Episode 18, Season 2. Chuck and Chris welcome Rob Kamal from Stanford to discuss distal radius fractures, the new Clinical Practice Guideline(CPG) on distal radius fracture, and quality in outcomes. We do focus to unwind the CPG and highlight key points with Dr. Kamal who led this effort of the AAOS and ASSH.
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Episode 18, Season 2. Chuck and Chris welcome Rob Kamal from Stanford to discuss distal radius fractures, the new Clinical Practice Guideline(CPG) on distal radius fracture, and quality in outcomes. We do focus to unwind the CPG and highlight key points with Dr. Kamal who led this effort of the AAOS and ASSH.
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Welcome to the upper hand for Chuck and Chris talk Hand Surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
Charles Goldfarb:Thank you for subscribing. Wherever you get your podcasts
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I am really well tonight.
Chris Dy:Oh, just another weeknight on zoom. We love this.
Charles Goldfarb:We love it. But it's a special night.
Chris Dy:It is it is we have a friend joining us Rob Kamal from Stanford. I'm excited. I'll let you introduce him in a second. But tell me what's going on in your world right now.
Charles Goldfarb:You know, all good. Actually, I'm working on this grant, which is absolutely killing me. But it's I got another week or so I look, I'm I'm trying to walk in your shoes and be successful in the grant world. But you know, I don't have your experience.
Chris Dy:You know, this is probably the only area in which I might might have a little more experience than you. But can you know, good luck with the grants? You know, I think like we talked about in the past that grant is a labor of love. But it's a nice way to crystallize your thought process and really understand A what you're trying to do and B does what you're trying to do really matter. And sometimes I've scrapped ideas, because I've tried to write a grant around it and realize it's awful.
Charles Goldfarb:Well, it's interesting not to go down too much of a rabbit hole here. But I wrote what I thought was a great grant last year, and it was it was scored well, but not well enough through the Shriner system, and sizable grant. And I was really, you know, the first reaction is anger. And then now that I'm redoing it, it's a better grant. You know, it really is there's no doubt about it.
Chris Dy:As painful as the peer review process is, it does end up with a better product, I think, especially for grants, and most of the times for papers. But especially for grants, at least, you know, when you submitted to, to places that give you good feedback, even if that's internal feedback.
Charles Goldfarb:Absolutely. Can I share a super quick and short review? And then I have a question from a listener for you.
Chris Dy:Oh, all right. Fantastic.
Charles Goldfarb:All right. So the review is from a one of our physical therapy colleagues here in St. Louis, Laura Jenkins, she does not work directly with us. But we were emailing about a conference we do on Friday mornings around sports. And so she emailed to say how great that was. And then she says, I know that I've told you before, but I also really enjoy your podcast. I recently caught up on a quick trip to and from Iowa. And you and Dr. Dy kept me entertained the entire trip. Laura, thank you. That is our goal we want to entertain.
Chris Dy:We are driveway radio. So I hope when you pulled into St. Louis, you weren't sad that your trip was done.
Charles Goldfarb:We'd like to think we're driveway, radio or whatever, whatever the NPR comment is, we like to think that way.
Chris Dy:Hashtag squad goals.
Charles Goldfarb:Yes. So here was the question I got for you. And then we really need to jump to our guests because he has a lot to share them. And it's going to be gold. The question was, is it really true that Dr. Dy does a pronator decompression in 20% of his carpal tunnel release patients? Because apparently, that's what you said. Is that, Does that ring true still today?
Chris Dy:Um, I will you know, what I've started to do in patients, for example, asked me something like, how many of these have you done? I will then actually pull up in my Outlook calendar and say, This is how many I've done. So I told the patient a month ago exactly how many ulnar nerve transpositions I have done within the last like three or four years. So I will look, I am not sure. I don't think it's there anymore. It was at one point, maybe even a little higher than that. But I think I've settled into probably a 10 to 15% range. But when was the podcast recorded?
Charles Goldfarb:I didn't ask that question. I think it was in the last couple of months.
Chris Dy:Show me the receipts.
Charles Goldfarb:Well we'll dig it up.
Chris Dy:Alright, so one and one thing that I wanted to, you know, last last week, we did our detail episode. And we talked about carpal tunnel release incisions. And I said I made mine three or four centimeters. And then I thought about that. And the women in the who are listening, are gonna laugh about a man not knowing how to measure, but actually went and measured my incisions and I'm like, shit I was wrong. Actually is two to three centimeters. And I remember now that in retrospect, I tell patients, it's about an inch or a little bit less than that, because that's what Americans understand.
Charles Goldfarb:That is for sure. All right, I want to ask our guests one of these questions, but let's jump in and introduce Rob Kamal our friend from Stanford. Rob if it's okay, I'm going to just share a little of your bio and I hope I get this right. But and I've learned a little bit about reading your bio. So Rob went did his undergraduate and medical education in our great state of Missouri.
Rob Kamal:That's right.
Chris Dy:Oh, you were one of those baby docs, aren't you?
Rob Kamal:That's right. I'm still a baby doc. I'm still a baby doc.
Chris Dy:Yeah, yeah, apparently that's gonna work for us at some point around
Charles Goldfarb:From one to another, from me who knows nothing about that. And he then went to Brown University, which we all know is a wonderful place, and did your trauma fellowship at Brown did your hand and upper extremity along with microsurgery at Duke, and then you went on to even more training a Master's or an MBA at UMass Amherst, which is awesome, I'm jealous of that for sure. And then you have been adding to your skill set, including a research fellowship at the University of Barcelona, and the NIH and the University of Iowa. So we know and you and you shared with us that your role at Stanford is super important as you are the value based care champion, the director of the voices Health Policy Research Center for the Department of orthopedic surgery, and you've really at a, really super impressively in all seriousness at a young age established yourself and your area of research in a really remarkable way. So first of all, thank you for joining us. We're excited to learn from you. And welcome.
Rob Kamal:That's very kind to you. But thanks for having me. I'm looking forward to it. Especially when we're talking about length and measurement. I'm really interested in how we're going to.
