Episode Transcript
[00:00:03] Speaker A: Welcome to your Cases on Hold, a JBJS podcast hosted by Antonia Chen and Andrew Stonefield.
[00:00:10] Speaker B: Here we discuss the science of each issue of JBJS with an additional dose of entertainment and pop culture.
[00:00:17] Speaker A: Take us with you in the gym, on the commute, or most certainly whenever your case is on.
Welcome back everyone, to your Cases on hold, episode 91 as we begin the journey to episode 100, this is the episode one on the path to 100. The next 10 episodes of your Case on Hold. If you're listening, on the day we drop, it's September 30th for the October 1st issue of JB JS.
I, as always, am Andrew Schoenfeld, Associate Editor for Methods, and I have with.
[00:00:57] Speaker B: Me Antonia Chen, Executive Editor at jbjs.
[00:01:01] Speaker A: For a limited time only. As always, these opinions the takes probably get hotter as we go to episode 100.
[00:01:11] Speaker B: They are like hotcakes hot.
[00:01:13] Speaker A: There we go. My opinions the opinions of Dr. Chen, not those of the Editor in Chief of JBJS or the other constituent journals in the JBGS family of publications, should not be taken as the opinions of the Executive Board. The Board of Trustees. This episode of JBGS is brought to you by JBGs, CME and clinical Classroom. So check that out if you're not already subscribing and getting credit for everything you do in association with the journal to begin with. If you haven't already, please like and subscribe. Share the podcast so that others can join the your Cases on Hold family.
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Barring that, you can get it at the JVGS website or maybe on YouTube. There's someplace that these videos get posted, but I don't even know where and I hate looking at myself on video anyway, so I'm not interested in finding out. But so if anybody find knows, don't. You don't have to tell me. The only place I see it is at the Academy meeting. They always have like at the JBGS thing we're in the background on a big screen.
[00:02:23] Speaker B: Well, it's also even more awkward when they take a picture of you in front of that big screen with you on it, right?
[00:02:28] Speaker A: Yes, like a frozen. And you never flat. Never flattering Anyhow.
So let's get into it. This is the top of the pile. The role of non inferiority studies in orthopedic surgery determining whether the outcomes are the same, no worse, or simply not different.
That sounds like a riddle. This is by BIRX Then we have the Presidential installation. I believe this is an AOA article. Institutional trust and leadership, or lack thereof. That's my own editorializing. This is by Dr. Ganayim. Then we have impact of Tourniquet Use on Arthroscopic Anterior Cruciate Ligament Reconstruction. Systematic review and meta analysis of Randomized control trials by Mirgadiri et al. You will notice that that's it for top of the pile. We are starting to see that the issues of JBGs are shrinking some. And we're going to have our headlines. We're going to have our your case on hold featurette. And then there's just a small handful of honorable mentions and a few on top of the pile. I think in the, in the next issue it's a little bit larger. But then I think, I believe once we get into November, most of these issues will be the size that we're seeing here right now in episode 91. At least that's my understanding from the powers that be. We'll see what comes to pass in the end. Let's get into the headlines here. My headline is Predicting Anterior Cruciate Ligament Reconstruction Revision Risk and Enhanced Machine Learning. Analysis of the Danish Knee Ligament Reconstruction Registry by Anderson and Colleagues. This comes with a comment and an infographic. I like stuff from Denmark. You ever have the Danish cookies at Christmas?
[00:04:13] Speaker B: Danish butter cookies, love those things.
[00:04:15] Speaker A: Yes, those are. Those go down way too easy.
[00:04:19] Speaker B: But look, I think it's the sugar crumb crisps on top that really my.
[00:04:23] Speaker A: Favorite is the pretzel.
[00:04:25] Speaker B: Oh, the pretzel one's my favorite too because it's got maximum surface area with the crisp. The sugar crystals on it.
[00:04:31] Speaker A: So.
