Bernadette G Dijkman

The radiographic union scale in tibial fractures: reliability and validity.

Radiographic assessment of tibial fracture healing continues to pose significant challenges to both routine fracture care and clinical research. Orthopaedic surgeons fail to achieve sufficient agreement on fracture healing when using conventional radiographic measures such as their general impression or the number of cortices bridged by callus. Moreover, the extent to which radiographic assessment of healing corresponds to patient-important outcomes is largely unknown. In an attempt to improve the former (ie, reliability) and inform the latter (ie, validity), recent studies have explored a novel radiographic assessment for tibial shaft fractures, the Radiographic Union Scale for Tibial fractures (RUST). The RUST score assesses the presence of bridging callus and that of a fracture line on each of 4 cortices seen on 2 orthogonal radiographic views. A recent study has found that RUST scores have greater inter-rater reliability when compared with surgeons general impression or the number of cortices bridged by callus. This may increase the utility of radiographs as a standardized measure of treatment efficacy in the follow-up of tibial fractures.

How to Design a Good Case Series

A case series is a descriptive study that follows a group of patients who have a similar diagnosis or who are undergoing the same procedure over a certain period of time. As there is no experimental protocol or control for allocation of patients to treatment, surgeons and patients decide on whether or not treatment is given, making the clinical sample representative of a common clinical population. Results of case series can generate hypotheses that are useful in designing further studies, including randomized controlled trials. However, no causal inferences should be made from case series regarding the efficacy of the investigated treatment. This article will provide principles for the design, analysis, and reporting of case series, illustrated by examples from the orthopaedic surgical literature.

When Is a Fracture Healed? Radiographic and Clinical Criteria Revisited

Selecting the most appropriate outcome measures can be especially burdensome in trials studying fracture healing, because the process of fracture healing is subjective and without a gold standard. Although a wide variety of radiographic modalities are available, plain radiography remains the most common approach for healing assessment. Radiographic criteria, however, do not correlate well with fracture strength and stiffness. Additional challenges include a lack of consensus in what radiographic measures are most appropriate in the assessment of healing. In this article, we provide an overview of the most commonly used radiographic and clinical criteria for defining fracture healing. The validity and reliability of alternative approaches is also discussed.

Twenty Years of Meta-Analyses in Orthopaedic Surgery: Has Quality Kept Up with Quantity?

BACKGROUND As the number of studies in the literature is increasing, orthopaedic surgeons highly depend on meta-analyses as their primary source of scientific evidence. The objectives of this review were to assess the scientific quality and number of published meta-analyses on orthopaedics-related topics over time. METHODS We conducted, in duplicate and independently, a systematic review of published meta-analyses in orthopaedics in the years 2005 and 2008 and compared them with a previous systematic review of meta-analyses from 1969 to 1999. A search of electronic databases (MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews) was performed to identify meta-analyses published in 2005 and 2008. We searched bibliographies and contacted content experts to identify additional relevant studies. Two investigators independently assessed the quality of the studies, using the Oxman and Guyatt index, and abstracted relevant data. RESULTS We included forty-five and forty-four meta-analyses from 2005 and 2008, respectively. While the number of meta-analyses increased fivefold from 1999 to 2008, the mean quality score did not change significantly over time (p = 0.067). In the later years, a significantly lower proportion of meta-analyses had methodological flaws (56% in 2005 and 68% in 2008) compared with meta-analyses published prior to 2000 (88%) (p = 0.006). In 2005 and 2008, respectively, 18% and 30% of the meta-analyses had major to extensive flaws in their methodology. Studies from 2008 with positive conclusions used and described appropriate criteria for the validity assessment less often than did those with negative results. The use of random-effects and fixed-effects models as pooling methods became more popular toward 2008. CONCLUSIONS Although the methodological quality of orthopaedic meta-analyses has increased in the past twenty years, a substantial proportion continues to show major to extensive flaws. As the number of published meta-analyses is increasing, a routine checklist for scientific quality should be used in the peer-review process to ensure methodological standards for publication.

Prospectively screening for eligible patients was inaccurate in predicting patient recruitment of orthopedic randomized trials

OBJECTIVE To compare the accuracy of estimates of potential recruitment from a prospective 8-week screening study compared with a retrospective chart review across sites participating in two fracture management trials. STUDY DESIGN AND SETTING During the planning phase of two large, multicenter, randomized controlled fracture management trials, 74 clinical sites provided estimates of the annual recruitment rate both retrospectively (based on chart reviews) and prospectively. The prospective estimate was generated by screening, for 8 weeks, all incoming patients for eligibility in the concerning trial, without actually enrolling any patient. We compared these prospective and retrospective estimates with one another (for 74 sites in the two trials) and with actual 1-year recruitment rates in the definitive trial (for nine sites in one trial). RESULTS There was a median difference of four patients (interquartile range: -14 to 18 patients; P=0.89) between a centers prospective estimate and its retrospective estimate. Both predictions were overestimations of recruitment in the definitive trial; only 31% (95% confidence interval [CI]: 28, 35) of retrospectively estimated patients, and 31% (95% CI: 27, 35) of prospectively estimated patients were recruited in the definitive trials. CONCLUSION Compared with relatively simple chart reviews, prospectively screening for eligible patients at clinical sites, which is associated with substantial costs, did not result in more accurate predictions of accrual in large, multicenter, randomized controlled trials.

Low-intensity pulsed ultrasound: Nonunions

Nonunions occur in 5–10% of fractures and are characterized by the failure to heal without further intervention. Low intensity pulsed ultrasound therapy has been developed as an alternative to surgery in the treatment of nonunions. We describe a systematic review on trials of low-intensity pulsed ultrasound therapy for healing of nonunions. We searched the electronic databases Medline and the Cochrane library for articles on ultrasound and healing of nonunions published up to 2008. Trials selected for the review met the following criteria: treatment of at least one intervention group with low intensity pulsed ultrasound; inclusion of patients (humans) with one or more nonunions (defined as “established” or as a failure to heal for a minimum of eight months after initial injury); and assessment of healing and time to healing, as determined radiographically. The following data were abstracted from the included studies: sample size, ultrasound treatment characteristics, nonunion location, healing rate, time to fracture healing, fracture age, and demographic information. We found 79 potentially eligible publications, of which 14 met our inclusion criteria. Of these, eight studies were used for data abstraction. Healing rates averaged 87%, (range 65.6%-100%) among eight trials. Mean time to healing was 146.5 days, (range 56-219 days). There is evidence from trials that low-intensity pulsed ultrasound may be an effective treatment for healing of nonunions. More homogeneous and larger controlled series are needed to further investigate its efficacy.

Decision making open reduction/internal fixation versus arthroplasty for femoral neck fractures

Summary: Femoral neck fractures account for half of all hip fractures with a rapidly increasing incidence. Since they are associated with high mortality, decrease in quality of life, and high total costs, much research on the optimal treatment of these fractures has been undertaken. In this article, we provide a summary of the available evidence comparing open reduction and internal fixation and arthroplasty. We focus on the treatment of displaced femoral neck fractures in active, healthy elderly patients. Additionally, we discuss treatment options for patients with undisplaced femoral neck fractures, younger patients, and patients with cognitive impairments. Furthermore, we present cost-effectiveness analyses on the treatment of these fractures, comparing both costs and patient benefits between internal fixation and different arthroplasty approaches.