Charles Goldfarb:As the old guy I'll need to redirect both of you.
Chris Dy:Oh boy, we have to put the explicit tag on this one pretty soon. So a couple things about Rob. Rob is incredibly impressive, and that, you know, so Chuck talks about all the things that Rob has accomplished, but he has a career development award from the NIH, which is an uncommon accomplishment is probably a handful of hand surgeons in the country that have done that. So, congrats to you Rob on that, and we look forward to seeing where that's going to go. The second thing I wanted to say is that Rob is an example of living your best life because the last memory I have of seeing Rob in person was on the beach in Fort Lauderdale where at the ASPN meeting and while it was ASPN for me, AHS for everybody else as well. It was windy, it was 50 degrees or 60 degrees. He's sitting in one of those little covered beach cabanas with his laptop just knocking it out.
Rob Kamal:I was doing some work.
Chris Dy:And I was there with my kid who was just wanted to be on the beach even in 50 degree weather. I'm freezing. But Rafi wanted to build a sandcastle. So that's what dads do.
Rob Kamal:Awesome.
Chris Dy:And then the last thing I will ask you rob, does being the quality and value champion come with a belt? Like a WWF?
Rob Kamal:It does. Yeah. No, but it does here. It's an organic type of Bell local. Locally sourced. Yeah.
Chris Dy:Tell tell my gardener. He's got to get you a better belt.
Charles Goldfarb:Rob, I need to know where you fall on the original question of the night. When you perform a carpal tunnel release. Are you closer to Chris does 15% of those patients get a pronator decompression, or my 2%?
Rob Kamal:Yeah, I'm like probably less than 1%. For me. I've probably I can count on one hand, maybe.
Charles Goldfarb:Thank you for your being a reasonable person. Rob.
Rob Kamal:No maybe something is seeing me and I'm not seeing it. But I don't know.
Chris Dy:I saw it after I went to Switzerland or Sweden. Excuse me, Sweden. So.
Charles Goldfarb:Alright, well, let's jump in.
Chris Dy:Yeah. So Rob, you we asked you to be on the podcast because these clinical practice guidelines for disarray as factors came out. And clearly you were leading this effort because
Rob Kamal:I didn't know if you ask me because you were just upset or something. And so I was sort of I would I debated for a while whether I should do this or not. But uh, hopefully it's all good.
Chris Dy:The bag is coming over your head pretty soon. So you have a reputation in this area. So how did you start working in the quality field because you really, you know, work this space. You know, as an orthopedic surgeon.
Rob Kamal:You know, this is a fun space to be in because it is a little bit of a moving target, which which makes it kind of interesting, right? So when you talk about quality, just in and of itself, what it is changes as we begin understanding science better. And so what perhaps was quality care, quote, unquote, 20 years ago is different now. Right, sort of, it's like doing 20% pronators now versus maybe 20 years from now we won't be doing it, I don't know. But it's sort of like how things are moving and changing based on how we learn. And that makes it interesting because it stops things from getting a little stale. It keeps you on your toes, you start having to figure out The different perspectives that begin driving those definitions, right, who's calling something quality oftentimes depends on their perspective. And there may be, you know, certain incentives for that. And so it makes it interesting. In that way, it also makes it really challenging in that way. But yeah, it's fun. And I think, I think we all are learning about it together, right, it took, you know, 10 years ago, as a concept, or as a construct, even it was probably hard to wrap ourselves around it. And even now, we have some difficulty, but we're getting better at and I think, as a field, we've all been learning about it together over the past, you know, 5-10 years.
Charles Goldfarb:So, if you don't mind, take us a little bit of a step back. And let's make sure all of our listeners are on the same page. And so, you know, I don't want to make any assumptions. And I think we have listeners at all levels. So essentially, we are paid today, based on the time and I guess, effort we put forth in clinic. And we are paid based on the procedures we do in the operating room to dumb it down. And the hope is that in time, we will be paid for how well patients do what their outcomes are, and how well we provide a valued service. Is that a fair? very generalized summation?
Rob Kamal:Yeah, I think, I think you're jumping into value, which adds another sort of step to this whole process. But yeah, so it's, it's, it's easier to reimburse based on things that we can all agree, we can control and measure, which is why it's easier to pay people based on what they do. Because it's a it's a defined moment. It's harder when you start saying, Well, I'm going to pay you based on the outcome that you achieve, because you have to ask questions. Well, who's defining the outcome? There's a value system to the outcome itself, right? So is it what I consider an outcome or what you consider an outcome or the patient? And how might that change? The how you begin defining what that outcome is changes as our evidence improves, right? And so the interventions for that change. And then, when you talk about value as an example, then you start talking about cost, right? So when we talk about the, let's say, paying you, but I'm not just paying you, right, I have to pay your hospital system, as a patient, I have to pay out of pocket. So there's all these other costs that are occurring, that if you took them all together, that's really the value of care that's being provided, right? You as a surgeon, you know, as a surgeon, if you told me, well, I'll pay pay you based on outcomes, you should really only pay me on the outcomes that I have. I can control, it probably isn't fair to pay me based on outcomes that I can't control. But who defines what's controllable and not right, well, who defines what's modifiable, and non modifiable. And perhaps there's newer evidence on ways that we can begin modifying things that we used to think were not modifiable? So you can see how it gets a little bit muddy. But But I think there's an opportunity there, because certainly what you mentioned before is right now the incentive is to pay you for doing stuff.
Chris Dy:Rob, can I ask you? For again, you know, we have listeners from various backgrounds, you know, what exactly is a clinical practice guideline? And how do we use them? And we'll get into the weeds a little bit about how this particular one was, was conceived and kind of brought to fruition but just a high level view? What are these?
