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.

Aims

We performed a systematic review of the literature to determine whether earlier surgical repair of acute rotator cuff tear (ARCT) leads to superior post-operative clinical outcomes.

Background: The selection of presentations at orthopedic meetings is an important process. If the peer reviewers do not consistently agree on the quality score, the review process is arbitrary and open to bias. The aim of this study was:

1) To describe the inter reviewer agreement of a previously designed scoring scheme to rate abstracts submitted for presentation at the Dutch Orthopedic Association.

Methods: We calculated intraclass correlation coefficients (ICC) to measure the level of agreement among reviewers using the International Society of the Knee (ISK) abstract quality of reporting system. Acceptance rate and quality of the abstracts are described.

Results: Of 419 abstracts 229 (55%) were accepted. Inter-reviewer agreement to rate abstracts was substantial 0.68 (95%CI 0.47, 0.83) to almost perfect 0.95 (95%CI 0.92, 0.97) and did not change over the eligible time period. Less abstracts were accepted after 2004 (p = 0.039). The mean ISK abstract score, maximally 100 points, for accepted abstracts ranged from 60.4 (95%CI 57.7, 63.0) to 63.8 (95% CI 62.0, 65.7). The mean ISK abstract score for rejected abstracts varied from 45.8 (95%CI 40.3, 51.2) to 50.6 (95% CI 46.5, 54.8). Both scores for accepted and rejected abstracts did not change over time. Workload of the reviewers did not influence their level of agreement (p=0.167).

Interpretation: The ISK abstract rating system has an excellent inter observer agreement. Other scientific orthopedic meetings could adopt this ISK rating system for further evaluation in local or international setting.

Background: While surgical trials can rarely blind surgeons or patients, they can often blind outcome assessors. The aim of this systematic review was threefold:

1) to examine the reporting of outcome measures in orthopaedic trials,

Specifically, we focused on an association between blinding of outcome assessment and the size of the reported treatment effect; in other words: does blinding of outcome assessors matter?

Methods: We reviewed 32 identified RCTs published in the Journal of Bone and Joint Surgery (American Volume), in 2003 and 2004 for the appropriate use of outcome measures. These RCTs represented 3.4% (32/938) of all studies published during that time period. All RCTs were reviewed by two of us for:

1) the outcome measures used and

We calculated the magnitude of treatment effect of blinded compared to un-blinded outcome assessors.

Results: The methodological validation and clinical usefulness of the clinician-based, patient-based, and generic outcome instruments varied. Ten of the 32 RCTs (31%) used a modified outcome instrument. Of these 10 trials, 4 (40%) failed to describe how the outcome instrument was modified. Nine (90%) of the 10 articles did not describe how their modified instrument was validated and retested. Sixteen (50%) of the 32 RCTs did not report blinding of outcome assessors where blinding would have been possible. Among those studies with continuous outcome measure, unblinded outcomes assessment was associated with significantly larger treatment effects (standardized mean difference 0.76 versus 0.25, p=0.01). Similarly, in those studies with dichotomous outcomes, unblinded outcomes assessments were associated with significantly greater treatment effects (Odds ratio 0.13 versus 0.42, unblinded versus blinded, p< 0.001). The ratio of odds ratios (unblinded to blinded) was 0.31 suggesting that unblinded outcomes assessment was associated with an exaggeration of the benefit of a treatment’s effectiveness in our cohort of studies.

Conclusion: Reported outcomes in RCTs are often modified and rarely validated. Half of the RCTs did not blind outcome assessors even though blinding of outcome assessors would have been feasible in each case. Treatment effects may be exaggerated if outcome assessors are unblinded. Emphasis should be placed on detailed reporting of outcome measures to facilitate generalization. Outcome assessors should be blinded where possible to prevent bias.

Background: The Journal of Bone and Joint Surgery, American Edition (the Journal) recently initiated a section called “Evidence-Based Orthopaedics”. Furthermore, a Levels of Evidence rating is now used in the Journal to help readers in clinical decision-making. Little is known if this recent emphasis of Evidence-based Medicine (EBM) influenced surgeons’ perceptions about and competence in evidence-based medicine. Therefore, we examined perceptions and competence in evidence-based medicine among Dutch orthopaedic surgeons.

Methods: Members of the Dutch Orthopaedic Association were surveyed to examine surgeons’ attitudes towards evidence-based medicine and competence in evidence-based medicine. We evaluated perceptions using a newly developed instrument tailored to surgical practice. Univariate analysis, and a multivariable analysis using Generalized Estimating Equations were performed to model the competence instrument.

