BJJ Podcasts

BJJ Special Edition Podcasts…Insights from the US with Prof Heather Vallier

June 17, 2021 The Bone & Joint Journal Episode 40
BJJ Podcasts
BJJ Special Edition Podcasts…Insights from the US with Prof Heather Vallier
Show Notes Transcript

Our first podcast in this edition is with the President of the Orthopaedic Trauma Association (OTA) Prof Heather Vallier.

Papers discussed: 


[00:00:00] Welcome everyone. I'm Andrew Duckworth and I'd like to thank you for joining us for one of our podcasts for the month of June. We hope all of you are keeping safe and well during these uncertain times, although positive signs do appear to be on the horizon. We also hope you've enjoyed our podcast so far this year. We've covered a range of topics, including the role of patellar resurfacing and total knee replacement, as well as the results of a multicentre randomized controlled trial, looking at different hip fracture fixation techniques from the WHiTE cohort. We also continue to deliver our special edition podcasts with our Specialty Editors here at the journal which we hope you are finding informative and are giving you all a good overview and insight of the research in their respective areas, as well as all the hard work that they do. 

Overall, we hope you're enjoying all the content from the knowledge translation team here at that BJJ and that we're achieving our primary aim to improve the accessibility and visibility of the studies we publish here at the journal.

 With this in mind this year we'll also be delivering special edition podcasts with our guests being world leaders in the field of trauma and orthopaedic surgery for their respective fields. Kicking things off today for the first episode in this series, which will focus on the area of orthopedic trauma. I have the great honour and pleasure of being joined by the [00:01:00] President of the Orthopaedic Trauma Association, Professor Heather Vallier from MetroHealth medical center in Cleveland. Welcome Heather. Thank you so much for joining us. It's so great to have you with us today. 

Thanks so much, Andrew. I really appreciate the opportunity to be a guest on your podcast. This is very exciting for me. 

That's great. So, Heather, just before we sort of talk about, I know we're going to talk about the highlights of trauma research over the past few years, but I just thought, you know, it's been a difficult year for everybody with the COVID pandemic, and just maybe give us a brief overview and insight for our listeners, both regards your own clinical practice but also in the US as a whole. 

It has been such a crazy year. And you know, now that it's been going on for over, you know, 16 months really, here in the United States and I work in Ohio at a large urban trauma centre in Cleveland and so our population are a few million people, and a lot of baseline morbidities in the way of obesity, tobacco use, diabetes and just generalized [00:02:00] less than  optimal health and management of baseline medical conditions at this county hospital where I work and my population is a little bit biased in terms of the rest of the United States and the world as a whole just to give you some flavour for that. 

Interestingly, you know, knowing that we are the least healthy of all the hospitals in our state, for sure, we didn't see a lot of COVID illness at our hospital, which is good. And I think that part of that is that we developed a no testing policy for all comers. Some of the hospital systems in the area, were just testing everybody routinely as they were picking up a lot of asymptomatic people, which I guess is good to learn about them even from an ecological standpoint, as well as from a safety standpoint, just to see what the result is.

I don't think we really know. I think we're continuing to learn but unfortunately, because we weren't testing we were continuing to stay open and said we were able to manage baseline medical problems and [00:03:00] certainly some elective orthopaedic work relatively early on, as well as our fracture work without a lot of challenges.

Oddly some of my patients who were pretty unhealthy in the way of a hip fracture patients or elderly co-morbid patients with key fractures were noted to be positive for COVID when we were trying to transition them to skilled facilities that require testing. And so this became a little bit of a dilemma because then the patients would get stuck here because the facilities wouldnt accept them. So that was actually an unforeseen issue that we did run into quite a bit, especially last year. It's not so much a problem now as the frequency of the pandemic, both in the illness and in an asymptomatic positive testing has gone down. And so that's been a challenging time of certainly a huge spike in mental illness, anxiety, a lot of increase in interpersonal violence, like domestic violence and assaults, which we unfortunately see a fair amount of baseline has been [00:04:00] tripled now same with gun violence and inner city gangs and things like that have really been on the loose and we're sadly seeing probably the highest gunshot presentations that we've seen since in like the 1980s.

Right. So we're hopeful that you know, with time, this is going to invade a little bit. I think there's a lot of things aside from this playing into this politically, economically, and that's made it difficult. So it's strange, and my answers have been long-winded and all of the, what I've seen, hasn't been so much COVID respiratory illness per se has been more the ramifications of some of the changes that have taken place in our community, in our economy that have kind of led to some shifts. 