Rob Kamal:Yeah, so clinical practice guidelines are a way of synthesizing the current state of the evidence for a given question or topic, and giving people a sense of the strength of the evidence for that question. Perhaps giving them a little bit of background as if there's evidence that supports something or goes against something, but generally, what the conclusions can be for a given question how strong that conclusion is. So it, it comes from not only the strength of evidence and the quality of the papers, for example, that you're evaluating, but also some some amount of ability to analyze those and get a sense of, you know, how do we package that together to make it something usable, so that we can read it as orthopedic surgeons and say, Okay, I understand the background for this and I understand sort of what I should do with this information when a patient is in front of me.
Chris Dy:Are they like algorithms on to tell you how to do you know how to make decisions in the clinic?
Rob Kamal:They're, they're guiding you know, I think we look at them as guiding structures and that they're not going to be specific enough for individual patients. And, and if you get if you dive into them, they very much will tell you a lot of this, there's a level of assumption, and you have to sort of treat the patient that's in front of you based on their own sort of values and preferences. But it does give you some guidance as to when things have been studied in very controlled ways. What are those results look like? And how might I take those and apply them for the person in front of me without being too prescriptive?
Charles Goldfarb:And your expertise in quality, obviously, is what this is all about helping to judge the quality of the literature that should serve to guide the care that we provide. Correct?
Rob Kamal:Yeah, so it's, it's a judging the quality of studies and also assessing sort of how to synthesize some conclusions from that in a way they're usable for surgeons that are, you know, they're taking care of patients.
Charles Goldfarb:And so just for, again, for our audience a little bit, as I understand, there's four upper extremity guidelines, there's carpal tunnel, there's distal radius, I think there's rotator cuff and maybe shoulder osteoarthritis. And there's multiple others in orthopedics for different parts of the body. And they're, they're available online. But there's also an app, the ortho guidelines app, which has these as well, for a quick look for a quick reference, you know, as Chris said, maybe in the clinic, or just to access. So it is these these guidelines, you know, I find valuable, we'll get into the weeds, but but it is a tremendous amount of work. So thank you for all that you've done to make this happen.
Rob Kamal:Well, no, thank you. I mean, this is really based on people's studies. And there's a lot of, I think, sweat that goes into the studies that and the questions people ask. And so this really leverages, you know, well done studies that answer questions that we all ask ourselves when patients are in front of us and is able to then take those studies and give us something that's usable. So the app is definitely very friendly for that purpose of you know, you there's somebody in front of you, you're not really sure what to do, it does provide some of that guidance Now Rob, I'm going to call you out. I'm gonna I did a little word search in your PDF, and I found no studies by Chuck Goldfarb. The man is a workman with a hammer, looking for nails, but his hammering was not good enough for the distal radius CPG.
Charles Goldfarb:And we know therefore that it's high quality. So good work.
Chris Dy:You missed the boat on that one. Rob. Come on, man.
Rob Kamal:Yeah, I know, I'm sorry. I know, I have read Chuck's papers on distal radius fractures. I just don't know if they may be the time in which they're published didn't meet our, our threshold.
Chris Dy:The medical librarian threw it out. We know what happened.
Rob Kamal:No they had to be digital is the thing. And so yeah.
Charles Goldfarb:I just read that, like Chris says, Chuck's old, the paper's a long time ago.
Chris Dy:So Rob, how long did this take? Like, when did you, you know, when did you start this process? And then when was it released?
Rob Kamal:Yes, so we started this, it was the, I think the fall of 2019, is when we started sort of putting the group together and planning the meetings. And we didn't finish it till it was the if it was approved by the board at the end of last year, so December of 2020. So it was a year and a half or so plus of time and planning. You know, it's interesting, we, we, it's a multi stakeholder group. So the goal is really to get diverse perspectives. And this was one of the first that the academy had done with the plan of doing the meetings virtually even before so we're in the COVID area. And so it worked out, logistically actually quite well, where we had just very productive conference calls, we weren't doing zooms, and we were just doing conference calls on switch we've continued doing but they ended up being very productive. But it's a, it's a lot of time and effort, a lot of volunteer time and effort of hand surgeons and trauma surgeons and therapists, and general orthopedic surgeons, and a lot of time and effort from the Academy, the AOS, and this was actually a product where the hand society, the ASSH and the AOS did this together. So this was a joint venture, the funding and was split between the two groups. And it's, it's sort of endorsed by both groups. And again, that makes it pretty unique and at least from the academy side showed a good way of subspecialist society working on a common condition that a lot of surgeons deal with.
Chris Dy:So, um, so can you give us just before we dive into each recommendation, give us an overview of what just a process is like, you know, have to get into the weeds too much but what what is a CPG supposed to do in terms of you know, filtering the evidence.
Rob Kamal:Yeah, so it the one of the important things that I mentioned was really getting together a diverse group of stakeholders that deal with these patients, whether it's before surgery during surgery after surgery, and asking questions that are clinically meaningful, meaning asking questions that we really think are important and will change practice or inform practice, or we know that there's areas of variation that we could probably identify and help guide with the with the CPG. Once you get your group together, and you get a sense of what sort of topics people think, are important, you begin formulating these Pico questions. And essentially, what you're doing is formulating an answerable question where you can identify the population and what the intervention is, etc, what's the outcome you're assessing. And once you formulate that, one of the benefits of working with the Academy is that really the Academy's librarians and their sort of data analysis group can begin doing the review. And in some ways, it allows for it to be an unbiased analysis of evidence and the quality of evidence. At the same time, the reason you have the group in the CPGs is that as clinicians, there's some nuance to papers that we understand when you know, when we read them. And so there you have both of those, you have this very unbiased, in some ways, external group of people analyzing papers and giving you a feedback on their quality. And the other way, as surgeons, or physicians or clinicians taking care of these patients and reading these papers, we know some of the background and can add some of the context that's missing. So you take their the quality analysis, the papers and the conclusion from the papers. And based on that there's a preliminary sort of recommendation that the group then gets to begin analyzing and providing a strength for the recommendation based on the quality of the studies. And so that's what you see sort of in the summary table for the CPG is the strength of the recommendation based on the evidence that was found on that systematic review.