Nice, nice. Send us, send us some, some butter cookies, guys.
[00:04:37] Speaker B: We're on for it, guys.
[00:04:39] Speaker A: There are no butter cookies in the ACL area, unfortunately.
So this is a study that analyzed surgical and patient reported outcome measure from almost 19,000 patients over 18,500 patients in the Danish registry who underwent ACL WHO between 2005 and 2023.
It's a machine learning study.
Obviously the idea behind machine learning is that when you have large data samples such as this, you can or the machine can rather identify patterns and see predictions in areas that you can't with the naked human eye. That's the, the advertising behind machine learning is it's the power of the computer to make all sorts of comparisons over and over and over again looking for patterns. You know, it's like the terminator eye with like all the information running in the background. But basically it's going to tell you stuff that you didn't even know about. It's going to show you things that you could not perceive yourself without the power of the machine and, and AI and all these innovations behind it. I think at the end of the day, as we've presented many machine learning papers over the course of our 90 episodes thus far, in your case is on hold. And it really comes down to one, how big is the sample that you're working off of? Two, what's your approach to machine learning?
And then three, what's produced a new paradigm?
This real epiphany of, wow, you know, I never would have thought of that before and I wouldn't. I wouldn't have known it. Or does it end up, you know, is it like this really momentous, you're at the top of Mount Everest and the view is just breathtaking? Or is it a Sopranos paradigm where you're just left with really, that. That's it.
You did all that. Just all that buildup just for, you know, age and smoking is the. Is the situation here. Not that. Not that that's the answer for this, but I'm just saying, like, that that's kind of where you are. You get like this huge build. The methods are always, you know, very rich. It looks like they're doing a lot of things. Is it they're really doing stuff? Or is it a man behind the green curtain sort of paradigm where it's just.
It's just a lot of show. And in this case, I think it's a little bit of both, honestly.
[00:07:18] Speaker B: You mean like more than meets the eye, Transformer style, Right?
[00:07:22] Speaker A: But it isn't Transformers. It's just somebody in a plastic suit.
[00:07:28] Speaker B: Touche.
[00:07:28] Speaker A: Right? That's the analogy.
Turns into a car. Or is it just somebody dressed up in a costume? Like, you get in Times Square and they're all creepy and fawning around and be like, you want to get your picture with Bumblebee? No, I don't want to get my picture with Bumblebee.
[00:07:43] Speaker B: You get to give a tip if you do.
[00:07:44] Speaker A: Remember that it's $80.
So, yeah, that's what this is. This, I think, ends up being the dude in the Bumblebee costume who's a creeper in Times Square, following you around, harassing you to get a photo sneak preview.
[00:08:03] Speaker B: Sounds like the idea of nightmares, but please, go ahead.
[00:08:05] Speaker A: Yeah, so, I mean, you know, they run all of these different models. They run all the standard models. They have the lasso and the stable, iterative, variable selection approach. And basically what they come up with is that they run a Cox regression analysis because that works the best.
So you could have just done this by running a Cox regression analysis and you didn't have to do the whole machine learning bit behind it. That's all, that's all, just preamble. At the end of the day, this is, they call it an ML Cox. It's a machine learning enhanced Cox analysis because essentially the machine learning piece helped select the final variables that were included in the Cox analysis. But this is, this is really what where I'm at because it's. The model is developed to calculate the risk at different follow up time points beyond the 12 month postoperative assessment.
Which is cool. That part is cool because you know, standard, you've just seen people up to 12 months and then maybe you're stopping, right? So this is, is going to be telling people, look at 12 months, these individuals with these characteristics, you need to keep watching them. Okay. And that part is cool.
Then they give you the math equation. And anytime you're putting a math equation in like a clinical research journal, it definitely gets the dude and the brand paradigm where you're just saying, no, no, don't, don't do that. Why are we giving the, the math equation here? Somebody's going to do it on the blackboard. Like go up and calculate the Danish knee score criteria during grand rounds here, come up, come up to the front and, and do the math. The 1 minus ST exponent to the negative 0.07. I'm.
