July 2014 Journal Club

[ldsrmdude]

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With the new residents starting this month, and students starting out on rotations, I thought it would be a good time to start back up our journal club. Here's how it will work: Post here with your suggestions of a good article to discuss. Keep it pretty recent if possible. Pacpod and/or I will choose an article and whoever suggested the article will give us a little rundown on the article, what the key points are, what they took away from the article, how it will change how we practice, etc. Then we'll all discuss the article and hopefully have a good discussion/debate. Students, residents, attendings, pre-pods are all invited to participate with comments or questions. PM me with any questions. Let's hear your suggestions for articles!

 

[ldsrmdude]

Wow, 130+ views and no suggestions for articles? I'll assume all the students and residents have been too busy 🙂 If there are no suggestions this weekend, I'll go ahead and kick things off.

 

[ldsrmdude]

Alright, since nobody jumped forward, I'll kick it off. Here's our article (here is the pubmed link: http://www.ncbi.nlm.nih.gov/pubmed/23460669)

Title: Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.
Authors: Kline, Anderson, Davis, Jones, Cohen
Journal: Foot and Ankle International June 2013
Summary: This was a retrospective review of 112 calcaneal fractures treated by either a lateral extensile approach or a minimally invasive approach. Charts were evaluated for incidence of wound healing problems and the need for further surgery. Radiographs were reviewed for fusion rates as well as maintenance of Bohlers and Gissane angles. The minimally invasive group suffered 6% wound complications while the lateral extensile approach had 29% wound healing complications. 20% of the lateral extensile group and 2% of the minimally invasive group required re-operation. There was no difference in any of the radiographic criteria that were evaluated.

I've seen the trend shifting towards more minimally invasive approaches in many surgeries, not just calcaneal fractures. I think that a minimally invasive approach to calcaneal fractures can be a great way to address some wound healing complications, maybe not in every patient.

There are a lot of good points that we can talk about from this article. What are your thoughts? Please chime in attendings, residents, students, pre-pods.

 

[FootAndAnkle]

Alright, since nobody jumped forward, I'll kick it off. Here's our article (here is the pubmed link: http://www.ncbi.nlm.nih.gov/pubmed/23460669)

Title: Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.
Authors: Kline, Anderson, Davis, Jones, Cohen
Journal: Foot and Ankle International June 2013
Summary: This was a retrospective review of 112 calcaneal fractures treated by either a lateral extensile approach or a minimally invasive approach. Charts were evaluated for incidence of wound healing problems and the need for further surgery. Radiographs were reviewed for fusion rates as well as maintenance of Bohlers and Gissane angles. The minimally invasive group suffered 6% wound complications while the lateral extensile approach had 29% wound healing complications. 20% of the lateral extensile group and 2% of the minimally invasive group required re-operation. There was no difference in any of the radiographic criteria that were evaluated.

I've seen the trend shifting towards more minimally invasive approaches in many surgeries, not just calcaneal fractures. I think that a minimally invasive approach to calcaneal fractures can be a great way to address some wound healing complications, maybe not in every patient.

There are a lot of good points that we can talk about from this article. What are your thoughts? Please chime in attendings, residents, students, pre-pods.

That's a pretty cool article. While admittedly skewed to some degree with the increased Sanders III cases and over twice the sample size chosen for the extensile lateral approach, I think it proves the point that when the fracture pattern allows, the minimally invasive approach appears to be the better choice simply due to the lower incidence of post-op complications and comparable results. The fact that the surgeons had to pick and choose the fracture patterns they were comfortable using the new technique with probably doesn't change the fact that a direct comparison of matched RCT data with these preliminary findings would reasonably be expected to reflect a decreased incidence of complications, as well (though perhaps with somewhat less disparity than seen in this study due to matching injury patterns more consistently).

 

[ldsrmdude]

Good points. I'm curious what approach most residents are seeing. We've done a sinus tarsi approach on the last several calcaneal fractures we've done and have had pretty good results. Like you mentioned, I think the fact that the patients weren't randomized and the minimally invasive approach was used at the surgeons preference is a definite weakness and that a RCT would be a big step forward in this area. Any other thoughts on the article?

 

[FootAndAnkle]

Good points. I'm curious what approach most residents are seeing. We've done a sinus tarsi approach on the last several calcaneal fractures we've done and have had pretty good results. Like you mentioned, I think the fact that the patients weren't randomized and the minimally invasive approach was used at the surgeons preference is a definite weakness and that a RCT would be a big step forward in this area. Any other thoughts on the article?

For the given radiographs, it looks almost like the minimally invasive approach could possibly be less difficult and offer a shorter surgery time after gaining proficiency, especially with the posterior percutaneous placement of those screws. Is that kind of a "they make it look easy" impression or do you think that could actually be the case?

 

[ldsrmdude]

Probably some of both. I'm sure they save a bunch of time just in suturing using a minimally invasive approach. One of the lectures I watched about the minimally invasive approach recommended becoming proficient at the lateral extensile approach before trying the minimally invasive approach, so I think once you have some experience doing the extensile approach and feel comfortable with the anatomy, the minimally invasive approach would be relatively straightforward.