From evidence to action. Understanding clinical practice guidelines.

Good guidelines will help us to take evidence into practice. In a survey among Dutch orthopedic surgeons, development and use of evidence-based guidelines was perceived as one of the best ways of moving from opinion-based to evidence-based orthopedic practice. The increasing number of guidelines means that knowing how to make a critical appraisal of guidelines is now a key part of every surgeon's life. This is particularly true because guidelines use varying systems to judge the quality of evidence and the strength of recommendations. In this manuscript we discuss what a guideline is, where we can find guidelines, how to evaluate the quality of guidelines, and finally provide an example on the different steps of guideline development. Thus, we show that good guidelines are a summary of the best available evidence and that they provide a graded recommendation to help surgeons in evidence-based practic

Systematic review: Do patient expectations influence treatment outcomes in total knee and total hip arthroplasty?

<p>Abstract</p> <p>Objective</p> <p>This systematic review aims to summarise all the available evidence related to the association between pre-operative patient expectations (outcome expectations, process expectations and self efficacy expectations) and 5 different treatment outcomes (overall improvement, pain, function, stiffness and satisfaction) in patients with total knee or total hip arthroplasty at three different follow-op periods (>6 weeks; >6 weeks- ≤6 months; >6 months).</p> <p>Methods</p> <p>English and Dutch language articles were identified through PubMed, EMBASE.com, PsycINFO, CINAHL and The Cochrane Library from inception to September 2012. Articles assessing the association between pre-operative patient expectations and treatment outcomes for TKA/THA in either adjusted or unadjusted analysis were included. Two reviewers, working independently, determined eligibility, rated methodological quality and extracted data on study design, population, expectation measurements, outcome measurements and strength of the associations. Methodological quality was rated by the same reviewers on a 19 item scale. The scores on the quality assessment were taken into account when drawing final conclusions.</p> <p>Results</p> <p>The search strategy generated 2252 unique references, 18 articles met inclusion criteria. Scores on the methodological quality assessment ranged between 6% and 79%. Great variety was seen in definitions and measurement methods of expectations. No significant associations were found between patient expectations and overall improvement, satisfaction and stiffness. Both significant positive and non-significant associations were found for the association between expectations and pain and function.</p> <p>Conclusions</p> <p>There was no consistency in the association between patients’ pre-operative expectations and treatment outcomes for TKA and THA indentified in this systematic review. There exists a need for a sound theoretical framework underlying the construct of ‘patient expectations’ and consistent use of valid measurement instruments to measure that construct in order to facilitate future research synthesis.</p

How are you doing in the eyes of your spouse? Level of agreement between the self-completed EQ-5D-5L and two proxy perspectives in an orthopaedic population: a randomized agreement study

Objectives To determine the level of agreement between both proxy versions and the self-completed EQ-5D-5L. Design A randomized agreement study. Setting and participants We recruited 120 patients (compos mentis) and their proxies at the orthopaedic outpatient clinic. Patients completed the regular EQ-5D-5L and their proxy completed the proxy version of the EQ-5D-5L and rated the patients' health from their own (proxy-proxy) perspective (i.e. how do you rate the health of the patient), and from the patient's (proxy-patient) perspective (i.e. how do you think the patient would rate their own health if they were able to). Measures The primary outcome was the agreement between patients and their proxy, quantified as the intra class correlation coefficient for the EQ-5D-5L Utility score. Results Average Utility scores were 0.65 with the self completed EQ-5D-5L, versus 0.60 with the proxy-patient version and 0.58 with the proxy-proxy version. The ICC was 0.66 (95% CI 0.523, 0.753) for the proxy-patient perspective and 0.58 (95% CI 0.411, 0.697) for the proxy-proxy perspective. The mean gold standard score of the VAS-Health was 69.7 whereas the proxy-proxy perspective was 66.5 and the proxy-patient perspective was 66.3. Conclusion and implications The proxy-patient perspective yielded substantial agreement with the self completed EQ-5D-5L, while the agreement with the proxy-proxy perspective was moderate. In this study population of patients without cognitive impairment, proxies tended to underestimate the quality of life of their relative.Orthopaedics, Trauma Surgery and Rehabilitatio

Decision aids can decrease decisional conflict in patients with hip or knee osteoarthritis: randomized controlled trial

