Aims

The aims of this systematic review were to describe the quantity and methodological quality of meta-analyses in orthopaedic surgery published during the last 17 years.

Aims

The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients.

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

Aims

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

Objectives

The patient-rated wrist evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are patient-reported outcome measures (PROMs) used for clinical and research purposes. Methodological high-quality clinimetric studies that determine the measurement properties of these PROMs when used in patients with a distal radial fracture are lacking. This study aimed to validate the PRWE and DASH in Dutch patients with a displaced distal radial fracture (DRF).

Aims

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.

Femoroacetabular impingement (FAI) is a common cause of hip pain in the young adult. Uncertainty regarding surgical indications, outcome assessment, management preferences and perceptions of the literature exist. We conducted a large international survey assessing the perceptions and demographics of orthopaedic surgeons regarding FAI.

A survey was developed using previous literature, focus groups and a sample-to-redundancy strategy. The survey contained forty-six questions and was emailed to national orthopaedic associations and orthopaedic sports medicine societies for member responses. Members were contacted on multiple occasions to increase response rates.

Nine hundred orthopaedic surgeons from twenty national and international organisations completed the survey. Surgeons responded across 6 continents, 58.2 % from developed nations with 35.4 % having sports fellowship training. North American and European surgeons reported significantly greater exposure to hip arthroscopy during residency and fellowships in comparison to international respondents (48.0% vs. 44.5% vs. 25.6% respectively; p<0.001). Surgeons performing a higher volume of FAI surgery (over 100 cases per year) were significantly more likely to have practiced for more than 20 years (OR 1.91; 95% CI 1.01 to 3.63), be practicing at an academic hospital (OR 2.25; 95% CI 1.22 to 4.15), and have formal arthroscopy training (OR 46.17; 95% CI 20.28 to 105.15). High volume surgeons were over two-fold more likely to practice in North America and Europe (OR 2.26; 95% CI: 1.08 to 4.72).

The exponential rise in the diagnosis and surgical management for FAI appears to be driven largely by experienced surgeons in developed nations. Our analysis suggests that although FAI management is early in the innovation cycle we are at a tipping point towards wider uptake and utilisation. The results of this survey will help guide further research and study.

The Radiographic Union Score for Hip (RUSH) is an outcome instrument designed to describe radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining non-union in clinical trials and predicting patients that likely require additional surgery to promote fracture healing. We sought to determine a RUSH threshold score that defines nonunion at 6-months post-injury. Our secondary objective was to determine if this threshold was associated with increased risk for non-union surgery.

A sample of 248 patients with adequate six-month hip radiographs and complete two-year clinical follow-up were analysed from a multi-national hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the six-month post-injury radiographs, and agreement was assessed using the Interclass Correlation Coefficient (ICC). Fracture healing was determined by two independent methods: 1) prospectively by the treating surgeon using clinical and radiographic assessments, and 2) retrospectively by a Central Adjudication Committee using radiographs alone. Receiver Operator Curve analysis was used to define a RUSH threshold score that was specific for fracture nonunion.

RUSH score inter-rater agreement was high (ICC: 0.81, 95% CI 0.76 to 0.85). The mean six-month RUSH score for all included patients was 24.4 (SD 3.4). A threshold score of <18 was associated with a greater than 98% specificity for nonunion. Furthermore, patients with a six-month RUSH score below 18 were more the seven-times more likely to require revision surgery for nonunion (Relative Risk: 7.25, 95% CI 2.62 to 20.00).

The six-month RUSH score can effectively be used to communicate when a femoral neck fracture has not healed. The validity of our conclusions was further supported by the increased risk of nonunion surgery for patients below the RUSH threshold. We believe our findings can standardise a definition of nonunion for clinical trials and recommend the use of the RUSH and its <18-point threshold when describing femoral neck nonunion.

Level of evidence (LOE) determination is a reliable tool to assess the strength of research based on study design. Improvements in LOE are necessary for the advancement of evidence-based clinical care. The objectives of this study were to determine if the LOE presented at the Musculoskeletal Tumour Society (MSTS) annual meeting has improved over time and to determine how the LOE presented at MSTS annual meetings compares to that of the Orthopaedic Trauma Association (OTA) annual meetings.

We reviewed abstracts from the MSTS and OTA annual meeting podium presentations from 2005 to 2014. Three independent reviewers evaluated a total of 1222 abstracts for study type and LOE. Changes in the distributions of study type and LOE over time were evaluated by Pearson Chi-Squared test.

