which, and the number of office visits. We got to get the cost effectiveness analysis on this one.
[00:34:33] Speaker B: That's true.
[00:34:33] Speaker A: Let's see what that, what that shows. Okay, so they say that, you know, that first off, they then tell you in the limitations that maybe they weren't powered to the pain outcomes. Which is, I was like, you should have said that. Like that should have been the first sentence in the, in the methods. And then they say randomization mitigated the risk of imbalanced groups regardless of our ability to assess psychosocial risk factors for persistent pain. I don't agree with that at all.
How do you know that? Like, unless they were doing, you know, block randomization on sociodemographic factors or things like that, you can't just have, if we randomize. So that takes care of everything that isn't true.
And certainly there's, you know, the smaller the sample, not that this is like especially tiny, it's over two hundred and fifty patients. But it never amazes how what seems like a waterfall of patients turns into a trickle when you start breaking it down by education level and racial and ethnic background and zip code and social deprivation index. Once you start figuring all those things.
[00:35:38] Speaker B: Absolutely. Yeah.
[00:35:40] Speaker A: So to just have this blanket statement. Yeah, don't even worry about that. That's a ignore the man behind the green curtain paradigm. We're playing out all the paradigms here. We're getting all the paradigms.
We will not be getting a Kaiser Soze paradigm though. I wouldn't be. Like, the Met RC papers always show up on the web based longitudinal assessment.
And I'm reading them and it's like so many of them are like, oh, we're underpowered for this and we're underpowered for that. And the differences are not, are not.
There are differences, but they're not significant differences. And sometimes they're big differences and they're not significant, which then I get all anxious about. Well, if they ask the test question and they say like, you know, was there a difference? They mean a statistically significant difference or they just mean the difference. It's in the paper, right?
[00:36:23] Speaker B: Yeah.
But I suppose it's the best evidence that we have the largest group of these complex cases and that's why they get on the, you know, the longitudinal assessment list.
[00:36:37] Speaker A: One last thing that I was saying that I'm going to let you jump in is when I think about this, that they're saying at 12 months, patients with external fixation in place had greater pain intensity and interference than patients for whom external fixation had been removed. But. And approximately one third of all patients had moderate to severe pain at both time points. Okay, fine. But you have some folks who still have these things on at 12 months. They're not even done yet.
And so I just look at this as from a spine practitioner's perspective. This is like a halo vest. Like we used to put halo vests on people. It's. It was literally like medieval torture.
[00:37:17] Speaker B: You know, you're way worse.
[00:37:20] Speaker A: You're telling me where the gold is hidden for sure. You're telling me.
And you know, elderly patients were aspirating and you get pressure sores and the things would turn into, you know, intensely smelling, foul, noxious messes by the end, like, of course you would go to surgery. It's. And in this case, we're not even talking about surgery or not surgery, where the halo vest. You're potentially avoiding that. I mean, you're having a surgical procedure either way.
To me, it's like this. The conclusion should be you should have internal fixation. I mean, I think it's pretty clear cut.
[00:37:58] Speaker B: Yeah, I agree.
The other elephant in the room, of course, is in these complex 3a and 3b open fractures. The impact of the soft tissue reconstruction on pain. And they didn't really differentiate. I'm sure it would have been even smaller numbers if they looked at the type of soft tissue reconstruction and stratified based on whether people had rotational flaps or free flaps. There is a little bit in the fine print on one of the tables where they talk about five patients that had a rotational flap and they had shortening and they gradually extended them with the, or increased their length with the external fixator. But I would have liked to delve into a little bit more about the soft tissue. They sort of just Compared pain based on how we treated the bone, whether they had X fix or internal fixation. But the soft tissues really play a huge role in some of these patients. And the impact of whatever reconstruction and reconstruction they have would have been interesting.
[00:38:54] Speaker A: Especially because it comes down to the many of these papers end up being used for test like testing purposes.
I would just please have like a definitive statement one way or the other. If you don't see a difference, just say there is no difference. If there is a difference, don't say, well there's a difference, but you can still like just make it like adhere to the data.
[00:39:16] Speaker B: I agree.
[00:39:18] Speaker A: All right, so let's get into the honorable mention article which is a dedicated trauma operating room for hand surgery reduces after hour cases and costs without affecting wait times. A retrospective single center cohort study by Wong and colleagues. And it comes with a commentary. This is the third article that blew my mind in this episode of your cases on hold. So we don't usually do any kind of editorial commentary, but I just to point out a few things.
The quick premise here is that they're looking at dedicated trauma operating rooms as a way to improve access and care for patients. And they wanted to measure the impact basically a pre post kind of study of a dedicated trauma room for hand surgery on the proportion of after hours cases and wait times from consultation to surgery at a Canadian urban tertiary care center. So Drs. Terrence and Philip are ready to see you for your hand emergency surgery. Right.
Adult patients undergoing hand trauma surgery before the implementation, which was August 1, 2018 to January 31, 2020. And then there was after the implementation, which was August 1, 2022 to January 31, 2024.
So after hours cases decreased from 18% to 8%. Great.
Then they say adjusting for covariates, the dedicated trauma room was associated with fewer emergency hand surgeries. Awesome.
Being performed after hours. The median wait times were similar however, before and after.
So before the wait times were six days and then eight days for emergencies.
I mean either we're not using the word emergency hand or surgery here correctly.
I don't know what you thought about that, but I was just like, I was thinking like it's going to be like, you know, 48 hours versus 31 hours or something like that. Six days, eight days.
[00:41:26] Speaker B: I don't know. I did my residency in Canada. I don't remember there being wait lists that long. They were long, but not that long for emergencies.
[00:41:32] Speaker A: But what are you doing? Like they're there with the finger on ice for seven days.
[00:41:40] Speaker B: I don't know. I was surprised by that myself.
[00:41:44] Speaker A: Well, all right. So that's what blew my mind. Overall, in line with other, you know, that the outcomes didn't change, complications were less frequent. After they got the dedicated trauma room, revision rates did not change. So they, they support integrating dedicated orthopedic trauma rooms to improve operational efficiency and, and outcomes and hand trauma care. But I think, I think we can get the wait times down.
[00:42:08] Speaker B: So, yeah, that's something to work on.
[00:42:12] Speaker A: All right. Well, thanks, everyone. I think this was a great episode. We had lots of fun stuff to talk about, and definitely I learned a lot.
I know that I learned a lot about wait times in Canada.
So if you enjoyed what you heard, please, like, subscribe. Hit the notification bell.
Don't miss an episode, listen to back episodes and come back and see us in two weeks when Dr. Abdeen will be taking over and leading the charge. If you didn't like what you heard, maybe you're a hand surgeon from Canada and you're like, what do you mean a week is unacceptable?
Then thanks for listening to us this long. And again, everything here, take it a little bit with a grain of salt. We want to keep the conversations fun and come back again and hear what Dr. Abdiel has to say.
