A hierarquia das evidências em cirurgia da mão nas revistas ortopédicas nacionais

CONTEXT AND OBJECTIVE: There is no systematic assessment of the quality of scientific production in the specialty of hand surgery in our setting. This study aimed to systematically assess the status of evidence generation relating to hand surgery and to evaluate the reproducibility of the classification method based on an evidence pyramid. DESIGN AND SETTING: Secondary study conducted at Universidade Federal de São Paulo (UNIFESP) and Faculdade Estadual de Medicina de Marília (Famema). METHODS: Two researchers independently conducted an electronic database search for hand surgery studies published between 2000 and 2009 in the two main Brazilian orthopedic journals (Acta Ortopédica Brasileira and Revista Brasileira de Ortopedia). The studies identified were subsequently classified according to methodological design (systematic review of the literature, randomized clinical trial, cohort study, case-control study, case series and other studies) and evidence level (I to V). RESULTS: A total of 1,150 articles were evaluated, and 83 (7.2%) were included in the final analysis. Studies with evidence level IV (case series) accounted for 41 (49%) of the published papers. Studies with evidence level V (other studies) accounted for 12 (14.5%) of the papers. Only two studies (2.4%) were ranked as level I or II. The inter-rater reproducibility was excellent (k = 0.94). CONCLUSIONS: Hand surgery articles corresponded to less than one tenth of Brazilian orthopedic production. Studies with evidence level IV were the commonest type. The reproducibility of the classification stratified by evidence level was almost perfect.CONTEXTO E OBJETIVO: Não há uma avaliação sistemática da qualidade da produção científica na especialidade de cirurgia da mão em nosso meio. Este estudo objetiva analisar o status da geração de evidências em cirurgia da mão, por meio de avaliação sistematizada, além de avaliar a reprodutibilidade da classificação baseada na pirâmide das evidências. TIPO DE ESTUDO E LOCAL: Estudo secundário realizado pela Universidade Federal de São Paulo (UNIFESP) e Faculdade Estadual de Medicina de Marília (Famema). MÉTODOS: De forma independente, dois pesquisadores promoveram uma busca eletrônica dos trabalhos envolvendo cirurgia da mão, no período de 2000-2009, para duas principais revistas na literatura ortopédica nacional (Acta Ortopédica Brasileira e Revista Brasileira de Ortopedia). Os trabalhos identificados foram subsequentemente classificados pelo tipo de delineamento metodológico (revisões sistemáticas da literatura, estudos clínicos randomizados, estudos de coorte, estudos caso-controle, séries de casos e outros estudos) e nível de evidência (I a V). RESULTADOS: Foram avaliados 1.150 artigos, sendo 83 (7,2%) considerados para a análise final. Estudos com nível de evidência IV (séries de caso) correspondem a 41 (49%) das publicações. Estudos nível de evidência V (outros estudos), corresponderam a 12 (14,5%) da amostra. Apenas dois estudos (2,4%) foram identificados como nível I ou II. A reprodutibilidade interobservadores foi excelente (k = 0.94). CONCLUSÕES: Os artigos de cirurgia da mão correspondem a menos de um décimo da produção ortopédica nacional. Estudos nível de evidência IV foram os mais encontrados na literatura nacional. A classificação estratificada por níveis de evidência apresenta reprodutibilidade quase perfeita.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Department of Orthopedics and TraumatologyFaculdade Estadual de Medicina de MaríliaFaculdade Estadual de Medicina de Marília Department of Orthopedics and TraumatologyUniversidade Federal de São Paulo (UNIFESP)UNIFESP, EPMUNIFESP, Department of Orthopedics and TraumatologyUNIFESPSciEL

Outcomes in orthopedics and traumatology: translating research into practice

Clinical research is focused in generating evidence that is feasible to be applicable to practitioners. However, translating research-focused evidence into practice may be challenging and often misleading. This article aims is to pinpoint these challenges and suggest some methodological safeguards, taking platelet-rich plasma therapies and knee osteochondral injuries as examples. Studies and systematic reviews involving the following concepts will be investigated: clinically relevant outcomes, systematic errors on sample calculation, internal and external validity. Relevant studies on platelet-rich plasma for muscle-tendon lesions and updates on osteochondral lesions treatment were included in this analysis. Authors and clinicians should consider these concepts for the implementation and application of dissemination of the best evidence. Research results should be challenged by a weighted analysis of its methodological soundness and applicability. Level of Evidence V, Therapeutic Studies - Investigating the Results of Treatment.Universidade Federal de São Paulo (UNIFESP) Department of OrthopedicsUNIFESP, Department of OrthopedicsSciEL

High-energy extracorporeal shockwave therapy in a patellar tendon animal model: a vascularization-focused study

OBJECTIVE: The aim of this study was to analyze the effect of high-energy extracorporeal shockwave therapy on tendon angiogenesis in the patellar tendons of rabbits. We sought to investigate whether different voltage and number pulses modify the angiogenesis pattern. INTRODUCTION: High-energy extracorporeal shockwave therapy is an option in the treatment of orthopedic diseases such as chronic tendonitis. Despite its potential clinical applicability, there have been few studies on this technique that examine both its clinical effectiveness and its effect on angiogenesis. METHODS: High-energy extracorporeal shockwave therapy was applied at the tibial insertion of the left patellar ligament in 30 rabbits that were separated into six groups that differed in terms of the voltage and number of pulses that were applied by high-energy extracorporeal shockwave therapy. The tibial insertion in the right legs of the animals was used as the control. After six weeks, we performed histological analysis on the region and quantified the number of blood vessels. RESULTS: No significant differences in the number of blood vessels between the left and right patellar tendons were found within groups. Additionally, no significant differences in the number of blood vessels in the left patellar tendons were found between groups. CONCLUSIONS: The application of high-energy extracorporeal shockwave therapy did not cause a change in vascularization in the patellar tendon in rabbits