There were a total of 577 podium abstracts from the MSTS and 645 from the OTA. Of the MSTS therapeutic studies, 0.5% (2/376) were level I, while 75% (281/376) were level IV. There was a seven-fold higher proportion of level I studies (3.4% [14/409]) and less than half as many level IV studies (32% [130/409]) presented at OTA. There was no improvement in the MSTS LOE for all study types (p=0.13) and therapeutic study types (p=0.36) over the study decade. In contrast, the OTA LOE increased significantly over this time period for all study types (p<0.01). The proportion of controlled therapeutic studies (LOE I through III) versus uncontrolled studies (LOE IV) increased significantly over time at the OTA (p<0.021), but not at the MSTS (p=0.10).

Uncontrolled case series continue to dominate the MSTS scientific program, whereas over the past decade, higher-level studies and more modern study methodology has been employed by members of the OTA.

Electrical stimulators are commonly used to accelerate fracture healing, resolve nonunions or delayed unions, and to promote spinal fusion. The efficacy of electrical stimulator treatment, however, remains uncertain. We conducted a meta-analysis of randomised sham-controlled trials to establish the effectiveness of electrical stimulation for bone healing.

We searched MEDLINE, EMBASE, CINAHL and Cochrane Central to identify all randomised sham-controlled trials evaluating electrical stimulators in patients with acute fractures, non-union, delayed union, osteotomy healing or spinal fusion, published up to February 2015. Our outcomes were radiographic nonunion, patient-reported pain and self-reported function. Two reviewers independently assessed eligibility and risk of bias, performed data extraction, and rated overall confidence in the effect estimates according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Fifteen randomised trials met our inclusion criteria. Electrical stimulation reduced the relative risk of radiographic nonunion or persistent nonunion by 35% (95%CI 19% to 47%; 15 trials; 1247 patients; number needed to treat = 7; p < 0.01; moderate certainty). Electrical stimulation also showed a significant reduction in patient-reported pain (Mean Difference (MD) on the 100-millimeter visual analogue scale = −7.67; 95% CI −13.92 to −1.43; 4 trials; 195 patients; p = 0.02; moderate certainty). Limited functional outcome data showed no difference with electrical stimulation (MD −0.88; 95% CI −6.63 to 4.87; 2 trials; 316 patients; p = 0.76; low certainty).

Patients treated with electrical stimulation as an adjunct for bone healing have a reduced risk of radiographic nonunion or persistent nonunion and less pain; functional outcome data are limited and requires increased focus in future trials.

Objectives

The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial.

Objectives

Despite the fact that research fraud and misconduct are under scrutiny in the field of orthopaedic research, little systematic work has been done to uncover and characterise the underlying reasons for academic retractions in this field. The purpose of this study was to determine the rate of retractions and identify the reasons for retracted publications in the orthopaedic literature.

Objectives

Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making.

Objectives

Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property.

Objectives

Current studies on the additional benefit of using computed tomography (CT) in order to evaluate the surgeons’ agreement on treatment plans for fracture are inconsistent. This inconsistency can be explained by a methodological phenomenon called ‘spectrum bias’, defined as the bias inherent when investigators choose a population lacking therapeutic uncertainty for evaluation. The aim of the study is to determine the influence of spectrum bias on the intra-observer agreement of treatment plans for fractures of the distal radius.

High-quality randomised controlled trials (RCTs) evaluating surgical therapies are fundamental to the delivery of evidence-based orthopaedics. Orthopaedic clinical trials have unique challenges; however, when these challenges are overcome, evidence from trials can be definitive in its impact on surgical practice. In this review, we highlight several issues that pose potential challenges to orthopaedic investigators aiming to perform surgical randomised controlled trials. We begin with a discussion on trial design issues, including the ethics of sham surgery, the importance of sample size, the need for patient-important outcomes, and overcoming expertise bias. We then explore features surrounding the execution of surgical randomised trials, including ethics review boards, the importance of organisational frameworks, and obtaining adequate funding.

Cite this article: Bone Joint Res 2014;3:161–8.

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs.

Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036).

The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

Cite this article: Bone Joint J 2013;95-B:1673–80.

Introduction

There has been a paradigm shift in orthopaedic research, it is now recognized that the extent to which interventions really make a difference to a patient's overall life is indicated by measuring one's general health status. The primary aim of this study was to report how the methodology of current evidence in hip fracture research can improve if studies included patients with cognitive impairment.

Purpose

We explored the role of patients beliefs and attitudes towards their likelihood of recovery from severe physical trauma.

Purpose

The recent emergence of autologous blood concentrates, such as platelet rich plasma (PRP), as a treatment option for patients with orthopaedic injuries has led to an extensive debate about their clinical benefit. Our objective was to determine the effectiveness of autologous blood concentrates compared with control therapy in improving pain in patients with orthopaedic bone and soft tissue injuries.