Yeah, no, I think I would say that's very much the same here, Heather. We have some COVID-related illness as well, but it's now I think we are getting more of a feel of that [00:05:00] unquantifiable effect it's had on everybody else's health in other ways, you know, and I think certainly, obviously not the gun crime, but the mental health issues that we're seeing coming through and deliberate self-harm and all these other things, and people have just neglected themselves, or have neglected to come to hospital early enough for significant conditions. And I think we're not going to really know the full effect of that for some time, probably I suspect in terms of the way things move forward. 

In terms of though, obviously in your role of the president, what's been your role in sort of, I suppose, supporting the orthopaedic community in the US. What has the OTA taken on from that point of view?

Yeah, it's been really interesting. It has been an interesting and challenging time to be part of the leadership team at the OTA. And, you know, we meet pretty frequently as a board and we've had to meet extra as a board kind of very early on in the pandemic, looking at some of our educational offerings, particularly the in-person meetings, which obviously have been canceled altogether or postponed. And so [00:06:00] early on shifting to a lot of virtual education opportunities and learning about platforms and kind of troubleshooting, I think we've learned a lot. We've gotten better at it. We've learned what some of the limitations are as well so that that's been all right. You know, the 2020 annual meeting was a big deal for us and, it's interesting. I think as trauma providers, seeing as we were working all along and some of our colleagues in elective specialties in orthopaedics, or just elective medicine practices, we're working very little clinically for a period of time. I believe that we had a different view of what the pandemic meant, based kind of along the lines of what I said a few minutes ago in that for most of our patients, it wasn't, as we didn't need to be as fearful, we felt confident about that. And I think that that attitude was not really accepted or understood by other colleagues of ours and certainly not by a lot of healthcare administrators and hints there was issues in terms of looking at the OTA as a whole and was it safe to have a meeting, can we do [00:07:00] this? A lot of people in the leadership felt, you know, it probably is. And we can take some basic safeguards and maybe make some virtual options available to allow people to decide what level of risk they'd like to assume. It gives us what we'd have to do in our lives anyway, for various matters each day. And unfortunately, due to a variety of constraints ranging from,  you know, Nashville in Tennessee where our meeting was to be in person in October of 2020 had limits on the size of gatherings. And so it really became a non-starter if we weren't able to continue with that contract because they couldn't honour it. And so fortunately, we were able to renegotiate with them to do the meeting there later on, years from now, which I think will benefit both parties. And sadly we lost that in-person experience, which wasn't really feasible or practical or appropriate for 2020. And there's a lot of revenue, of course, that goes with that because the OTA, you know, we try to really bring in [00:08:00] some revenue primarily for our annual meeting, but we use it to fund research grants and other things. And so the whole budget really hinges on that event. So that was a big financial downside for us and not to sound whiny, I think everybody's had their set of economic difficulties that have resulted from this, but it definitely did have some impact and so we started looking at that. Now, because we were not doing some of our courses in person, we were shifting to more of a virtual format. There is some cost savings involved there. So we've learned how to come up retool and reinvest in. I think ultimately our products going forward will be probably better for it. I think of any positives that come from this. I see some benefits .

One of the neat things that we didn't envision to be as much of a success as it was, is that here in the States, we've been doing a thing called fracture night in America, every Wednesday, and anybody can log on and you guys will be in the middle of the night cause it's Wednesday evening, of course, but it's been highly popular. It's several hundred people who are listening in each week with this on [00:09:00] various fracture topics, cases around the body. And it's also given a lot of new instructors, the ability to engage and to teach. And so that's been kind of fun. And so that's been a real win in kind of something new that we tried. And we're just going to continue that. 

We've also really increased the number of podcasts that we're doing as a society. I think this has happened in general. Probably accelerated because of the pandemic. But you know, even doing this podcast with you all, I think that there's been a real uptake in these opportunities to report conversations and to exchange ideas more avidly and more accessible to a lot of people. And so ou r podcast and the icon podcast are kind of, if you look at the ratings on the top 1% of views, which we will be getting  a lot o f feed. And so I think there are ways that we're able to connect with the world around us that we've learned about. And so it'll be interesting to see, you know, going forward after making some of these shifts that, like I said, I think [00:10:00] the end result will be that we'll be better as a society in terms of our ability to communicate and engage.

