Episode Transcript
[00:00:03] Speaker A: Welcome to the Orthojoe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
[00:00:18] Speaker B: Well, good morning, Mark. Good morning. And I'm hoping you're enjoying some sun wherever you are.
[00:00:25] Speaker A: Yes, I'm actually up in the lake region of Minnesota, which is a long ways from any. Well, it's probably closer to Tim Hortons than it is to a Duncan, so I've had to make my own coffee. And in this part of the world, what is of major interest is northern pike. Oh, wow.
[00:00:47] Speaker B: Yes, yes. That looks an aggressive, aggressive fish there.
[00:00:51] Speaker A: Yeah. And here is, here's the brand of.
[00:00:55] Speaker B: Oh, repella. Yes, of course. Yeah, yeah, Classic the shark.
[00:00:59] Speaker C: Truce.
[00:00:59] Speaker B: Rapella.
There you go.
That's the only word. That's only, that's the only time I use the word chartreuse when it comes to a fishing repellent.
But anyways, listen, we have a very interesting chat today and actually, Mark, it's about a paper that's just come out in this, this month's issue of the Journal.
Before I introduce our guests, let me just introduce the paper itself and then we'll introduce our guests to help us think through some of these issues. But this is a cost effectiveness study. The cost effectiveness study is really a comparison ultimately of the cost and the effectiveness of surgery versus functional bracing for humeral shaft fractures in adults. This was a pre specified in the original protocol economic evaluation of the fish group, which is the finished shaft of humerus trial group.
And they've had a few papers, the initial paper in JAMA in 2024, which was a five year follow up of a randomized trip, this randomized trial. And ultimately what they found at that time was there really wasn't a difference ultimately between functional bracing and choice of operative fixation. They did note though in that, and this comes into play, as I'll share with you a little bit about the results does come into play a little bit about the, in this particular case, the non operative treatment group, the bracing group had a 32% rate of requiring secondary surgery. So that's something that at least is in the, you know, in the fabric of that trial and comes up again as they think about what's going on with the economic analysis. But the economic analysis basically is 84, 82 patients or so follow for two years.
And what they found basically was that at two years surgery, in this case surgery produced Slightly higher quality adjusted life years and was more cost effective from a societal perspective, mainly because it reduced broader costs such as lost productivity.
On the healthcare system side, functional bracing was less expensive and therefore more cost effective. In other words, because the direct medical costs were lower. The argument they ultimately make is that decisions should, in this case should, you know, shouldn't think. You should always think about the economics of the treatments we provide but be really focused on patient specific factors. Overall though, didn't seem to be a big difference whether you treat it one way or the other. And certainly the economic cost in the longer term didn't seem to make a difference.
Now we have Dr. Brad Petrasor. Professor Brad Petrasor, who is in the Department of surgery at McMaster University and is currently the Associate Chair of education at McMaster University. Welcome, Brad.
[00:03:45] Speaker C: Thank you. Thanks for having me. Good morning.
[00:03:48] Speaker A: Always nice to see you, Brad.
[00:03:50] Speaker C: And you.
[00:03:52] Speaker B: So Brad, maybe like without, I'll leave it open ended. What were your thoughts on this paper? And then I'm sure Mark will have some more poignant thoughts on you.
[00:04:02] Speaker C: Well, my thoughts are that the paper is really consistent with what people are finding in the literature and other people who are doing trials about humeral shaft fractures. If you look at a couple of other papers that were done, the Edinburgh group published in JAMA last year, very similar results in terms of the core randomized trial looking at 70 patients, dash scores, functional outcome scores were better within the first six months. And the Canadian Orthopedic Trauma Society group also found similar with 180 patients randomized that yeah, for the first six months, patients that were treated with an open reduction internal fixation in a plate were better than those treated with a functional brace, at least functionally. But both of those studies found exactly what the Finnish study found. At one year, no difference. And so everybody looks at the trials and they say, ah, then don't do surgery because at one year nobody's different. And everybody, I guess kind of forgets about the power of a good operation is that, you know, stability early and getting people back to work early is actually really important.