Charles Goldfarb:So there's a lot of smart people in the room, no doubt about it there during the panel was great. How often? Did you guys find yourself disagreeing with one another? about things? And how often is it just a, you know, agreement? And massaging maybe how you say what you say, but but how contentious does this process? Or is it not at all?
Rob Kamal:Yeah, I think I think like you guys probably know, a lot of it depends on just who you have on around the table on how well people can work together and collegial. And generally, I think we try to work collegial with each other. And everybody has diverse opinions that may not agree. The beauty of this process, I think is that it is grounded in the evidence. So there, you know, while there is some opportunity and leeway for subjectivity, maybe in your analysis, or maybe knowing something that's not written in the paper, you really have to be grounded in your conclusions based on the quality assessment of the evidence which occurred by an unbiased group of people at the AOS, and what you know, when you add all those up what you get. So it does, you know, grounding the discussion in this is what the paper showed, does help, I think, minimize a lot of those conflicts, but there's always going to be conflict and disagreement. And you'll find if you, if you dig into the CPG, there's areas where we highlight some of that, you know, there's maybe areas where there's inconsistent, inconsistencies in the evidence, and we highlight that and say, you know, a lot of papers said A and some papers said B, and that's why we had this result. And perhaps there's an opportunity to really figure some of this out by another study.
Chris Dy:So let's let's dive in. And we'll start with the first one. And you can, you know, I'll read the recommendation, and then you guys can debate him.
Rob Kamal:I think, I think I think Chuck published a paper on this in the past, I don't know how much I want to debate him on this.
Chris Dy:Alright, so it can inconsistent evidence suggests no difference in outcomes between use of arthroscopic assistance and no arthroscopic assistance when treating patients for distal radius fractures.
Charles Goldfarb:Well, and the strength is moderate. So.
Rob Kamal:Yeah, so to get a moderate strength recommendation, you have to have one high quality study or I think two moderate quality studies, this is where some you know, some of the expertise can come into play, because you are able to analyze these papers and downgrade their strength based on some nuance, you know, in terms of, for example, the population that was used or something like that. Generally, when we looked at the literature for this, a lot of them our single surgeon retrospective reviews, but there were some randomized controlled trials that we included the inconsistent because there was some debate, even between, let's say two randomized control trials in terms of what the results are. But there was more literature supporting, no difference. Certainly a high level of evidence studies showing no difference with arthroscopic versus not in reduction.
Charles Goldfarb:And remind me that there was a, the most famous paper on this, I think is what is old from Doy. But this CPG only goes back a certain number of years is that is that accurate?
Rob Kamal:So we went back 10 years, there was a high RCT from Yamazaki in 2015. That was, I think, at least one of the studies included in in this analysis.
Chris Dy:So to pull it out of the librarian mode. Does this CPG does this match with your practice before the CPG? And has it changed what you do now for for both of you, because I don't scope wrist for fractures.
Rob Kamal:Yeah, I don't scope wrist for fractures either. But I think that it occurs, I would assume that perhaps it occurs on a individual basis for specific patterns or things like that. And I think there's probably some opportunity here. So again, the recommendation is based on the level of evidence that exists. And when when perhaps you read this, you might say, well, there's certain scenarios where this can be helpful, but there's no studies supporting that. And so really, it's just a question at that point. So I don't know I didn't do this in my practice before, but I do know that this does happen. Maybe Chuck Chuck does or doesn't, I don't know.
Charles Goldfarb:I am an arthroscopist. I guess I should start with as a preface, but I don't I think this resonates with me, specifically, exactly how it was worded. No, it resonates. That I think that's true. I don't think there's any, you know, I think it would take be very hard to imagine a study that could prove a benefit of the assistance of a scope. But it also doesn't say that, you know, it is important to note what it doesn't say, right? Because we know what happens with these guidelines. And we worry about attorneys reading these guidelines and saying, Well, why did you do that there? There's no evidence, I mean, that came up with the carpal tunnel CPG a lot. And so I do worry about over interpretation. I like how this is stated, I still think there's a place for some people for some fracture types for using a scope. And this certainly doesn't say don't do that.
Chris Dy:The next one is probably relevant to our therapy audiences. So this is for home exercise programs. So this is a limited strength recommendation. inconsistent evidence suggests no difference in outcomes between a home exercise program and supervised therapy following treatment for distal radius fractures. So Rob, can you fill us in on some background on this topic?
Rob Kamal:I mean, I don't think this requires much for this is a contentious topic. With different depending on which stakeholder you may be. We've seen evidence that goes in both directions. I think if you take a step back at CPGs, and you take a step back evidence, and maybe Chris, you can resonate, this resonates with you, certainly me being early in practice, or on the early side, it it always seemed to me to make sense that if there wasn't something sort of strongly pushing me in one direction that perhaps I needed to take a second think about what I was doing, and what are the risks and benefits of that work. And it also it sort of makes sense that the strength of your conclusion, or your belief should really align with the strength of what's been proven, right. So when things aren't strongly proven, perhaps it's a second to step back and say, you know, is this something I got to? I got to do, right? Is this really gonna help. With therapy I think it's sometimes easy, perhaps, to say, well, patients like it, it's beneficial. And that's probably the case for a And use the word treatment as a broad term, I assume every word lot of patients. There's a lot of patients where these are excess costs and deductibles. And I have a lot of patients that asked me, you know, how much do I have to pay for this? And do I really have to do it, etc. So I don't I don't necessarily buy into the fact that this is sort of low risk. And, you know, it's not worth asking. I think it's worth asking, especially when patients are paying out of pocket for it. That being said, this is a it's a low risk thing. In my practice, a lot of my patients end up going to therapy because they've had it before or they've talked to people that have had a wrist fracture. I don't not let them have it as an option, especially when they're asking about it. So but if you go in the evidence, there were a number of well done studies that showed it was beneficial. There were some studies that showed it was not beneficial and it was a quick therapy. Formal therapy was as equivalent to just getting one formal therapy visit and a home exercise program. And then even some that showed just the surgeon teaching people what to do is just as good. And so that's why you'll see in the language the inconsistent because there certainly is well done studies that supported both conclusions. But generally there was a suggestion that there was no difference is carefully chosen. So not surgical treatment or non surgical treatment. So this is a this is an all encompassing recommendation. Correct?
