How good is the orthopaedic literature?

Randomized trials constitute approximately 3% of the orthopaedic literature Concerns regarding quality of the orthopaedic literature stem from a widespread notion that the overall quality of the surgical literature is in need of improvement. Limitations in surgical research arises primarily from two pervasive issues: 1) A reliance on low levels of evidence to advance surgical knowledge, and 2) Poor reporting quality among the high level surgical evidence that is available. The scarcity of randomized trials may be largely attributable to several unique challenges which make them difficult to conduct. We present characteristics of the orthopaedic literature and address the challenges of conducting randomized trials in surgery

The incidence of type 2 diabetes in patients presenting for bariatric metabolic surgery at a tertiary bariatric surgery centre in India

Background: In recent years, there has been a marked change in life-style of developing countries caused by economic growth, affluence, urbanization and dietary westernization. Few studies on the prevalence of obesity with diabetes in the Indian population have been reported. Therefore, this study was planned to estimate the prevalence of type 2 diabetes (T2D) in patients presenting for at a tertiary bariatric surgery centre in India.Methods: In this retrospective study, authors estimated the prevalence of T2D by analyzing the hospital-based data, who were came for bariatric surgery at tertiary bariatric surgery centre in India from January 2010 to June 2018.Results: From the hospital-based data of eight years the incidence of T2D was found 24% of the Indian population in series, who came for bariatric metabolic surgery (BMS). There was slight male preponderance in incidence of T2D based on gender. The higher incidence of T2D was found mostly in 45-60 years age group in both the male and female patients. Incidence of T2D in class of obesity was 4.3% of class I, 18.6% of class II and 77.1% in class III. The incidence of hypertension was seen 41.8% and co-prevalence of both obstructive sleep apnea syndrome and hypertension was 16.2%.Conclusions: Age and higher BMI are strongly and independently associated with the risk of being diagnosed with T2D. The association of BMI class on the risk of T2D is stronger for people with a higher BMI relative to people with a lower BMI

Closed Limb Fractures With Compromised Vascularization: A Narrative Review

© The Author(s) 2019. Vascular compromised fractures typically result in a high rate of healing complications, such as avascular necrosis, nonunion, delayed union, and arthritis, which severely affect a patient’s function and quality of life. The purpose of this review was to identify and describe the epidemiology and available treatment options for the most well-known vascular compromised closed fractures. The injuries discussed in detail in this review were scaphoid, lunate, femoral neck, and talar fractures. Current evidence suggests that optimal treatment for vascular compromised fractures is dependent on the degree of fracture displacement and comminution, and the patient’s post-injury functional demands, age, and bone quality. Conservative efforts generally include casting or splinting with a period of immobilization. Surgery is indicated for substantially displaced fractures, patients who require higher functional demands and an earlier return to activity, or if complications occur following nonoperative treatment; however, operative intervention is typically performed for femoral neck fractures regardless of the amount of displacement. Various surgical techniques exist, though internal fixation with screws is a common procedure among these injuries and can be used in combination with other implants, such as plating or Kirschner wires (k-wires), when needed. Severe fracture comminution, poor bone quality, or arthritis can contraindicate the use of screws and more invasive intervention will be required. Bone grafting is done in some cases to enhance vascularity. Salvage procedures exist for patients who develop severe complications, but these will permanently alter the anatomy of the injured area and should be considered a last resort

Meta-analysis: A practical decision making tool for surgeons

AbstractBackgroundThe exponential rise in published medical research on a yearly basis demands a method to summarise best evidence towards its application to patient care in clinical practice. A robust meta-analysis is a valid tool. It is often considered to be a simple process of pooling results from different studies. This is not true. It appears that surgeons lack a reference guide to help them conduct and appraise a meta-analysis.MethodsThis paper provides a structural framework to perform a meta-analysis. It guides the surgeon on a journey from identification of the correct clinical question to data analysis and through to producing a structured report. Statistical methods are discussed briefly as most commercial software calculates most results in the background. An example of a recent meta-analysis is given. However, important caveats are mentioned as there are limitations of the meta-analytical technique.ConclusionWhereas meta-analyses of homogeneous studies are the highest form of evidence, poorly conducted meta-analyses create confusion and serve to harm the patient. Surgeons practising their art in an era of evidence-based surgery need to understand the principles of meta-analyses