And we think about it all the time in athletics whereby put a screw in here and fix this and we'll get you back on the pitch. It's faster than any, but ultimately you're not going to be that much better. But we'll get you back playing faster. The cost, the money's much higher. But if you look at the person who's going to go to work down the street and needs to provide as well, we don't necessarily think about it the same way because the money is sometimes different. But, but the power of a good orthopedic operation is it makes people better early on so they can get return to function early range of motion, get their therapy going and get back to work.
Those are my thoughts.
[00:05:53] Speaker A: Yeah, I agree completely with your analysis, Brad.
And I guess I've got a question for both of you. I've always thought of this condition to be one of the most robust ones for shared decision making where you can lay out to the patient what are the risks of infection, a radial nerve palsy, et cetera, versus the advantages. So how does an economic analysis aid in shared decision making or does it aid in and maybe these are done for other audiences. What are your thoughts?
[00:06:28] Speaker B: Well, I mean, I think, you know, Mark, I'll start off by saying also there's a really thoughtful commentary by Doctors Band and Zuckerman that's associated with this paper and I encourage those who are interested in this topic to take a look at that commentary as well. But they make a pretty good point, right? It depends who like the economic analysis is solely based on perspective.
So if you look at the healthcare system in general, it would probably suggest that it doesn't make a huge difference in the long term.
But if you look at the reality of equity of care and access to care, one might also argue, and as they argue that in US patients with Medicare, Medicaid or no insurance, they're less likely to receive surgery. So from their perspective, there is going to be some of these factors, I think, that are going to come into play. Is it right or is it correct?
Well, I can't speak to speak to that, but I would hope that when you're making a decision with an individual, individual patient that they will be able to weigh the benefits and risk of whatever you're doing. I would typically say costs are usually not something that we discuss, but they're reality. When we talk about knee injectables where there's going to be real outpatient costs, you have to discuss that there are costs and there's going to be some that cost more or less. But in principle, in the ideal world, you don't want cost to be a factor and why someone has to decide what they do. But unfortunately the reality is we do that. I don't think cost is really a major tenet in evidence based medicine, but it's definitely one we think about and
[00:07:57] Speaker C: I think it allows us to bring in that piece of the puzzle as well. So the trials give us really Excellent data on. Okay, here's your risk of infection. Here's your risk of radial nerve palsy. Here's your risk of union.
Oh, by the way, we need to be able to get you back just a little bit quicker to work. And that's a piece that is really important to some people. Other people may say a month. I'm okay, just let me, I'll be in my functional brace and that'll be fine. And I think it actually brings in that extra piece just to tack onto the shared decision making because we treat patients throughout a lifespan and people have different values and preferences depending on where they are in life. So I think it really brings in that piece.
[00:08:40] Speaker B: So, Brad, so you go and say, listen, at five years, there's probably no difference. You know, I don't think it's going to make an ultimate difference. Yeah, you might get back to, you know, surgery a bit earlier and then you can decide on which type of internal fixation you're going to do. You know, whatever you're going to do there. Yeah. And then you tell them, oh, by the way, there's a 1 in 3 chance you might have to have an operation anyways. Even if we go through some weeks of this and you go through the discomfort, how do you think that's going to sway patients?
[00:09:05] Speaker C: It's very interesting because we, we do that in other, like clavicle and this very similar. And so some people are, are not swayed by that at all. They'll say, you know what, I'll give it six weeks or two months, I'm okay with that. Other people, as you say, are very much to the no, I just want it done over with. Let's go and get on with things. And so I really find that again, it does allow the patient to take that bit of control into their life and say, and some patients are happy to wait it out a little bit. And so it's just another really important piece to have the discussion. And the one piece is as long as waiting doesn't make the operation harder, more difficult, et cetera, which in the humerus, that's an argument. In the clavicle, not so much. I don't think in the humerus, maybe there's that other little piece to pull out as well. But I find that people bring their values and preferences to the table when you have that discussion. And I just, I really do think it gives them a bit of control too.