Charles Goldfarb:Perfect.
Chris Dy:I think this is a sin, I will probably continue to commit in terms of sending patients to therapy, although I will, I will give it some thought. Because the vast majority of my patients after surgical treatment, have a distal radius fracture will go to therapy. And there are some patients who you know, mentioned the cost involved, and the time involved and I've become more sensitive to that. So I've started I will probably start to ask the question more in terms of, you know, would you like to do some some therapy, although there are some patients, of course, following anecdotal kind of experience that I will steer towards there, because I do think that there's a subgroup who do better.
Rob Kamal:Yeah, I mean, I have some patients like, yeah, take carpal tunnel, for example, which routinely, I do not send them to therapy. But if you have some finger stiffness and arthritis, and you can't make a fist before surgery, I'll send you to therapy, oftentimes, before you have your carpal tunnel, because I know you're gonna have trouble afterwards. And so they're, you know, if you again, dive into the CPG. Here, we highlight how they're likely subpopulations that haven't really been studied well enough to show there's the benefit, but the elderly with finger arthritis and stiffness, you know, when they step in your office, then are probably at high risk of continuing with that and benefit from therapy. And so, I think there's some opportunity here, but again, the conclusions we can draw are only based on what's been studied.
Chris Dy:Shall we jump into a juicy one, indications for fixation non geriatric patients, so moderate strength recommendation. Moderate evidence supports that for non geriatric patients, most commonly defined in studies as under 65 years of age operative treatment of fractures with post reduction radial shortening greater than three millimeters, dorsal tilt greater than 10 degrees, or intra articular displacement or step off greater than two millimeters leads to improved radiographic and patient reported outcomes. Okay, so, yeah, young patients with a disc generally agreed upon displaced fracture using criteria. So in young patients with the displaced fracture, surgery leads to improved radiographic and patient reported outcomes.
Charles Goldfarb:This doesn't strike, this doesn't strike me as-
Rob Kamal:I didn't know this was controversial. I thought-
Chris Dy:No, I think I was maybe I was looking to head to the geriatrics.
Charles Goldfarb:But But you don't say what kind of surgery you just say, operative treatment, which I happen to like. And I obviously, again, you chose those words carefully.
Chris Dy:What I like is how you guys, you know, obviously, the literature is the cut point on aging in the literature is biased because of Medicare eligibility United States, which is obviously somewhat arbitrary. But it's what's used was often what was the discussion in the room about how to negotiate where you draw that line?
Rob Kamal:Yeah, I mean, again, the recommendation comes based on the cut point, and the variables that people use in studies, like you mentioned, and so even 65 is commonly used, but not always use some papers use 60, some use 55. And we wrote in the CPG, very specifically, that one, the conclusions can be only based on the cut points that the evidence uses. But two we understand that age is used as a proxy for function. And really, you know, that it's understanding the level of function of the person in front of you what their functional demands are, their expectations, etc, that should sort of really swing you perhaps in one direction or the other, for what you might counsel that patient on. So there are certainly 65 year olds that are incredibly active and this CPD doesn't apply to them. And we were very clear about writing that in this guideline, to prevent the conclusion that somehow 65 becomes this age and where 64 you get one treatment and then 65 you get something different, which is not the goal.
Chris Dy:So how do you reconcile that with at least one paper showing that, you know, activity, activity level is not necessarily even a good enough proxy, you know, when trying to decide in whom to operate because I know that Ryan Calfee had written a paper about that, you know, with the hypothesis that, you know, even in these active 70 year olds, there's going to be an advantage for surgery and there ended up not being one.
Rob Kamal:Yeah, I mean, if that that's a whole, you're getting to like a whole nother level, which is how do you get beyond age? And then how do you get beyond stated function to actual like objective measurements of function right, which is a whole nother level? It's beyond PROMs, right? Because PROMs now are not necessarily reflective of exactly what you do on a daily basis. It's just a reflection of what you think you do. And those don't always align.
Chris Dy:Wait, timeout. So is, do the people in the know and call them PROMs? Because I was always calling him PROs. So is it PROMs?
Rob Kamal:In my world it's PROMs? I don't know, what is in your world? What do you, Chuck what do you say?
Charles Goldfarb:I'm judging Chris right now. I always hedge my bets to be totally honest. I say it both ways.
Chris Dy:You got to go with the guest. I just end up saying patient reported outcomes.
Rob Kamal:Yeah, no, I there. But I think people use them both outcomes are just the outcomes. And the measure is the actual instrument or something like that used to measure the outcome.
Charles Goldfarb:So which of the three radiographic measures shortening more than three millimeters dorsal tilt more than 10 degrees? Or intra articular displacement more than two, more than two millimeters? Which of those feels most controversial to you after? You know, analyzing literature? Or are they all I mean, they're all pretty commonly used, and maybe they all fall into the same bucket?
Rob Kamal:Yeah, I don't have the I don't know the answer that I thought you may be Chris might have the answer to that. I think, you know, when I talk to patients, I tell them, Look, there are a lot of studies that use age as a cut off. And when people have used age as a cut off, this is generally the conclusions that people have drawn. But these are based on, you know, arbitrary ages, and you have to sort of, we have to get a sense of where you lie in that spectrum of function. And people, I think, generally know themselves well enough to at least be comfortable with what they decide to do. Right. So plenty of patients say, do not come close to me with the scalpel. I'm good, right? And I'm okay, with X, Y, and Z. And other people are, you know, very adamant about what they do. I know, the evidence, at least from some of Kevin Chung's work with the wrist group did show that the degree of shortening or the millimeters of shortening was a pretty strong predictor of loss of grip strength. And so I do talk to patients about that, because there's some nuance to even shortening and giving people some sense of, well, how much strength Am I really going to lose? And is that going to affect me? And so there are some, at least some of my patients that do want to dive a little bit into those details. But that's generally the conversation I have, I try to get people to get a sense of as best as they can, what their functional demands are, and we try to use that as the start of the conversation.