No one is going to do the calculation. Right. And you don't need to do the calculation because now it's the dude and Brandt paradigm times two.
They of course have a handy dandy clinical utility that is available online for the risk monitoring tool. And again, no, don't, don't say that, don't say that. So don't give the math. And until you're, your model is like super vetted, prospectively validated, analyzed in other clinical contexts with complete. Until you have all of that, you shouldn't be making the tool available for clinical use because that part is not validated. You just came up with the model and the reality is that we know from most, and you've heard me say this before, but in most of these types of studies, these models don't hold up in other settings.
They're very good at predicting within the context of these parameters like how they operate in Denmark and nothing you know or how they operate in Norway, but these are countries that it's the size of like Boston, like population, or the greater Boston area, right?
There are more people in New York City than live in some of these, some of these countries in total.
And that's not anything. It's not casting aspersions or anything like that. But it's just when, when you're talking about a model that you're developing within a population that's already quite small, even though you can say, oh, we have 18,000 people, patients, right? But even among the 18,000 patients, is that spanning the complete spectrum of all possible iterations of patients with this condition in sufficient numbers? When you consider how it may present in the United States context or in the Chinese context, or in the Russian context or the Indian context or Southeast Asian context. No, it isn't. And it is a simple answer. It's rhetorical question. It's not.
And that's why they don't perform as well.
And that is why you need more scientific work around developing these types of parameters and looking at these types of predictive models before you start making handy online calculation tools that people can use to move on. And not belabor that point, they found that the enhanced ML Cox regression analysis that combined the LASSO and the SIEVES approaches demonstrated good accuracy. Their C index was 0.73. Their end of the curve C statistic is 0.73.
I'd like to see it a little bit higher, honestly.
And the ML Cox regression model provide the best prediction accuracy while utilizing four variables.
Age at surgery and three individual coos items. Pain, P1, quality of life, Q2 and Q3.
So the first thing is that this could be done if they just said, based on our conceptual model, we're going to go with age and these three coos items and run it in a Cox regression analysis at the end of the day. That's. That's what this is. The machine learning model picked out these, these variables. They let the machine learning model decide on that, and that's fine, but I'm like, you have 18,000 patients, and out of all these parameters, you just picked four parameters. It just doesn't seem like the machine learning model should have.
[00:13:19] Speaker B: It can take a lot, right?
[00:13:21] Speaker A: What did you eat for breakfast the day before the surgery? And all of these different things that are playing into the system, not just for fairly mundane characteristics that you could have come up with on your own, essentially. Like, so if I told you, you know, patients of a certain age, we'll just say in this context, you know, older patients who have higher pain and aren't doing well at 12 months after an ACL, do you think they're going to be more likely to need a revision surgery or not?
Yeah, I think they're going to be more likely to need a revision surgery. And any kind of percent estimates that you're getting off of this model are going to be parochial by definition to this Danish cohort, and not necessarily so. You could say, oh, if you have these, you know, there's a 20% risk, right? And in your, in your setting, in your highly involved athlete who's playing football, American football, not soccer in Texas, their revision risk could be 50%.
That's the other thing is that they say it's a simple tool for identifying patients who are considered at an increased risk for ACLR revision. Beyond routine orthopedic follow up. These patients may have already returned to pre injury, sporting or occupational activities, but their coos values place them in a cohort with a predicted increased risk of future ACL revision. This is also to some extent ignoring the intersection and important intersection, I believe, in this context, of how is the patient doing and how are they trying to return to their sport?
The person who's not doing well but keeps trying to push, push, push, push, push to get back to their sport, they're probably need a revision. The person who says, all right, you know what, I can't get back to my pre injury activity level. I'm just accepting it at this point. Maybe they don't end up needing a revision.