I think that's right, isn't it? I have spoken to a lot of people about the effects of the pandemic. But I think for all the negatives there have been these positive things that have come out of it in terms of, you know, the way that we were using, whether it be social media or online platforms to educate and connect. And I suppose in many ways, connect a lot easier than we could in the past, but I suppose we were maybe going to talk about it at the end, but it's probably a good time now, you're still confident though that they're the place of the in-person conference in-person meeting is still the very much a need for that.

I believe so. It's really interesting to me. I think maybe it's just my own enjoyment of really savouring those interpersonal interactions and the relationships that are enhanced a little bit by actually being in person. I think there's an element of relaxing. And even if it's not really a vacation or a holiday per se, it has a little bit of that feel because we had some [00:11:00] times and downtime with colleagues or with maybe friends who live in the area and that those pieces of it, we can't discount the importance of. And so I think that there is an element of that, that we will all still want to have some in-person engagement . Clearly for certain educational venues, such as cadaver courses, technical things. It's just not the same to do it when you're not in person. And even I think with small groups and discussions, It's just not as effective. And so my guess is that there will be more hybrid meetings and, you know, more opportunities to do things in a newer way. And we have technology that supports that, and we have a set of experiences that understand the benefits, but I mean, we, as human beings still thrive on the relationships and the interpersonal connections. And so I think that going forward, we'll still have a lot of that. And I think for the OTA as a society, our plan is to try to do some of both so that we can, for [00:12:00] people who travel, have time away, you know, time zone differences, things like this, we can kind of mitigate that burden and the costs around it by offering alternatives that have both in-person and virtual elements. 

I agree. I agree. I think you're right though. I think in terms of the needs and the want to get back to these in-person meetings, I think is very much there. 

So if we move on here, so we've been talking about a few sort of highlights of trauma research. So sort of before we move on to maybe certain specific topics, what do you you feel have been the, sort of the main themes coming through, you know, year on year from the, you know, the OTA and published in the big journals, what do you think the main sort of areas that we've been looking at in orthopadic trauma?

Yeah. Well, it's mostly just the management of fractures in the elder patients is really one area that's received a lot of attention and rightfully so, you know, the population of the world is ageing of course. And then I think that our healthiness as we get older has gotten better around the [00:13:00] world. And so people are living longer and so just looking at new opportunities to take care of patients, maybe more aggressively with certain clashes and the elderly patients. And is that reasonable or not? Use of new implants, osteoporotic bone, all of those things that kind of go in that realm, I think has received a lot of attention and it seems very worthwhile to look at.

 I think that some of the new technologies that have come out, a lot of them have been nuances to existing logging technology variations in how they all can be secured. And is it a variable angle? And what angle? And this and that, and kind of looking at stiffness of constructs and things. And I personally feel like there's been very little improvement in the way that we're delivering clinical care, because I think that it's already quite good in terms of the existing implants. So we're perfecting things that are already functioning quite well. So there's not a lot of margin for improvement there, but there's certainly been a fair amount of activity in that area.

I think the other [00:14:00] thing that we've noticed is more of a general research trend in that we're partnering more effectively. You know, you look at like the Canadian Orthopaedic Trauma society, for example, has done quite a good job for a long time now. And they've been an example for others, you know, you guys in the UK, of course have done a lot of work together. And part of it is I think because of the way that your health systems are configured and the way that data can be shared or gathered or even processes mandated or agreed upon, which is good and I'm encouraged by these larger groups of studies that are coming out because I think the quality of the work we're doing is better and more applicable in this study. This can get done quicker and the work disseminated more widely. 

In the United States, there's been, you know, the metric consortium, for example, which I think has a lot of administrative and bureaucratic burden. And so it's hampered somewhat the pathway to publication. There's good work going on. Certainly a lot of interesting studies that I think are gonna [00:15:00] affect the way that we're doing things that have already affected it a little bit more to come maybe in the next five to 10 years. And so I see the alignment of people working in larger groups toward a good research question has really accelerated in the world of orthopaedic trauma, which is great.

No, absolutely. I completely echo that. I think in terms of the way I think it happened during COVID as well as the collaborations that that came about and the quality of the data that we can get from that. And then ultimately we can improve and effect good patient care can't we? I think it's interesting what you said about the elderly factor, it seems to be the two things that you say in terms of the elderly fracture where maybe we considered nonoperative management more such as around the olecranon or the distal radius, but actually with the elderly fractures actually fixing them and getting them up and mobilizing earlier maybe is a good thing as well. It's finding that balance as well isn't there? There's been a sort of a range of research about that. Would you say that that is taken on in the states as well in terms of that role of nonoperative management, whether it be the olecranon or the distal radius or... 