Chris Dy:My sense is that, you know, the intra articular displacement part of it probably doesn't matter as much as we think it should. But that being said, you know, Chuck, you wrote the paper on that, you know, more than 10 years ago, so outside of the range of the CPG. But that's the one where I think that you if you had to pick one where you probably could discount its importance, I wouldn't place a lot of stock in that one.
Charles Goldfarb:Well, I wasn't trying to lead, Rob, but I guess that would be my feeling as well. But then there's people would just count the 10 degrees of dorsal tilt and question that you know, how strong the studies are with, you know, adaptive midcarpal instability, all of that. I mean, it's a it's a lot of many years of anecdotal evidence and hopefully now starting to be guided by the real evidence. So it's a super interesting conversation. Let's get on to the to the meat.
Chris Dy:Oh, yes. To the actual one that I thought-
Charles Goldfarb:Can I can I interrupt? Just I am not geriatric. I'm less than 65 years of age. Let's get that off the table, Chris.
Chris Dy:Okay. You stole Thunder already. So a strong evidence suggests that operative treatment for non Chuck geriatric patients are most commonly defined in studies as over 65 years of age does not lead to improve long term patient reported outcomes compared to non operative treatment, strong recommendation. So does this let's start with you, Chuck. Does this match how you are practicing say in the last three or four years pre the CPG? And do you think this will change your practice going forward?
Charles Goldfarb:And this gets to the fundamentals of orthopedics, right? We see a broken bone or I shouldn't just say what the basics but hand surgeons or orthopedic trauma surgeons, we see a broken bone that's markedly displace. It is our natural instinct, backed by years of training, that we can improve that alignment in therefore the patient will do better. I mean, this is a little hard to swallow. And I certainly agree with it. I, there's nothing about it that I don't agree with. But it is very hard to swallow not only for us. But when a patient sees an X ray, and for me to have a conversation with that patient saying, you will be fine. It's hard for me to say it's hard for them to hear. So this is tough. I recognize this is tough. But I think this is one of those conversations that has to happen over and over and over until we start accepting the evidence. I didn't really answer your question, but that's how I think about it.
Chris Dy:Well, then Rob answer the question.
Rob Kamal:Well, why don't why don't I do this? Why don't instead, you know, we started this whole thing talking about quality of care, and how it continues to evolve, right? 20-30 years ago, we would say, the 20 year old with a broken wrist, and the 90 year old with a broken wrist both have distal radius fractures, and it needs to be put back and fixed. Right. And clearly, our evidence has grown and improved from that. So it's an it's a perfect example of how quality of care has shifted as our evidence and our understanding of patients and their demands, etc. influence outcomes. The second thing I'll say is, I think it's I don't think it's as difficult to have this conversation as perhaps maybe some do, which is if you tell people the evidence, which is when they use these random age cut offs, by six months to a year, most people can perform at a level, that's the same as if they had it fixed. But they don't get better as quickly, with some nuances to that write a little bit of grip strength loss, cosmetically, it's not going to look great, you can for the most part get a sense of what patients are willing to do or what they want to do. I had a patient that had bilateral distal radius fractures that did that did when I told her the evidence didn't want surgery, right? I mean, bilateral would be almost an indication to just get it fixed, right. So a lot of reasons to get that fixed, her sister lived next door, her sister wanted to take care of her and she didn't really want to have surgery. And she was in a bilateral short arm cast. And she did amazing, she had her PROM scores were great, she had really no limitations, she had, you know, sort of shortened looking wrist with these but ulnar positive variance, etc. And she did great. And what I oftentimes tell people is, if we had to, we could perhaps revise these if you're not happy in the future. But it's very, very, very rare that we have to do that. And for some people, that's some level of comfort. But I To be honest, my practice is very much telling people that this is the evidence, and let's sort of make a decision based on what you think your demands are and what your timeline expectations look like. And things like that, if you want to get back to you know, to function faster, and you're concerned about some of that grip strength loss, and etc, etc, then we fix you. And if that doesn't concern you, and you really aren't interested in surgery, you'll do great, it will just take about six months to a year, and you'll do the same. And people can generally get behind that. But I agree that it does go to some degree against the mantra of orthopedic surgery and broken bones.
Chris Dy:And that's the same discussion I end up having, even before the cpj came out based on the literature that we've been seeing. But for those of us that, you know, are a little more inclined to fix bones, where's the wiggle room? In the evidence? Is there any wiggle room in the evidence in this category?
Rob Kamal:Um, so that, you know, there there, there is some evidence that conflicts with this. There were there were, I think, one or two RCTs that were moderately graded that suggested that people had some continued benefit from having surgery versus not. But overall, when you look at the sort of overall evidence, most of it points in the favor of there being no difference, at least in patient reported outcomes by six months to a year, the wiggle room in the evidence is really figuring out the patient that's right in front of you and what they expect and demand and what they what they want out of their care and what they understand in terms of risks and benefits, etc. And I think that's where the so it's not I don't think of it as wiggle room as much as how do I take this guideline and apply it to the person in front of me and make sure we get the right treatment for the right person at the right time. That's That's how that's in some health systems, how you define quality of care, right, getting the using this guideline in the right way for the right person in front of you.
Charles Goldfarb:It does get to the heart of what we do, right. I mean, we I think how both of you have stated this is exactly right. In my hands, I think of examples about patients that are overly concerned about the aesthetics. And you mentioned that Rob, and, you know, we our goal is to treat the patient in the best possible way that will restore function and lead To patient satisfaction, it's frustrating sometimes when I realized that aesthetics are gonna have an outsized role in the decision making for the patient, but yet it is what it is. And so I absolutely present the evidence. It doesn't always go the way we want, though. And I guess if we are judged by some quality metric down the road, we're not going to be judged on one offs, but we'll be judged on the body of our work, presumably, right, so 100 patients over 65 with distal radius fractures, how many of those do we treat? It really is, it's a fascinating concept to understand. And I realized that insurance companies have a great deal of data on how each of us care for patients. And I wish I had access to understand how I care for patients. But the reality is, we have to treat each patient as individual and aim for patient satisfaction. in the best way we know how and this, this helps to guide us for sure.