Randomized Controlled Trials in orthopedics and traumatology: systematic analysis of the national evidence

OBJECTIVE: To assess whether there was an improvement in the quality and quantity of randomized controlled trials (RCTs) in nationally published journals through an application of standardized and validated scores. METHODS: We selected, electronically, for the period of 2000-2009, all RCTs published at the two indexed, orthopaedics-focused Brazilian journals: Acta Ortopédica Brasileira(AOB) and Revista Brasileira de Ortopedia (RBO). These RCTs were identified and scored by two independent researchers according to the JADAD scale and Cochrane Bone, Joint and Muscle Trauma Group score. The selected studies were grouped: 1) by publication period (2000-2004 and 2004-2009); 2) journal of publication (AOB and RBO). RESULTS: Twenty-two papers were selected, 10 from AOB and 12 from RBO. No statistically significant differences were found between the proportion (nRCT/nTotal of published papers) of RCTs published in the two journals (p=0.458), as well as for the JADAD score (p=0.722) and Cochrane score (p=0.630). CONCLUSION: The quality and quantity of randomized clinical trials in the period was similar in the journals analyzed. There is a trend of improvement of quality, yet there was no increase in the number of randomized clinical trials in both periods.OBJETIVO: Verificar se houve melhora da qualidade e quantidade dos ensaios clínicos randomizados (ECRs) publicados na literatura nacional, por meio da aplicação de escores estruturados e validados na literatura. MÉTODOS: Selecionamos, eletronicamente, todas as edições das duas revistas indexadas e de escopo ortopédico da literatura nacional - Acta Ortopédica Brasileira (AOB) e Revista Brasileira de Ortopedia (RBO), no período de 2000-2009, todos os ECRs publicados. Dois pesquisadores independentes identificaram e pontuaram os ECRs de acordo com as escalas de JADAD e do grupo de trauma musculoesquelético da Colaboração Cochrane. Os trabalhos selecionados foram agrupados: 1) pelo período de publicação 2000-2004 e 2004-2009; 2) periódico de publicação (AOB e RBO). RESULTADOS: Vinte e dois trabalhos foram selecionados, sendo10 da AOB e 12 da RBO. Não houve diferença entre o número proporcional (nECR/nTotal de trabalhos publicados) de ensaios clínicos randomizados publicados nos dois periódicos (p = 0,458), assim como para os escores de JADAD (p = 0,722) e da Colaboração Cochrane (p = 0,630). CONCLUSÃO: A qualidade e quantidade relativa de ensaios clínicos randomizados nos periódicos analisados foi semelhante. Há uma tendência de melhora da qualidade; contudo, não há acréscimo da quantidade de ensaios clínicos randomizados nos dois períodos analisados.Universidade Federal de São Paulo (UNIFESP) Departamento de Ortopedia e TraumatologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de Ortopedia e Traumatologia Setor de Ombro e Cotovelo da Disciplina de Mão e Membro SuperiorUNIFESP, Depto. de Ortopedia e TraumatologiaUNIFESP, Depto. de Ortopedia e Traumatologia Setor de Ombro e Cotovelo da Disciplina de Mão e Membro SuperiorSciEL

Pancreatite Crónica

INTRODUCTION: Previous reviews have demonstrated that patient outcomes following orthopaedic surgery are strongly influenced by the presence of Workers' Compensation. However, the variability in the reviews' methodology may have inflated the estimated strength of this association. The main objective of this meta-analysis is to evaluate the influence of Workers' Compensation on the outcomes of orthopaedic surgical procedures. METHODS: We conducted a systematic search of the literature published in this area from 1992-2012, with no language restrictions. The following databases were used MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and Pubmed. We also hand-searched the reference sections of all selected papers. We included all prospective studies evaluating the effect of compensation status on outcomes in adult patients who had undergone surgery due to orthopaedic conditions or diseases. Outcomes of interest included disease specific, region specific and/or overall quality of life scales/questionnaires and surgeons' personal judgment of the results. We used an assessment tool to appraise the quality of all included studies. We used Review Manager to create forest plots to summarize study data and funnel plots for the assessment of publication bias. RESULTS: Twenty studies met our eligibility criteria. The overall risk ratio for experiencing an unsatisfactory result after orthopaedic surgery for patients with compensation compared to non-compensated patients is 2.08 (95% CI 1.54-2.82). A similar association was shown for continuous data extracted from the studies using assessment scales or questionnaires (Standard Mean Difference = -0.70 95% CI -0.97- -0.43). CONCLUSIONS: Among patients who undergo orthopaedic surgical procedures, those receiving Workers' Compensation experience a two-fold greater risk of a negative outcome. Our findings show a considerably lower estimate of risk compared to previous reviews that include retrospective data. Further research is warranted to determine the etiological explanation for the influence of compensation status on patient outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42012002121