[00:16:00] Yeah, that's it. That's a really interesting question. I feel like I'm a bit of an outlier amongst some of my peers in that in United States , in particular, many traumatologists are very enamored with new technologies and a lot of operative management. And we get very focused on the literature available on the detailed radiography that we pertain now. And it just really getting sucked into the concept of, I guess, for lack of a better way of saying this, treating the radiograph rather than treating the patient. And I think we all need to take a step back to really reflect on what problems are we really trying to solve here. And do we have evidence for a more aggressive intervention for said patient. And in many cases we do. And that evidence is mounting that nonoperative management is equal or potentially better for serving these fractures you're alluding to. And I think some of the work you've done have addressed this. I really commend you because I think those are difficult studies in [00:17:00] my experience here in Cleveland. And then through an order network in the United States. To get people to engage it. And I think they look at it as like, no, I'd rather do surgeries. And we look at surgery, we are surgeons. It's fun. We enjoy taking care of fractures and helping patients get well. But the reality is that there's just so many cases where either a patient can choose, I didn't want surgery or do. You dont have to talk them into it if there's no clear benefit to that procedure putting them at substantial risk and additional cost.

And so I think that we really do need better evidence. I am always excited when I see well-designed studies that look at things, I think there have been a fair number of them now in the last few years, just the radius on the proximal humerus , a little bit with ankle, really trying to distill down. You want to worry indications for surgery.

And if it's very fuzzy and there's a couple of [00:18:00] benefits where nonoperative management and a couple of benefits in the way of surgery. Let's communicate this clearly to this individual so that they can decide what they want to do. And that's what we have to do. And I think it's going to be slow coming in US because many surgeons or generalists are more of the mindset that we'd have rather do surgery. This is how we are moving. And so there's a trend in it and a historical push in that direction. And I also think that there's many patients who are suspicious when you tell them well, you don't need to have a surgery and they actually work out better. It sounds as though they don't believe you. They feel like no, it's an operation. So it must be good. It's more fancy. And so I hate to say it, but there's a fair number of people that can come into that mindset. And it's tricky to try to get them to just take a very close look for themselves at what the evidence shows. 

No, I think that's right. It's interesting you say that. Cause I would definitely experience that as well, the [00:19:00] way when you say that we can manage this naturally, they think that you're almost trying to hide something from them, you're not gonna offer them something and it's actually, it's, it's in their best interest really in many ways. 

But before we move on from the elderly fractures, you know, something we said we might talk about was sort of cemented versus uncemented hemiarthroplasties for neck of femur fractures. Now we have obviously North American fellows come through and I'm told you guys are just uncemented for everything. And obviously what's your sort of take on that in the states? What is the current sort of, would you say the main trend is for that and what about the evidence with it? 

Right, right. So, you know, it's interesting when I was a resident in the 1990s there was a little bit of a push for uncemented but not in this population, except for people who are very much in the mind to get this patient in and out of the ward. Cause cemented is going to take a little bit longer, not a lot longer, but you're looking at another 10 minutes more for preparation, cement and all. And I think [00:20:00] that even then we understood that there there's more risk of fractures when we do non cemented has been worn out at that time. 

And then also issues around cementing other problems in terms of each role, but it would be the procedure or the cement in itself doesn't create any issues with the chemicals, and with any physiological response to that. And so that's been very, very little but occasionally there's a problem. So you know, kind of grew up in the era of just cement almost all of these hemiarthroplasties unless there's a reason of concern about infection, very robust cortex and younger patient, perhaps, but you're not going to.

And so then even in the  regenerative hip  for, you know, total hip arthroplasty, many of the stems were cemented and then it was kind of a move towards cemented probably in the next, you know, 10, 15 years following it. And that's kind of stood up over time so that most of those are uncemented now. But I think that I would say that about well for about 5 or 8 years now, and I [00:21:00] see this in my younger colleagues that come into practice, they almost always do uncemented. And some of them will say, well, I never really did much cementing when I was a resident so I'm more comfortable with it. And I think that's a valid point. We all draw from our experiences and we get good at doing things a certain way because we have repetitions and we understand our limitations in our abilities. And we have to take that experience set and look at what the literature says and determine when is it appropriate to modify what I'm doing? Or am I really close to what everybody else is doing? And will continue because this is something I'm pretty good at. And because we make those determinations each day, each time we take care of somebody. But the bulk of the literature supports you doing cemented hemiarthroplasty in the elderly in most cases. 