Chris Dy:Yeah, I was on a call with a with the insurance company as an advisory board. And the person leading the call was saying, Well, when I was in practice, they always used to say that the insurance company knows how many suture packs I open for a case, he's like, we know.
Rob Kamal:So I had, I had a VP from optim presented at the hand society symposium was five years ago, who presented a bubble chart on the opioid prescriptions that were filled by surgeon for carpal tunnel surgery, and that was, you know, five years ago. So they, they definitely can track that. I think, Chuck, you're bringing up a common concern for people, which is how, how is an insurance company going to get a hold of this and, and perhaps use it to guide what I do. And I think that's a reasonable concern. Again, these are grounded in the evidence. And we we try to have language that aligns with the evidence and the support for that. But we also highlight where, for example, the use of age and things like that as cut offs might not be the best for the person in front of you. So we definitely tried to make it so that it is usable for the person that's in front of you, as opposed to just having very strict age cut offs.
Charles Goldfarb:Yeah, it's it's hope I didn't sound like I was being critical. I mean, this is incredibly important. And it's about socializing these and making sure we all understand them, because eventually practice will catch up with the literature. It's not about insurance companies seeing them, I think all of us have this fear of insurance companies mandating how we treat patients. I don't think we're anywhere close. And I can't imagine that ever really happening. But but maybe I'm naive, I don't know.
Chris Dy:So the next recommendation was a limited strength of evidence. And it says limited evidence suggests no difference in outcomes based on frequency of radiographic evaluation for patients treated with this treated for distal radius fractures. So is this this is for non operative and surgical treatment?
Rob Kamal:Yeah, so this question, I mean, it's a limited recommendation, because really there there wasn't a lot of evidence for or against this. But we this comes the stem of this question is just based on how we asked the question, which is, is there evidence that supports how frequently we get x rays on these patients, there is one pretty well done study that followed post surgical patients and demonstrated no change in their outcome. After getting the two week X ray not getting, you know, our standard six weeks, three months, etc. But generally, there wasn't enough evidence here to come up with any type of conclusion. But we did bring the question up, because the I think it's a reasonable question. And there will likely be more studies, especially as we focus on costs and utilization. And are we making a whole lot of different decisions when we look at our six week post op X ray, that in a fracture that, you know, usually goes on to Union very reliably and, and we're not typically tracking the level of union there to increase activity levels and things like that right there. It's pretty, at least in my practice is pretty regimented. But the two week X ray, people oftentimes look just to make sure hardware is stable, and things are moving the right direction. So we brought this up, only because I think in the future, we might find that, you know, there will be stronger levels of evidence for this. And perhaps other things like preoperative testing. As another example, you know, what labs Do you really need to get on a risk fracture before surgery? In this spirit of quality and value?
Chris Dy:So before we get Chuck's thoughts, what did what did you do or what do you do now in your practice, for like a straightforward volar plate? Patient getting a volar plate? everything went smoothly? What's your protocol?
Rob Kamal:Yeah, so my protocol is still the standard two weeks, six weeks, three months, six months, I follow up with all my patients out for a year. My wrist fracture patients up to a year. So they get all the way to a year.
Charles Goldfarb:It's interesting yeah. And Chris, I would like to hear so mine first, again, taking the standard volar plate for distal radius fracture. I never get the two week X ray ever, simply because I think if I leave the OR and I'm comfortable, it's not gonna look any different Two weeks later, there are studies in the pediatric literature about that, because for a while supracondylar humerus fractures, you put them in the OR, everyone used to get the one week X ray, I don't think that's done anymore. But for me, it's six weeks, and three months. And I'm done. Chris?
Chris Dy:I will get the two week mainly out of necessity, because my interoperative fluoros don't typically make it into the system. And I will get the six week, most of the time, although if the patient's doing really well, and the trainee hasn't already gotten the fluoro images, I'll usually let them go, especially if they're non tender over the fracture site. You know, so, and I typically do not get formal radiographs. So maybe that's I don't know costsaver or not, but did you guys look at that fluoro scan, you know, mini C arm versus-
Rob Kamal:We had I don't think that's been studied. But that's a great example of potential for cost savings. Like I seem to be wasting the most money out of the three of us right now on
Chris Dy:Finally we got him Chuck.
Charles Goldfarb:Alright that's it, have a good night.
Chris Dy:So speaking of spending money, the last one, we'll talk about fixation technique. strong evidence suggests no significant difference in radiographic or patient reported outcomes between fixation techniques for complete articular or unstable distal radius factors. Although volar locking plates lead to earlier recovery of function in the short term, three months, a strong strength of this recommendation. So tell us the the insider knowledge on this one, Rob?
Rob Kamal:Yeah, I mean, we started asking, I think what a lot of us ask, which is, am I missing something? Is there evidence somehow that really points to one technique over the other? I think we all periodically, in some level of reflection, say like in my shabby changing something, is there something out there that suggests perhaps there's something else better for patients? And generally, the conclusion was, there's no conclusion. So you could you could run a lot of pairwise comparisons between pins versus plates and plates versus bridge plates, etc, etc. and the conclusion is that you can't really show one thing is better than the other. So we that was the conclusion of this, we did find a relative number of well done studies that were at least comparing volar plates, with, let's say, k wires as an example, that generally showed people could move a little bit faster with volar plates. So we did include that in the in the CPG.
Charles Goldfarb:So give our audience something, Rob, what is what is the ROB Kamal algorithm for your choice of hardware?