That's a component that I think is missing here and isn't considered and isn't presented. And you know, the way they present it in the discussion, it's sort of clear that it's not a seminal component of the prediction model. And that's a piece that I think is vital, really.
So I think it's a cool concept. I think it's a cool article.
I think there's just a lot of issues around both the approach and what they ended up coming up with.
And I have questions about how ultimately valid the predictions will be.
So if you're trying to do the math or make, you know, make the math math. The math is not mathing. Make the math work. Whatever Instagram meme you want to go with and use this yourself, I would say be very cautious.
Yeah, a lot of these end up like these prediction model validations. When they say, oh, it's validated, that really just means that your practice is similar to their practice and you have similar outcomes to them, which, which means you can use it, you certainly can use it, but it doesn't mean that it's going to be universally applicable to every sports medicine practice everywhere.
[00:16:20] Speaker B: And remember, we started this by talking about Denmark. So another big area, right?
[00:16:25] Speaker A: Yeah, yeah, it's probably good for Denmark. I mean Denmark is probably the place. I don't have questions about it being being applied to. Yeah, get those people back into the, into their sporting activities. And they probably don't even eat the Danish cookies there.
[00:16:42] Speaker B: They say they're dry, not as tasty for them.
[00:16:46] Speaker A: All right, your headline, Conversion of fused knees to total knee arthroplasty. The 21 to 31 year clinical results and patient satisfaction by Kim and colleagues.
30 days free with a visual summary. Take it away.
[00:17:00] Speaker B: Talk about long term follow up. And this is real world data, not necessarily just like AI learning and things like that, which I think is important.
So knee fusions converted to total knee arthroplasty is not necessarily a very common procedure, but there's very limited long term data on it. This study looked at the long term and when they say long term they said minimum 21 years, which is pretty impressive. Minimum long term typically means 10 years, I would say, but this is 21 years. Results of total neuroplasty and a fused knee looking at the following clinical and radiographic results, revision rates, complication rates, TKA survivorship and patient satisfaction. So they looked at patients from January 1993 to December 2005 and looked at 128 consecutive fused knees in 123 patients who were converted to total knee arthroplasty. And the indications for conversions were patient dissatisfaction with a disability, inability to sit properly, inability to use public transportation, difficulty in climbing stairs and low back pain due to garden gait alteration or limb length discrepancy. They excluded patients with active infection, foot and ankle disorders, dementia or history of stroke. Over the follow up period. Seven knees were excluded because they declined to participate in the study. Six knees died and that's actually pretty impressive. Over 21 plus year history, 20 knees were lost to follow up and clinical and radiographic results and patient satisfaction were analyzed in the remaining 93 patients which were 51 men and 42 women and and 50 or 95 knees.
The range of follow up minimum 21 which we already knew and it goes up to 31 years. And the mean follow up time was 25.1 years.
The mean age and standard deviation of the patients at the time of the index procedure was 42 years. Approximately the range was 23 to 62. So it is a younger patient population than what we typically do. For total knees, the mean weight was 59 kg, not BMI kilograms and the mean BMI was 24. So a different population than we typically have in the United States.
As I said, I said to clarify, the mean weight was 59. Truly weight, not BMI.
So why did all these patients undergo knee fusions? The most common reason was childhood tuberculosis in 56% of the patients. There was childhood pyogenic arthritis in 34% of the patients and rheumatoid arthritis in 11% of the patients. The mean duration of fusion was approximately 20 years, range of 5 to 36 years.
Previous operations were performed in 83% of the knees. They did to have arthrotomy for the knee joint to drain pus was in 21% of the knees, twice in seven knees and three times six knees. So a lot of infection and then finally just led to fusion. Probably to reduce the likelihood of needing to undergo these treatments for infectious processes.
Surgical arthrodesis had been performed in 48% and the remaining knees had undergone spontaneous fusions. These weren't all surgical fusions. Some of these are spontaneous fusions.