I think there's another paper that came out in The Journal of Bone & Joint Surgery last year that showed some benefit for us. I think it's some populations where that may be appropriate. And so I cement almost all my [00:22:00] hemiarthroplasties. I will occasionally do an uncemented if it's a younger patient, if there's an issue with the pre-existing infection in that limb, or just unusual set of circumstances for whatever reason, but it is almost always cement and I feel like patients are more comfortable postoperatively. They can get moving a little bit quicker. There's less issues with subsiding and certainly less risk of fracture. I can say that just based on all the work I see in our department here and across the landscape in the Cleveland area, for sure. 

Yeah, it's interesting. I think, because that very much I would agree with you fits with the literature, doesn't it? In terms of, you know, whether be, you know, Martin Parker did a trial here that was published in the journal a couple of years ago, which said that they seem to be more comfortable but then I think  Mike Whitehouses group had a systematic review in the journal just over a year ago now of just that very thing that, you know, the cemented is associated with a lower risk of intraoperative and periprosthetic fractures as you've just described. So it's quite interesting that isn't it? But like you say, I suppose it's what you're comfortable doing. And if you're uncomfortable doing a certain technique [00:23:00] that has its own risks associated with it as well doesn't it really? So there's a balance to be had there. 

So Heather, if we move on to, we're going to talk about maybe about ankle fractures. I mean,  it's like the clavicle fracture now there's literature everywhere about it. But whether it be about the medial or posterior mal, but two things we're going to talk about maybe weight bearing, you know, so when is it safe to weight bear? It's sort of quite topical because we have the wax trials sort of being run over here at the moment, which is looking at early weight bearing. But obviously the cots group as well, they've published about that before. And in relation to that, what is the general principle over there in terms of weight bearing after ankle fractures?

Yeah, it's interesting. I think the Canadians have embraced it a little bit more than this in the United States. And again, I'm generalizing, but part of it is just the experience that a lot of people have with treating all the ankle fractures and they come in all varieties. They are subtle, some of them make a minor adjustment. In this person who's 23 and has [00:24:00] excellent quality bone. And is very easy logically fit versus our, you know, 83 year old diabetic patient who's *inaudible*. I mean, it's just a lot of different comers and we're trying to pigeon hole them all into one thing. And so at the end of the day, my personal take is to try and modify our individual patient care based on the literature and our experiences like we were discussing earlier. And then trying to say, well, you know, we may be able to get some of these people walking earlier than we've had in the past. And there's some utility in doing that.

I think we also get hung up by maybe our last complication and those, you know, they've seen, and I've mentioned before the population that we care for, unfortunately over half of my patients are obese. And many of them are morbidly obese with a BMI over 40. We have, sadly, an unhealthy  population here. Over half of my patients are tobacco users and many of the obese are [00:25:00] diabetics. And a handful of those that are non obese are also diabetics. It's a very comorbid population that is going to be slower to heal. They're going to be heavier. They're going to be less adept at maintaining their balance and everything after surgery. And so they're slower to heal, slower to function as a whole. 

The ankles were interesting to me, because you know, when the cots paper came out, I was impressed. It was a pretty high quality study. That's certainly just early follow-up. And it's one of those things where you're letting these patients go at about two weeks. Half of them were allowed a force to weightbear as tolerated for that first month afterward. And the others were instructed to maintain non-weightbearing status. And so the patients probably self-regulate. I bet they're not all just running right back to it. You know, there is just no taking care of people. They're going to modify as they feel better and they can gradually do things. Suffice to say there were some early improvements in their functionality and then over time, it levels out a little bit. So they get that early enhancement of kind of being [00:26:00] able to get back to things. And the nuances in that paper that I think were tricky based on the sample size, relative to what types of occupations people were trying to get back to. I think it was a larger sample. All of that probably would have neutralized, maybe favoured the weight bearing a little more than it's suggested. 

Yeah. 

And I think that interpreting it that way makes it more practical. And so if I have patients that are healthy, acting good bone quality, good quality reduction and no syndesmotic injury be inclined to get them walking on it a little quicker than I would say five, 10 years ago. That's influenced by the cost for sure. Problems in my practice is I just don't have that many people that fit in that category. And I definitely still do protect even patients with less obvious injuries who have all these co-morbidities because they're very slow to heal. 

And I've had, each year, probably a couple of patients who have some failure fixation who are just sort of stepping on things in their splints, just going to the [00:27:00] bathroom. And it doesn't even hold up to that. And so that's one stream and not trying to taint my practice where it certainly advocates maintaining people for a prolonged time of non-weightbearing as a whole. But there's some where you got to really watch it because once they start to fall apart, you're either going to revise them, or I think there's a role now for maybe *inaudible*, you know, doing some early more aggressive intervention, and then they can walk on it. We know that population enough. 