[00:10:07] Speaker A: I've got another question I think is more heavy on the methodologic side of things. So one of the Issues that has affected the outcome of patients that I've had more than I would like is a radial nerve pulse. You know, you do the careful dissection, you're looking at the nerve, you know, it's not injured, etc. Yet it can take three to six months for it to recover.
So the methodologic implication, how do you figure in that, that complication where a patient is really unhappy with having to wear a splint and their hand function isn't great. I mean it's continuing to come back the whole time, but it's a real, real nuisance.
How is that figured in to the calculation?
[00:10:52] Speaker B: Yeah, that's a great point. I mean, I guess it would be based on.
This is the interesting point. If you're in it, let's say the non operative treatment or in the brace, it would, you know, some of the more crude measures are going to be, well, are you back to work? Are you back to, you know, are you back to any sort of societal function? What are the costs of you not being able to do that?
So if a radial nerve palsy persists, for sure it's going to have some impact on that individual's ability to get back to work. But that could happen on both sides of it, right. It wouldn't just be necessarily always related to one side. So that would be one that I think that you would just factor in and look at the overall complication rate. What is interesting though is they're still pretty crude, right? Brad? Mark, like in my mind, like I still think like if you, you have to collect a lot of data if you want to really capture all of the costs, right? Simply to say, well listen, the cost of the implant is more, therefore, you know, it's, it's, it's, it's, it's less, you know, in, in the, from the hospital's point of view, how we pay more money. But then they're gone and 24 hours and now it's now the cost of being shifted to somebody else, right? It's the lost productivity, it's the, it's the, all the physiotherapy, it's the hand therapy, it's the, maybe the additional splints that have to be made. All of those things I think would have to get factored in. But it is very segmented. It's just based on whose perspective because money is so much around, you know, the, you know, who's winning here and who is a cost to like, you know, who's. So I think that's the Challenge. And I'll tell you, it's. It's not easy to interpret because if you look at this, it says, you know, at the end of the day it's saying, well, there's no difference, but there may be a difference.
Okay, so you still have to go back and try to figure it out. Yeah.
[00:12:28] Speaker C: In the Canadian data, there were what, 12 radial nerve palsies out of 180 patients. So very similar. Seven in the non op, five in the op. So it was, it was very similar between.
[00:12:40] Speaker A: And.
[00:12:41] Speaker C: Yeah. So the other thing that I find, obviously from an operative point of view, treating complications is. Is never pleasant. But there's something also moderately disconcerting. Watching a humorous that, you know, isn't about to heal and people coming back in this functional brace and just not happy, oh, wait another month. And then not, you know, and, and there's, there's something not very nice about that either. Even though you haven't actually done a surgery.
[00:13:10] Speaker B: Well, Brad, you know, and Mark, on this one, even on the operative side, I don't think maybe, maybe the evidence is saying there's no difference between different operative approaches. Whether you're. It's an open reduction fixation or it's, you know, more of a minimally invasive, less invasive, you know, intermedullary nailing or approach.
Do you think any of that would have had any impact? I mean, they certainly did. They. They took it all as internal fixation.
But I do wonder about the just within.
Within operative treatments. You know, I don't think they had enough patients to be able to tease it out. Right. But it would be an interesting thing to think about. Right. Because we've often talked about the gold standard for a shaft fracture. If you're going to treat it to be, you know, basically, you know, open reduction internal fixation. Has that changed?
[00:13:52] Speaker A: I don't think it has that. Brad. Do you think it has changed?
[00:13:56] Speaker C: No.
It's very interesting when you look at the meta analyses over the years. There's this ebb and flow between, you know, open reduction internalization with plate synthesis is better.