The mean position of the fused knees was 40 degrees of flexion. This is what's interesting to me. They have a range of 0 to 135 degrees of flexion.
I guess they spontaneously fused in 135. That's a really interesting way to ambulate. You talk about a fully fully flexed legged all the way. And that's what their fusion was, a vy. So from a surgical perspective, when they underwent the conversion from the fusion to a total knee, a VY quadriceplasty was performed in 75% of patients to prevent patella tender evulsion. The patella was osteotomized from the femoral condyles in almost 70% of patients. The two implants they used were from the same company.
One was a semi constrained and that was done in 47% of patients. And then a PS or posterior stabilized components were used in 53% of patients. So they were able to use primary knee components in the slight majority of patients. But really it was almost 50, 50 divided down the center.
The semiconstrained knee components that were used in the 26% of knees these patients refused in greater than 75%. Sorry, 75 degrees of flexion. So these type of patients you probably do a huge amount of soft tissue releases medial lateral collaterals, everything to go.
Actually not, no, they didn't do hinges. I'm sorry, this is a semi constraint. So they just wanted to release more. So they ended up using revision components or as we'll talk about in a little bit. They also had bone loss. And so because of bone loss they used femoral and tibial augments in a in about 52% of patients. So that helped maintain the joint line, et cetera.
For those who had been fused in greater than 75 degrees of flexion, if they ended up in 45 degree of flexion or more at the end of surgery, they use skeletal traction through a threaded Styman pin in the distal tibia to pull on the patient as opposed to further soft tissue releases or bone resection.
So that's pretty impressive. I don't know if that would work as well in our country. I don't know if people would be okay with have skeletal traction for long periods of time, but they did that and it seemed to help with people's range of motion.
They were followed up at three months, one year, and then every five years they had knee society scores, Womack scores and UCLA activity scores.
@ the outpatient final follow up, patients got a five point Likert scale to look at their satisfaction and their ability to perform housework and yard work, ability to engage in recreational activity and just their overall results.
They graded their change in quality of life with one of six different responses. More than I ever dreamed possible. Great improvement, moderate improvement, a little improvement and no improvement or the quality of my life is worse than prior to surgery.
How did these patients do? The mean Knee Society score started at 60 and went up to 88 postoperatively. At the final follow up, very few had excellent Knee society scores, only 5%. The majority, 69%, had good scores, 14% had fair scores and 12% had poor scores. The mean Womack score was approximately 68 points pre op and 21 points post op.
The mean knee flexion at the final follow up was 76.4 degrees with a range of 70 to 105. The mean extension lag was 13 degrees with a range between 8 to 21 degrees. Before the operation, 13% had been non walkers while 87% had been able to walk less or equal to five blocks. But no patients were able to walk more than five blocks. At the final follow up, there were no patients that was a non walker, so everyone was walking.
16% were able to walk less than or equal to five blocks and 84% were able to walk greater to five blocks. So from a functional standpoint, that's pretty impressive. Being able to walk more. Now what? It doesn't tease out is it, you know, six blocks, seven blocks, eight blocks. We don't know, you know, walk a marathon, that sort of stuff. We don't know the details of how much they can actually walk. The mean UCLA activity score was five points preoperatively and six points postoperatively. At final follow up, knee alignment was pretty good at 3.6degrees of valgus. The final follow up, no knee had greater than 5 millimeter of instability on manual stress testing, probably because they were incredibly stiff. And radiographs had no visible radiolucency at the bone cement or cement implant interface in 91% of the knees.
With regards to revisions, 9% underwent revision for aseptic loosening.
One knee was revised for infection and another knee was revised for recurrent tuberculosis infection.
The overall patient satisfaction score at the final follow up was 77 points.
Satisfaction regarding pain relief, housework, recreational activities and surgical Results were approximately 80%.