Yeah, no, absolutely. I completely agree. I think you're right . The great thing about theses RCTs is the level of evidence they provide in the data they provide, but they don't give you an answer for all your patients. They just give you that information, but you have to adapt it to that patient in front of you. Like you say there is an exclusion criteria with that trial in terms of, you know, obviously syndesmotic injuries, but posterior malleolar fractures are fixing.  You've got to adapt it to that, isn't it? But I think it just makes you... the great thing about that study is it just makes you think about that. And actually we can be potentially more aggressive with these patients and we just have to adapt it with time. 

So related to ankle fracture, the other [00:28:00] thing I just wanted to touch upon was about the suture button versus the screw. There's been a couple of randomized controlled trials. There has been obviously again, the guys that was published in the JOT recently and also the one in the BJJ as well looking at sort of five-year outcomes. And has that changed your practice at all? 

Not a lot. It's changed my attitude a little bit because I am more open to it. So at the end of the day, the syndesmosis, most of us are using *inaudible* or some type of plain radiography to assess fracture alignment. And so some people are routine using an OR, but many facilities are not outfitted with that type of setup. To get it more accurate we assess quality of the reductions and with the quality reduction you want to maintain it there. And so that's the thing. And so I think that the piece that's hard in these studies is that the quality of the reduction is really based on an interoperative position, just plain imaging of some kind.

And so, you know, we're going to get it there and probably we're imperfect a lot of the time and we don't really [00:29:00] appreciate that. But as it heals, the fibula wants to go back to where it belongs. So this, I think even suture button allows for that sensation as low as if you assume it's normal place, it likes to be sooner. So this should be a quicker recovery and then less bother down the road. Whereas with the screws they need to mucin and or break for the fibula to find it's home and to find that improvement in ankle motion. And so there's some prolongation of that part of the recovery. That's my sense, clinically based on my experience. And I think that the literature supports that and I am making this very general of course, but what's interesting to me about the papers is I thought that the second year, the two year follow-up in the study of Norway was interesting because, you know, they saw more synostosis after the tightrope, which I thought was interesting. And I was a little bit puzzled because you'd think like, well, there's a little emotion there where they see more synostosis. I don't know, [00:30:00] but they, but they did. And, and really that. The functional outcome scores were the same. And then at five years they noticed a little more arthritis and a little bit less good outcome with the screws. And so I believe it's real. And I think that their studies are good and if you look at the composite of all the literature in this area, it's tricky because some of the studies are so small where there's methodological criteria that are just not comparable, one study to the next to try and get some solid takeaways. But my gut is that the suture button performs better long-term in the whole population of patients. The cost thing is really a problem for us. So at my hospital, the suture button is over $2,000, US dollars, and a screw is like $10. So it's a huge, huge difference in price. And so if we put one of those in the hospitals already losing a lot of money just based on the fixation. And so I am trying to right now just assess the type of [00:31:00] patient. If I have a younger, very highly functioning patient who enjoys a lot of recreational activities or has a vocation where they need to do a lot of climbing and lifting and heavier walking, I would err toward using the suture button to try to get them to recover a little quicker as well as to have that potential for less arthitis risk and let's follow-up down the road. So there's the cost piece of the implant itself. 

I think the other issue is around how often do you reintervene? And I don't reoperate all that often. I think many people, when they have a broken or a loose screw, they go to review, they don't automatically remove all of their screws. I believe that literature suggests that that is not necessary. And it really is a lot of extra surgery. And a lot of extra costs. Some of the studies you have to be careful because if you read into how they perform their economic analyses, they're accounting for a certain number of those to be removed.  It's [00:32:00] not necessarily indicated and it flaws all of the financial analysis. And so you need to read it carefully and sort of recalculate it based on your practice where you live and what is the type of patient that you're treating. 

So in taking all of that into account best I can tell at this point in time is that the suture button performs better in the longer term in terms of the outcomes and less arthritis risks. But my personal population, it's not very often because of the types of patients that I treat. 

That's interesting. I think that's a really nice way to interpret the data, particularly the Noway study. Like you say the numbers for things like ankle arthritis particularly, you know, they're small numbers, but 65% versus 35%.That's quite a big difference, but actually is that symptomatic? And is that actually cost effective to put the suture button and everybody just for that difference. You know, we don't know that do we? And it sort of requires some nice studies, but that's really interesting. I think because the data around there is, [00:33:00] on first look, quite convincing for it. But actually there's more nuances there isn't there?