Rob Kamal:I think I'm an outlier. And you know, there's a lot of people that say you, you can't treat a lot of these with volar plates, I can get a lot of these treated with volar plates and different add ons. So my general standard is volar plate, and then I sort of look at patterns to see what extra things do I need. So I will oftentimes put pins underneath the volar plate to capture the volar lunate facet. And that's just, you know, you can use fragments plates, I just put pins in capture it and then bend them and do the Dave Dennison technique on putting the volar plate over that my general plan is if the carpus is sub luxating dorsally with a dorsal lunate facet to me that's a reason to capture the dorsal lunate facet piece either with the dorsal buttress plate or something like that and then you know level of comminution etc all that drives me towards bridge plates versus no bridge plate but so that's my general I I'd be interested to hear your guys's because I probably have something to learn.
Charles Goldfarb:I'm not sure about that. Let me one hypothetical patients here 64 year old patient.
Rob Kamal:Yeah, but like 64 or is it? Are they your level? What's their level of function? I want to know is it Chris or you?
Charles Goldfarb:very young 64 year old so Chris-like.
Chris Dy:On the peloton.
Charles Goldfarb:Falls off the peloton when the shoe comes unclipped. Would, do you ever consider for a metaphyseal distal radius fracture? Do you ever consider pinning?
Rob Kamal:Yeah, you know it's a conversation with patients definitely. So I mentioned it, but generally we talk about the return to function. So when I fix wrist fractures with plates, they have a removable wrist brace and an ace wrap and I sort of let them take the wrist brace off whenever they want to. And so that's pretty enticing for patients versus pins sticking out and you can talk about moving, but nobody's really moving with pin sticking out of their wrist. And that's why the return to function's a lot slower. And pin site infection risk, etc. So, generally, people will go with the volar plate, I think probably the last I pinned a wrist maybe six months ago, for a patient that sort of didn't, you know, wanted to avoid the incision. But generally people are okay with that. So that's, that's my conversation.
Chris Dy:Let me ask you a question that will press Chuck on something he said in the past. So when you are when you are talking to patients about you having your discussion, you know, surgery, no surgery? Do you tell them that surgery will give them the ability to have an ace wrap and removal wrist brace from the get go? Or do you let them make the decision about surgery and say, oh, by the way, I'm going to let you you know, put on a brace in two days.
Rob Kamal:I think you're asking a good question. You're asking a nuanced question about shared decision making and what the bounds of shared decision making are. We have we published a paper on that, where we basically showed that most patients want to really be involved in the decision for surgery and like, control when surgeries and things like that and want to be less involved in interoperative decision making, and sort of less involved in the post op rehab. So if you ask patients, which we did, and we asked them for wrist fractures and carpal tunnel, they really want to be involved in the decision making process. But for example, they don't really want to control what suture you're using to close because we asked them that question. So I think that helped hopefully answers your question in terms of what really, at least in our small study, what patients wanted to talk about, it was less about the removable brace. But I do tell patients, you know, typical with a standard wrist fracture, you're going to be in a removable wrist brace, and whenever you're comfortable, you can take it off and move it and I don't really have much for limitation beyond what's comfortable.
Chris Dy:I think that's a that's, I think that's an then Chuck knows that's part of selling the surgery, which is probably why Chuck doesn't say it, you know, when he's discussing the options. I tell them that because I think it's practical information that probably informs for some people their decision making. You know, I don't think I operate on an excessive amount of distal radius fractures. I'm sure United Healthcare has information on that. But I don't think I operate more than the next person. So I don't know, Chuck, what are your thoughts after hearing us banter about it?
Charles Goldfarb:Well, I, you know, look, we're all surgeons as objective as we try to be I, you know, we're surgeons, and so I think when you offer a patient, an ability to take off their surgical brace Five days later, and shower and start moving their wrist, it's almost for most patients is almost impossible to pass that up. In my experience, I try to lead them to making the decision that is best for them, before they understand how easy their lives going to be with surgery. So for all you patients out there.
Rob Kamal:Yeah, but I don't want you to interrupt. But I mean, take a step back for a second because there's a value judgment you're imposing. You don't know, for example, how much work they might have to use and what the bills may be, etc. And so I think we we should give patients the data, and they decide. So there are plenty of patients where if you tell them that it doesn't matter, because they really just don't want it that the risks for them are too much, and they don't want to have it. But there's a plenty patients, as an example, you know, a manual laborer, perhaps, where they really, really, really want or need to get back and getting them back at four days, five days opposed to four weeks as an example is a big deal. So I think, you know, there's some value judgment, to not disclosing that to them. That's what I'll say to you, Chuck.
Charles Goldfarb:Yeah, I hear you. But I don't want you to think I'm totally holding out on patient. Here's how it goes, I have my conversation. And they say surgery or no surgery, if they say surgery, I say well, you're probably gonna like to hear that with the choice of surgery, that we're going to get you out moving very quickly. And if they choose no surgery, it really has been a conversation of exactly what you just said, trying to understand what their needs are. And I don't want to make it seem like I'm holding back information. I just feel like it's almost too good to pass up. If we just if we lead with. Well, you can be the cast for six weeks, or we can get you moving tomorrow.
Chris Dy:Or you can push back a little bit and spend a little bit of money and we can send you to therapy for a clamshell brace, that you can take off the shower instead of a cast.
Charles Goldfarb:Yeah.
Chris Dy:Compromise?
Charles Goldfarb:Alright.
Chris Dy:Well, thanks a lot for joining us, Rob. This was fantastic. You know, Rob, for anybody listening, Rob's published a ton of very influential papers every time you open the journal, his group is there. So kudos on some fantastic work, excellent body of work very early on in a career. So we look forward to seeing what you have for us next.
Charles Goldfarb:Yeah. And I would just echo that, you know, doing something like a CPG is a great deal of work and leadership amongst your peers. And it really is amazing that at your very tender age, you have accomplished a great deal. So thank you for what you're doing. And this is an amazing contribution. So thank you.
Rob Kamal:Well, thanks a lot guys. You guys obviously are too kind, but I appreciate it. Thanks for having me. Thanks for playing nice with the questions softballs. I love the softball questions. It's been a fun Time. Thank you so much.
Charles Goldfarb:Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time.