Approximately 20% were neutral or dissatisfied.
67% of patients said their quality of life improved greatly after surgery, but approximately 10% said their quality of life was actually worse. Kaplan Meier survivorship with failure as an end or vision for failure as an endpoint was 88.4% at 25.1 years postoperatively. This is a huge series of fused knees. I haven't seen that many fused knees in my own career. So to have such a collection of them over that period of time with 25 year follow up is pretty impressive. They might see more pathogenic arthritis than we do. More spontaneous fusions. I don't know what the Korean population is, but that is where the study was done. But it was surprising to see that many patients being converted to neuroplasty. Again, it's a different patient population for the United States, but you know, it gives us some tips and tricks. There are some surgical tips and tricks in here, but it is interesting data and I do respect that it is a long follow up study and give some outcomes of this difficult patient population.
[00:25:42] Speaker A: Yeah, no, you got to respect the follow up for sure. I mean that's a tremendous amount of time to, to keep track of these patients and have them come in for these functional evaluations. It is a rote clinical retrospective of this group's experience.
I would have liked to have seen 95% confidence intervals just developed around the small number of event rates. It's not that large. I mean it's large for the problem, but it's not that large when you just consider the total numbers and having some 95% confidence intervals developed around you Know the estimates regarding how many required revision or when a recurrent infection or etc. Would have been nice, but all in all you got to respect the follow up there. All right, moving into the your cases on hold featurette.
Efficacy and safety of tranexamic acid combined with absorbable hemostat in reducing perioperative blood loss in total knee arthroplasty. A prospective blinded randomized controlled trial by Zhang and colleagues. It's with a comment infographic 30 days free. You hit the Perfecta on this one. What's your TXA admin preference? Is it IV pre op and then before closing?
[00:27:01] Speaker B: Yes, that's the standard, right?
[00:27:03] Speaker A: That's the standard.
[00:27:04] Speaker B: That is a standard. It's easier from a perspective. Oral used to be a lot cheaper, but you administered that sometime before surgery. So for admissions trip we will take oral tranexamic acid actually, which is pretty nice and then topical for those patients who really can't tolerate it orally.
[00:27:20] Speaker A: Right. So this is a randomized trial that had three arms. This study included tranexamic acid and then in combination or separately with absorbable hemostat, which is a hemostatic agent that unlike the anti fibrinolytic mechanism of txa, the absorbable hemostat exerts a local hemostatic effect through physical and chemical pathways. Upon contact with blood, this agent causes erythrocyte destruction, exposing hemoglobin. The carboxyl groups in the hemostat further oxidize hemoglobin to hematin, releasing ferric ions. Accelerate plate with aggregation adhesion, leading to the formation of a hemostatic thrombus. Additionally, by providing a scaffold for platelet adhesion and aggregation and enabling the formation of a gelatinous mass through its water absorbing property, the hemostat effectively controls bleeding from capillaries, venules and arterioles. This is all language that's directly contained in the paper I just for me and spine, it's basically thrombin and gel foam. That's the equivalent that comes to mind.
The hemostat can also be used as a scaffold to absorb txa, they say preventing local loss.
So the way this study was done, all surgeries were performed by the same surgeon. Using a standard anterior midline incision, a tourniquet was applied for 10 minutes at the time of skin incision and then during cementation. In the TXA group, TXA alone, 1 gram of TXA was applied locally within the joint cavity.
In the hemostat alone group, they had a Sheet that was positioned posterior, inferior, medial and superior to the joint capsule. And then in the combined group, they basically did both things together.
The results show there was a significant reduction in perioperative blood loss in the combined cohort, which did the best, probably not surprisingly, the worst was TXA alone, and then in between the two was the hemostat alone. Regarding safety, the combination of the two did not increase risk of DVT and or pe, which is great.