Intimate partner violence (IPV) in male and female orthopaedic trauma patients:a multi-centre, cross-sectional prevalence study

Objectives Identify the proportion of patients attending fracture clinics who had suffered intimate partner violence (IPV) within the past year. Design Powered cross-sectional study using validated participant self-reported questionnaires. Setting and participants Adult trauma patients (no gender/age exclusions) attending one of three Scottish adult fracture clinics over 16-month period (from October 2016 to January 2018). Primary outcome measure Number of participants answering 'yes' to the Woman Abuse Screening Tool question: 'In your current relationship over the past twelve months, has your partner ever abused you physically/emotionally/sexually?' Results Of 336 respondents, 46% (156/336 known) were women with 65% aged over 40 (212/328 known). The overall prevalence of IPV within the preceding 12 months was 12% 39/336) for both male and female patients. The lifetime prevalence of IPV among respondents was 20% (68/336). 38% of patients who had experienced IPV within the past 12 months had been physically abused (11/29). None of the patients were being seen for an injury caused by abuse. Two-thirds of respondents thought that staff should ask routinely about IPV (55%, 217/336), but only 5% had previously been asked about abuse (18/336). Conclusions This is the first study worldwide investigating the prevalence of IPV in fracture clinics for both male and female patients. 12-month prevalence of IPV in fracture clinic patients is significant and not affected by gender in this study. Patients appear willing to disclose abuse within this setting and are supportive of staff asking about abuse. This presents an opportunity to identify those at risk within this vulnerable population.</p

Internet Versus Mailed Questionnaires: A Randomized Comparison (2)

BACKGROUND Low response rates among surgeons can threaten the validity of surveys. Internet technologies may reduce the time, effort, and financial resources needed to conduct surveys. OBJECTIVE We investigated whether using Web-based technology could increase the response rates to an international survey. METHODS We solicited opinions from the 442 surgeon–members of the Orthopaedic Trauma Association regarding the treatment of femoral neck fractures. We developed a self-administered questionnaire after conducting a literature review, focus groups, and key informant interviews, for which we used sampling to redundancy techniques. We administered an Internet version of the questionnaire on a Web site, as well as a paper version, which looked similar to the Internet version and which had identical content. Only those in our sample could access the Web site. We alternately assigned the participants to receive the survey by mail (n=221) or an email invitation to participate on the Internet (n=221). Non-respondents in the mail arm received up to three additional copies of the survey, while non-respondents in the Internet arm received up to three additional requests, including a final mailed copy. All participants in the Internet arm had an opportunity to request an emailed Portable Document Format (PDF) version. RESULTS The Internet arm demonstrated a lower response rate (99/221, 45%) than the mail questionnaire arm (129/221, 58%) (absolute difference 13%, 95% confidence interval 4%-22%, P<0.01). CONCLUSIONS. Our Internet-based survey to surgeons resulted in a significantly lower response rate than a traditional mailed survey. Researchers should not assume that the widespread availability and potential ease of Internet-based surveys will translate into higher response rates.Department of Surgery, McMaster University, Hamilton, Ontario, Canad

Anatomical Variants of Portal Vein Branching in CECT Scan of Abdomen: A Descriptive Study

Introduction: Various anatomical variants are encountered in portal venous system which are quite important while undergoing hepatobiliary surgeries and percutaneous radiological interventions. Contrast enhanced computed tomography (CECT) of the abdomen is considered a better imaging modality to identify these variations. Methods: A descriptive prospective study was conducted in 1000 individuals undergoing CECT of abdomen. Triple phase CECT scan of the abdomen was done and the portal vein anatomy was reconstructed and analyzed. Results: Normal branching pattern of the portal vein was seen in 786 (78.6%) patients. Variations were seen in rest of the 214 (21.40%) patients. The most common variant was trifurcation of the portal vein seen in 113 (11.3%) patients. Right posterior portal vein as the first branch of main portal portal vein was found in 72 (7.2%) patients. Right anterior portal vein arising from left portal vein was seen in 29 (2.9%). Sixty nine of the 567 males had trifurcation accounting for 12.1% incidence of this variation amongst males. Trifurcation was seen in 44 of the 433 females resulting in an incidence of 10.1%. Forty-four (7.7%) males and 28 (6.4%) females had right posterior portal vein as the first branch of main portal vein. Right anterior portal vein was noted to arise from the left portal vein in 20 (3.5%) males and nine (2.07%) females. Conclusion: The most common variation in portal venous system was trifurcation of portal vein followed by right posterior as first branch and right anterior branch arising from left portal vein respectively