And then there's been a recent one suggesting intramedullary nailing may be catching up. However, there are a couple of very interesting network meta analyses that were done that actually suggest minimally invasive plate fixation is probably the best, actually.
And there's people around the world who are doing lots of minimally invasive plate fixation. You know, an incision proximal, a little incision distally, move the nerve out of the way and slide the plate down and There's a suggestion that maybe that's the way we should be going. But again to your point, Mo, I don't think the numbers are there.
[00:14:43] Speaker B: I don't know why when I saw this and I saw that storyline that there's no difference between treatments operative versus non operative. Oh, by the way, the non operative group has a higher risk of having to have a reoperation. Do you remember any other trial in history, Brad?
Canadian trial of something you're a subspecialist in that had that exact same storyline starts with from a calendar with Aeneas Calcaneus
[00:15:11] Speaker C: that also had a subsequent economic analysis that suggested that operative fixation may be better.
[00:15:17] Speaker B: Yeah. Isn't that interesting? Like it's just, and, and the big storyline was there's no difference between opera non operative. And then everyone had their, had their viewpoints.
[00:15:25] Speaker C: Yeah.
[00:15:26] Speaker B: But then he said oh by the way, bunch of non operative treated people had to go to procedure and therefore you should operate.
[00:15:33] Speaker C: Yeah. 20% compared to 5%.
[00:15:35] Speaker A: Yeah.
[00:15:35] Speaker B: And that's the same thing. Right. So 32% here. So it is an interesting storyline.
[00:15:39] Speaker C: Isn't that the storyline though of a lot of non operative versus operative trials? And you know, it's, it's just so I, I, I sit and I, I think, you know, profer trial, similar non operative management of shoulders.
And I think what is it, what are we missing here? And I think we're just missing about that initial power of getting people back to work and movement and some of those original tenets of early pain free range of motion.
[00:16:10] Speaker A: Yeah. And I think that the common conclusion with many of these issues is that the surgeon is the method and there is, you know, no, no two surgeons really are alike in terms of their experience and ability. And that's, that's the take home message and that's the message that I've heard and I know that you have both heard as well throughout your career from very experienced and skilled surgeons. Those aren't my results.
Those are results of a, of a trial where there's a bunch of inexperienced surgeons.
[00:16:46] Speaker B: So, and you're right. And for those who are really, really strong advocates of non operative treatment, they would probably argue, they'd say, well Dr. Petrasor, you know, in your last, you know, 30 cases of humor, how many of you actually, you know, put a functional. Are trainees actually getting experience, you know, with the art of functional bracing and the art of bracing and the art of non operative treatment. And it's becoming harder and harder. Right. To defend that because just such a push now for patients, too. Right. They want to get back to function and. And you want to get fixed. So it's. It's an interesting. It's interesting time. The textbooks are being rewritten, aren't they?
[00:17:20] Speaker C: Yeah, they are. But this is one. Back to Mark's point. This is one where I. Well, I, I always take patient care, but this is one where you can really sit down, present the data on both sides, really bring in patient values and preference. I find it's the same with the clavicle and other other areas as well, where you can just really sit down, have a really good conversation, and move forward together on the same page for their treatment.
[00:17:44] Speaker B: Yep.
[00:17:45] Speaker A: Agree completely.
[00:17:47] Speaker B: Well, thank you. Thank you, Brad, for joining us. It's a bit of an early morning for you and certainly an early morning for you. To Mark, I didn't bring up the fact that we're up a little earlier than normal for these, for today's podcast, but that being said, thank you very much. I think we've helped clarify, you know, I think an important contribution to the literature and one that allows us to have, you know, a more robust conversation with our patients. So thank you again, taking time with us.
[00:18:11] Speaker C: Brad, thank you so much. Thanks for having me.
[00:18:14] Speaker A: Cheers. I'm going fishing.
[00:18:16] Speaker B: I like that. God, fishing.