But a couple of thoughts here. So the first thing that really struck me and love for you to weigh in here is the blood loss. Now, again, they. They immediately went to look at the surgical technique when I saw the blood loss in the abstract, and I was like, how are they doing the surgery? You know, what's the deal with the tourniquet? They only had the tourniquet up at certain small amounts of time because in the TXA alone group, the blood loss was basically 879ccs.
That just seems a lot.
I mean, you're. You're getting close to like a liter there.
[00:30:19] Speaker B: So this is the hardest part about blood loss, right?
Whenever you ask a surgeon how much blood loss they had, they're like minimal, you know what I mean? Or like 100cc, right?
[00:30:27] Speaker A: There will be minimal blood loss, there will be min.
[00:30:30] Speaker B: There will be minimal blood loss. The patient has a condition called asystole. I have not before and so. But the hidden blood loss, I think, is an interesting one that people don't take into account.
So I think we lose a lot more blood than we realize. Is it a literary time? I don't know, but it is one of those things where it can actually be a good amount of blood, surprisingly enough.
[00:30:54] Speaker A: Now, you know, they had all these other parameters, which I think I'm focused on the clinical aspects, but they did all of these other things where there's kind of like a basic science component to this too.
They had in vitro dynamic coagulation assays, LDH activity measurements, scanning em. They used a in vivo rabbit liver bleeding model to assess these different parameters. And that's all well and good, but the RCT part is what we're really focused on here. And that's the part where some of this is proof of concept. What we're talking about is translational capacity and generalizability.
I think that the single surgeon. So I mean, this is the thing like the single surgeon, good and bad, right? Because the single surgeon, there's no blinding here. The surgeon has to know what they're doing. You have to tell them, like, you're going to do the TXA or you're going to do the. And if the surgeon knows what they're doing, they, they could swing it a certain way, like they could do some things to try to reduce the blood loss. It's just one person.
So they're doing a randomized trial.
You want that randomized trial to have results that are reportable. Right. And if they all do the same, it's probably not going to be publishable. Right. So is there some implicit potential for bias there? I think there could be and I just have some concern, I get what you're saying about the hidden, the hidden blood loss, but I just have some concern with the face validity on the EVL for the 2 TXA, which I think is, is really so well established as far as its efficacy in reducing blood loss. If the TXA and the hemostat group together, like just that those two alone, if they had comparable blood loss, I'd say fine. But they don't. The TXA was 879, the hemostat was 693.
So I just think that those numbers are a little bit suspect to me. I think there's, there's some that the face validity there, I think you're kind of getting called into question.
[00:32:55] Speaker B: Doesn't pass the sniff test is what you would expect from blood loss, right?
[00:32:58] Speaker A: I'd expect what I'm, you know, just thinking of as like applying thrombin and gel foam or putting TXA around. Like they should basically be doing the same. Right. Otherwise why are we even using txa? We should just be doing the, the thrombin and gelfoam. Now again, that brings us back to the question I posed to you at the beginning where I. This is not the, this is not the ideal approach for txa. I think, I think the standard is the IV pre op and then prior to closure. Right.
[00:33:27] Speaker B: I think most people use that for sure.
[00:33:29] Speaker A: Yeah. So this is not an apples to apples comparison. And obviously if you're going to use two hemostatic agents, why wouldn't we expect that those are going to probably perform better than if you're just using one alone? Right?
[00:33:42] Speaker B: Exactly. More. Better. More.
[00:33:44] Speaker A: More is better. But is the cost just.
[00:33:48] Speaker B: Right. And that's where this money in dollar bills, Right.
[00:33:51] Speaker A: Do you need it? If we're just talking about the hemostat versus hemostat and TXA, it's about a difference of 130ccs.
So is the added cost of the TXA? TXA is not really that expensive at the end of the day is the added cost justified for 130cc?
[00:34:15] Speaker B: Exactly. And, and like there's no transfusion. Like it's not a transfusion rate thing. Right. Because that's where the money is. Right? If you have transfusion or transfusion reactions, that's the problem. But the actual just number of blood loss, it's harder to say that how important that is or not.