Implant Removal After Internal Fixation of a Femoral Neck Fracture:Effects on Physical Functioning

Objectives:The effect of implant removal after internal fixation of a femoral neck fracture on physical functioning was analyzed. Characteristics of patients who had their implant removed were studied, as it is currently unknown from which type of patients implants are removed and what effect removal has on function.Design:Secondary cohort study alongside a randomized controlled trial. Setting:Multicenter study in 14 hospitals.Patients and Intervention:Patients who had their implant removed after internal fixation of a femoral neck fracture are compared with patients who did not.Main outcome measurements:Patient characteristics and quality of life (Short Form 12, Western Ontario McMaster Osteoarthritis Index) were compared. Matched pairs were selected based on patient/fracture characteristics and prefracture physical functioning. Results:Of 162 patients, 37 (23%) had their implant removed. These patients were younger (median age: 67 vs. 72 years, P = 0.024) and more often independently ambulatory prefracture (100% vs. 84%, P = 0.008) than patients who did not. They more often had evident implant back-out on x-rays (54% vs. 34%, P = 0.035), possibly related to a higher rate of Pauwels 3 fractures (41% vs. 22%, P = 0.032). In time, quality of life improved more in implant removal patients [+2 vs. -4 points, Short Form 12 (physical component), P = 0.024; +9 vs. 0 points, Western Ontario McMaster Osteoarthritis Index, P = 0.019]. Conclusions:Implant removal after internal fixation of a femoral neck fracture positively influenced quality of life. Implant removal patients were younger and more often independently ambulatory prefracture, more often had a Pauwels 3 fracture, and an evident implant back-out. Implant removal should be considered liberally for these patients if pain persists or functional recovery is unsatisfactory.Level of Evidence:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence

Moving forward through consensus: protocol for a modified Delphi approach to determine the top research priorities in the field of orthopaedic oncology.

IntroductionOrthopaedic oncology researchers face several obstacles in the design and execution of randomised controlled trials, including finite fiscal resources to support the rising costs of clinical research and insufficient patient volume at individual sites. As a result, high-quality research to guide clinical practice has lagged behind other surgical subspecialties. A focused approach is imperative to design a research programme that is economical, streamlined and addresses clinically relevant endpoints. The primary objective of this study will be to use a consensus-based approach to identify research priorities for international clinical trials in orthopaedic oncology.Methods and analysisWe will conduct a 3-phase modified Delphi method consisting of 2 sequential rounds of anonymous web-based questionnaires (phases I and II), and an in-person consensus meeting (phase III). Participants will suggest research questions that they believe are of particular importance to the field (phase I), and individually rate each proposed question on 5 criteria (phase II). Research questions that meet predetermined consensus thresholds will be brought forward to the consensus meeting (phase III) for discussion by an expert panel. Following these discussions, the expert panel will be asked to assign scores for each research question, and research questions meeting predetermined criteria will be brought forward for final ranking. The expert panel will then be asked to rank the top 3 research questions, and these 3 research questions will be distributed to the initial group of participants for validation.Ethics and disseminationAn ethics application is currently under review with the Hamilton Integrated Research Ethics Board in Hamilton, Ontario, Canada. The results of this initiative will be disseminated through peer-reviewed publications and conference presentations

Clinical decision analysis: Incorporating the evidence with patient preferences

Decision analysis has become an increasingly popular decision-making tool with a multitude of clinical applications. Incorporating patient and expert preferences with available literature, it allows users to apply evidence-based medicine to make informed decisions when confronted with difficult clinical scenarios. A decision tree depicts potential alternatives and outcomes involved with a given decision. Probabilities and utilities are used to quantify the various options and help determine the best course of action. Sensitivity analysis allows users to explore the uncertainty of data on expected clinical outcomes. The decision maker can thereafter establish a preferred method of treatment and explore variables which influence the final clinical outcome. The present paper reviews the technique of decision analysis with particular focus on its application to clinical decision making