Results: 367 Surgeons responded (60%). Orthopaedic surgeons welcomed evidence-based medicine. Practical evidence-based medicine resources were perceived as the best methods to move from eminence-based to evidence-based practice. Four variables were significantly and positively associated with the competence instrument:

1) younger age, particularly age between 36 and 45 years,

The majority of the respondents (65%) were aware of the Journal’s evidence-based medicine section, and 20% used the Journal’s evidence-based medicine abstracts in clinical decision-making. This increased awareness in evidence-based medicine was also reflected in a frequent use of Cochrane reviews in clinical decision-making (27%). Surgeons who used the Journal’s evidence-based medicine abstracts and Cochrane reviews had significantly higher competence scores.

Conclusions: Evidence-based medicine is welcomed by Dutch orthopaedic surgeons. Recent emphasis of evidence-based medicine is reflected in an increased awareness about the Journal’s evidence-based medicine section, Levels of Evidence, and the largest evidence-based medicine resource: Cochrane reviews. Younger orthopaedic surgeons had better knowledge about evidence-based medicine. Development and use of evidence-based resources as well as pre-appraised summaries like the Journal’s evidence-based medicine abstracts and Cochrane reviews were perceived as the best way to move from eminence based- to evidence-based orthopaedic practice.

Purpose: To determine predictive factors for alloge-neic blood transfusion to aid in development of blood conservation strategies for the Hamilton arthroplasty population

Methods: A prospectively collected, retrospective study of 828 patients, who did not donate blood, treated with either primary total knee or total hip arthroplasty from 1998 to 2002 at Hamilton Henderson Hospital was carried out. A univariate analysis was performed to establish the relationship between all independent variables and the need for postoperative transfusion. Variables that were determined to have a significant relationship were included in a multivariate analysis

Results: The univariate analysis revealed a significant relationship between the need for postoperative blood transfusion and preoperative hemoglobin levels (p=0.000), age (P=0.000), and gender (P=0.005). However, the multivariate analysis only revealed significant relationship between the need for transfusion and pre-operative hemoglobin (P=0.000) and age (P=0.014). Patients with preoperative hemoglobin of > 150 g/L had a 10% risk of transfusion. Patients with preoperative hemoglobin of 141–150 g/L has 2.5 times greater risk, 131–140 g/L 4 times greater risk, 121–130 g/L 6 times greater risk, and < 120 25 times greater risk than patients with preoperative hemoglobin > 150 g/L.

Conclusions: The preoperative hemoglobin level and age were shown to predict the need for blood transfusion after total joint arthroplasty. These results of this will help to create guidelines for the Blood Conservation Program in HHSC.

Failed open reduction internal fixation (ORIF) of the proximal femur can render patients severely disabled. This study analyzed the short-term functional results and complications of total hip arthroplasty (THA) for complications of ORIF of the proximal femur. Using the Hamilton Arthroplasty Database, thirty-six patients treated with a THA for complications of ORIF of the proximal femur were compared to a matched cohort. Analysis showed that THA for complications of ORIF of the proximal femur is a successful procedure despite increased intraoperative difficulty that results in comparatively lower short-term Harris Hip Scores. No statistically significant differences in intraoperative or postoperative complications were noted.

Open reduction internal fixation (ORIF) of the proximal femur is a common, successful orthopedic procedure. However, failed ORIF of the proximal femur can render patients severely disabled. The purpose of this study is to analyze and compare the short-term functional results and complications of total hip arthroplasty (THA) for complications of ORIF of the proximal femur.

After ethics approval, the Hamilton Arthroplasty Registry, a prospective database, was used to identify thirty-seven patients treated with THA for complications of ORIF of the proximal femur. From September 1998 to the present a group consisting of sixteen males and twenty females, with a mean age of sixty-seven, were matched to a cohort of patients treated with a primary THA. Using Wilcoxon Test and Chi-Square Tests, the two groups were compared (p< 0.05).

Initially, ORIF was used to treat thirty-six patients for proximal femur fracture. The mean follow-up was 13.5 months. The experimental group had a significantly lower (p=0.035) Harris Hip Score at the one year follow-up, however both groups showed a significant improvement from preoperative scores (p=0.0001). A significant difference was noted between the two groups in estimated blood loss (p=0.01) and operative time (p=0.01). There was no significant difference in complication rate.

THA for complications of ORIF of the proximal femur is a successful procedure improving patient’s pain and functional status. This is a more complicated procedure than primary THA, at times requiring the use of a revision stem, which results in significantly lower Harris Hip Scores. Nonetheless, there appears to be no comparative increase in short-term complications.