So finally Heather, just to round off the research overview, I just wonder if you touched upon it. I know its an area you've done a lot of research in yourself as the role of sort of recovery resources and patient education and engagement on enhancing recovery after trauma. There's been some great work from yourselves included, you know, about this, and what's your sort of overview of the area? Where are we with that? Is that growing? Is that going to be the future do you think? 

I think there's a lot trending this way societaly particularly in developed countries and that others will follow suit in that, you know, we as traumatologists clearly understand that we enjoy doing the work that we do, taking care of specific injuries and finding that immediate gratification, and even developing those relationships with our patients that have longer term issues like arthritis and things. But in the bigger scheme, there are so many factors that obviously weigh into why [00:34:00] a patient even got hurt. Was their injury related to their underlying vocation, their mental health, their history of substance use and that sort of thing? And so many individuals and most hospital systems are not configured to traditionally incorporate any of that and how we acutely and more long-term care for our patients, whether it's rehabilitating from given injury or even just looking at the idea of recidivism and are patients coming back with additional injuries because of poor lifestyle choices? And it may be some failure of the social system around them or their own education, their injury or their education of life as a whole, and ways that we can try to help them to improve their wellbeing and their overall health. We suspected that injury. And so I feel like there's a lot of room for improvement.

And so we had started around 2013 to make this somewhat of an area of research to focus at our institution and I think that emphasizing these parts of [00:35:00] recovery has been very gratifying in that I think I've treated them better as a surgeon and more understanding of my own limitations in terms of technical capabilities or given injury, you know, and quite frankly, part of that is just technical limitations that we all have as individuals, but also because of the eateries themselves, which lead to things that are out of our control. 

But these other elements that are relational and the effect that we can have on better educating our patients and helping them to engage with their own social support system. And if they don't have one, helping them to connect with community resources. We've been developing resources and we've been developing a peer-mentorship programme in our hospital. We all have trauma survivors who will connect with new trauma patients. We try to match people based on gender, ethnicity, type of injury, that sort of thing. And so it's generally pretty well received and we know that the peer-programme has resulted in a lot of [00:36:00] increased patient satisfaction. 

Yeah.

 As well as less recidivism for trauma. And now that we've been doing it for several years, we're starting to put some of the numbers in and I think that some of the interventions that we implemented have included educational initiatives and we built an app, you know, she mentioned for trauma a few years ago and we started rolling it out here, just kind of pilot it and get some feedback as to what people liked and didn't like, and how we could improve it. And after about 18 months of going through some different iterations and improving the quality of the content and the scope of the content. So there's a lot of orthopaedic content. There's some general trauma content. There's some recovery elements that have to deal with connecting with the world around you, nutrition, basic questions that you may face as you return home from the hospital. And as you return to work place in life, that sort of thing, and just links to other resources. 

We rolled out the app [00:37:00] formally to several other hospitals, and we presented our work on that at the OTA in 2019. And noticed a pretty nice you know, uptake in terms of the patients are starting to use it more. I think that initially there was less familiarity with smartphone technology, even though this was just a few years ago, but that has gone up quite a bit, even our elderly folks who have smartphone access, and most of them are pretty comfortable with doing it. And so it's a very easy way to allow a patient or abandoned member to engage. So I think that that's important and that idea that most trauma patients have very poor recall. They probably are bombarded with a lot of information that they don't understand. They're in pain, they're overwhelmed by circumstances of their injury. They may be off medication that's hampering their thinking. And so for all these reasons recall is abysmal, on average, particularly in a fully traumatized patient. And so having an app where they can sit there and look at it and play with [00:38:00] it themselves on their phone and kind of review things has been helpful. 

We're hoping to learn a little bit more about this. We actually just did another study. It's still ongoing, but we had started it about a little over a year ago, looking at patients and usually at who didn't versus who did. And obviously there's a selection bias there because choosing to use the app probably more inclined to be engaged in their own healthcare and to be more educated on average. But we found that their knowledge about their injury and their propensity to follow weight bearing restrictions and other instructions with over twice as much in the patients that were engaging with the app versus not. 