[00:34:28] Speaker A: So I mean as far as like the RCT aspect and everything, I don't, you know, the study was well done. I think there's some. When you start to drill deeper below the surface, there are some things here that I think is a cause for cause. At the end of the day, don't have a problem with the ultimate message. Just clinical impact, I guess is probably my right.
[00:34:52] Speaker B: What does 100cc do for you and how much? 200. Now if you say it's a liter difference, then we're talking about some big real numbers here. Right? But you're not talking about transfusion. You're not talking about changes in clinical care.
We have very low transfusion thresholds now. So I think it's very different.
[00:35:09] Speaker A: Anything else from your end on that front?
[00:35:11] Speaker B: No, I'm with you.
Things where more is supposedly better, but at what cost?
[00:35:17] Speaker A: We're getting into the honorable mentions. Hang on everyone. So you can hear about what else there is in the best and brightest in JBJs. This issue we have. Involvement of oxidative stress and glycation stress in frozen shoulder. This is a study involving 38 participants, 35 to 70 years old, 16 with a frozen shoulder and 22 with a rotator cuff tear without range of motion limitations.
In the frozen shoulder group, oxidative stress was indicated by elevated DHE fluorescence and protein carbona levels in tissue samples from both the rotator interval and the middle glenohumeral ligament. They found that the frozen shoulder group showed increased expression of glycation stress genes and and nox along with decreased SOD expression and activity which they felt was indicative of oxidative stress. Oxidative stress in addition to glycation stress should be involved or could be involved in the pathogenesis of frozen shoulder, according to that report by Surakami and colleagues. Then we have effective communication strategies to address excessive waste and over consumption. In the orthopedic operating room by Bel Air and Frayling with a comment.
This has some clinical scenarios. It's Dr. A's first case of the day. That's you that they're talking about, I think. Except It's a type 3 supercharged hemorrhofracture so you must have been on call. And she says I'm planning to pin the elbow without an open incision. Should be a small and straightforward case.
I like hearing that they say so I'm just going to read this because I think it's, it's entertaining. So she finds herself standing among trash bags filled with discarded plastic drapes, unused basins and suction tubing, unused Bovie plastic holder, stacks of clean disposable towels, endless supply of barely touched egg crate foam pads. She and her team are piling each of these items into waiting trash bags destined for landfill.
Much of this waste could have been avoided if there were better systems to communicate the anticipated needs for a surgery. She tries to push aside the nagging thought that inaction on this issue violates her commitment to responsibly manage health care resources. As she stands among the trash, she cannot help but feel complicit in this large scale wrongdoing to our natural environment, patients and ourselves. It's like a choose your own adventure.
Remember those books?
[00:37:49] Speaker B: Oh, I love those books but I didn't feel so bad after reading them.
[00:37:56] Speaker A: Is definitely depressing.
Yeah. So check out what their recommendations are in terms of, you know, better practices to communicate. It sounded like she tried to communicate though in her defense.
But Next we have 4th generation transverse osteotomies for hallux valgus by Lam and colleagues. Permanently free.
This is a study That's a level 4 therapeutic study looking at 729ft. 483 patients who underwent 4th generation metatarsal extracapular transverse osteotomy. They maintain this is the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity conformity and demonstrate significant improvement in clinical and radiographic outcomes with a low rate of recurrence. Basically just a very large rote clinical retrospective of these authors experience with with this technique. But obviously there is definitely some real power there in terms of the total numbers of patients that rounds it out for this episode.
We're kind of running out of time at this point. We'll try to do better next time.
If you like what you heard, come back in two weeks where we'll be on episode 92.
If you didn't. Thanks for sticking with us this long and stay tuned as we continue to move towards episode 100. We can only work with the substrate that we're given in terms of the articles in every issue.