BACKGROUNDThe interest in shared decision making has increased considerably over the last couple of decades. Decision aids (DAs) can help in shared decision making. Especially when there is more than one reasonable option and outcomes between treatments are comparable.AIMTo investigate if the use of DAs decreases decisional conflict in patients when choosing treatment for knee or hip osteoarthritis (OA).METHODSIn this multi-center unblinded randomized controlled trial of patients with knee or hip OA were included from four secondary and tertiary referral centers. One-hundred-thirty-one patients who consulted an orthopedic surgeon for the first time with knee or hip OA were included between December 2014 and January 2016. After the first consultation, patients were randomly assigned by a computer to the control group which was treated according to standard care, or to the intervention group which was treated with standard care and provided with a DA. After the first consultation, patients were asked to complete questionnaires about decisional conflict (DCS), satisfaction, anxiety (PASS-20), gained knowledge, stage of decision making and preferred treatment. Follow-up was carried out after 26 wk and evaluated decisional conflict, satisfaction, anxiety, health outcomes (HOOS/KOOS), quality of life (EQ5D) and chosen treatment.RESULTSAfter the first consultation, patients in the intervention group (mean DCS: 25 out of 100, SD: 13) had significantly (P value: 0.00) less decisional conflict compared to patients in the control group (mean DCS: 39 out of 100, SD 11). The mean satisfaction score for the given information (7.6 out of 10, SD: 1.8 vs 8.6 out of 10, SD: 1.1) (P value: 0.00), mean satisfaction score with the physician (8.3 out of 10, SD: 1.7 vs 8.9 out of 10, SD: 0.9) (P value: 0.01) and the mean knowledge score (3.3 out of 4, SD: 0.9 vs 3.7 out of, SD: 0.6) (P value: 0.01) were all significantly higher in the intervention group. At 26-wk follow-up, only 75 of 131 patients (57%) were available for analysis. This sample is too small for meaningful analysis.CONCLUSIONProviding patients with an additional DA may have a positive effect on decisional conflict after the first consultation. Due to loss to follow-up we are unsure if this effect remains over time.Orthopaedics, Trauma Surgery and Rehabilitatio

Prosthetic joint infection and wound leakage after the introduction of intraoperative wound irrigation with a chlorhexidine-cetrimide solution: a large-scale before-after study

Background: Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage.Methods: All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders.Results: The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation.Conclusions: Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference. Level of Evidence: Level IIIduncontrolled before and after the study.(c) 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).Orthopaedics, Trauma Surgery and Rehabilitatio

Challenges in developing national orthopedic health research agendas in the Netherlands: process overview and recommendations

- Growing demand for clinical research to improve evidence-based medicine in daily medical practice led to healthcare evaluation, which assesses the effectiveness of the existing care. The first step is identifying and priori-tizing the most important evidence uncertainties. A health research agenda (HRA) can be valuable and helps determine funding and resource allocation, aiding researchers and poli-cymakers to design successful research programs and imple-ment the results in daily medical practice. We provide an overview of the development process of the first 2 HRAs within orthopedic surgery in the Netherlands and the follow-ing research process. In addition, we developed a checklist with recommendations for the future development of an HRA. This perspective guides the development of high -quality and widely supported nationwide HRAs, including preparatory actions. This improves the uptake of evidence uncertainties in a successful research program and dissemi-nates evidence-based literature in daily medical practice to improve patient care.Clinical epidemiolog

Enhanced Fusarium head blight resistance in bread wheat and durum by alien introgression

PURPOSE: In the Netherlands, over 20,000 patients sustain a hip fracture yearly. A first hip fracture is a risk factor for a second, contralateral fracture. Data on the similarity of the treatment of bilateral femoral neck fractures is only scarcely available. The objectives of this study were to determine the cumulative incidence of non-simultaneous bilateral femoral neck fractures and to describe the patient characteristics and treatment characteristics of these patients. METHODS: A database of 1,250 consecutive patients with a femoral neck fracture was available. Patients with a previous contralateral femoral neck fractures were identified by reviewing radiographs and patient files. Patient characteristics, previous fractures, hip fracture type and details on treatment were collected from the patient files. RESULTS: One hundred nine patients (9%, 95% confidence interval 7-10%) had sustained a non-simultaneous bilateral femoral neck fracture. The median age at the first fracture was 81 years; the median interval between the fractures was 25 months. Overall, 73% was treated similarly for both fractures in terms of non-operative treatment, internal fixation or arthroplasty. In patients with identical Garden classification (30%), treatment similarity was 88%. CONCLUSIONS: The cumulative incidence of non-simultaneous bilateral femoral neck fractures was 9%. Most patients with identical fracture types were treated similarly. The relatively high risk of sustaining a second femoral neck fracture supports the importance of secondary prevention, especially in patients with a prior wrist or vertebral fracture