And so this is a very simple thing. It's low budget, you  know, its easy. And it's just part of our discharge materials that we show it to them. And there's even people now in our clinic who will come around and say, oh, you know, did you get a chance to look at the app? Oh yeah, you have a rod in your leg. Look there's a picture of what it looks like. And so there's sort of a little bit of a public [00:39:00] relations element that we're trying to get patients more engaged with their own care, learn about it. We think that they're more satisfied, our early data suggests that they're more satisfied with their care as a whole. And I think that they're probably going to report less pain, less anxiety. We're in the process of measuring some of these things now. I think that just a small little budget intervention like this can go a long way to really improving the ability of the patient to recover from an injury. Maybe they are recovering from many injuries, or maybe it's something simple, just an ankle fracture. And so for all commerce, I think that interventions like this are going to be really important going forward to build upon what we can do as surgeons.

Yeah. 

I feel like, you know, for us, we have some, you know, big opportunities to take care of people who are profoundly injured. Some of them with their life have been threatened. And it's certainly very satisfying and quite an honor to be part of a team that's capable of doing that. [00:40:00] But the technical part, after, you know, you do it first, a number of years, you start to acquire skills. You have a competent team. I think that right now, the bigger way to improve on a care worker is to try to fill in some of these elements that have been traditionally neglected in our systems. And so those are the things that our recovery services team is touching upon in some of the projects that we're doing now, and that we're looking for other centres to join us on, to learn more about it and learn how to do these interventions. When is it effective? What is effective and which populations? Because not every population is going to respond to everything.

 No. Absolutely. It's interesting. Isn't it? Because like you say, I think it's, I know that the other work you've looked at and people like David Ringer have talked about a lot is it's just treating the whole patient, isn't it? The psychosocial aspects. And a lot of that stuff is going towards contributing to that. Addressing those issues that are out with just the fracture, which must have a massive, you would expect, a massive influence on the outcome for the patient really. So I think it's really interesting work. 

That [00:41:00] sort of leads into my final question for you Heather. What do you think are the challenges moving forward? You know, we've been through the pandemic, you know, in terms of orthopaedic trauma as a whole, in terms of research, what are our main challenges do you think over the next couple of years? 

Yeah. I believe that this is going to be one of them and that's kind of, you know, the longevity of trauma systems is going to depend upon us being healthy and us as providers maintaining our own wellbeing. And that's been one of the key initiatives of the Orthopaedic Trauma Association. Of course, this year, we have a task force. We are looking at provider wellness and wellbeing to make sure we're taking good care of ourselves. That we can take care of others. And I think along those lines, these issues around recovery of the whole person are going to become increasingly important as they have profound effect o n the costs of care and really the indirect costs in a way of the mental burden and anxiety and this means that can be a demise for a lot [00:42:00] of people following a major injury. And so we're looking to try to develop language and initiatives around this within the OTA and we'll partner with The American Trauma Society and kind of make it a more comprehensive, generalized trauma effort, if you will, that we focus on these things. 

We are trying to place some emphasis on including this more in medical school curricula. So that healthcare providers are trained with a similar set of understanding of these issues and the importance. And again, it's difficult. I realize I'm generalizing and we are applying this to a lot of patients and some have many needs and some have less needs and in various ways. And so just trying to help people to be the best that they can be. 

Yeah. 

Ass a sidebar, one of our former research coordinators, she just picked up her masters, started a whole programme, which we're still working on. It's turning into a study. It was a pilot. What [00:43:00] I think someone might want after their femur fracture may not be what they want. You know, what is important to them. And so really determining what matters to each individual and that personalized medicine. We talk about personalized medicine as relates to genotype and a basic science level. You know, looking at how do we tailor treatments and how do we measure human care based on these personalized traits, but there's all of these other psychosocial things that are quite personalized and not for us to judge the validity or are they right or wrong looking for another individual. We're ready to hear them out. And it helped them to construct what they believe to be a n  appropriate set of goals to work toward, to help them to be well. I see that as a way that our society will move in the future. Even more impactful than we already are. 

Yeah, no, absolutely. I think you're right. And like you say, we can look at implants all we want, but actually there's so much more that we need to look at with the patient and the whole psychosocial [00:44:00] aspects, and actually we can help and effect change, if we listen and find out what the patients actually want and what's concerning them. 

Well, that's all we have time for Heather, but thank you so much. That was excellent. I really enjoyed that overview of orthopaedic trauma and it was so great to have you with us. I really do appreciate it.

Thank you so much for the opportunity. It's really great that you're doing this. I wish you a lot of success with your future podcasts. 

Thanks very much Heather. And to our listeners, we do hope you really enjoyed joining us today. Feel free to tweet or post about anything we've discussed here today. Take care everyone.

Thanks for listening.