Clary J. Foote

Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study

BackgroundTibial shaft fractures are the most common long bone fracture and are prone to complications such as nonunion requiring reoperations to promote fracture healing. We aimed to determine the fracture characteristics associated with tibial fracture nonunion, and their predictive value on the need for reoperation. We further aimed to evaluate the predictive value of a previously-developed prognostic index of three fracture characteristics on nonunion and reoperation rate.MethodsWe conducted an observational study and developed a risk factor list from previous literature and key informants in the field of orthopaedic surgery, as well as via a sample-to-redundancy strategy. We evaluated 22 potential risk factors for the development of tibial fracture nonunion in 200 tibial fractures. We also evaluated the predictive value of a previously-identified prognostic risk index on secondary intervention and/or reoperation rate. Two individuals independently extracted the data from 200 patient electronic medical records. An independent reviewer assessed the initial x-ray, the post-operative x-ray, and all available sequential x-rays. Regression and chi-square analysis was used to evaluate potential associations.ResultsIn our cohort of patients, 37 (18.5%) had a nonunion and 27 (13.5%) underwent a reoperation. Patients with a nonunion were 97 times (95% CI 25.8-366.5) more likely to have a reoperation. Multivariable logistic regression revealed that fractures with less than 25% cortical continuity were predictive of nonunion (odds ratio = 4.72; p = 0.02). Such fractures also accounted for all of the reoperations identified in our sample. Furthermore, our data provided preliminary validation of a previous risk index predictive of reoperation that includes the presence of a fracture gap post-fixation, open fracture, and transverse fracture type as variables, with an aggregate of fracture gap and an open fracture yielding patients with the highest risk of developing a nonunion.ConclusionsWe identified a significant association between degree of cortical continuity and the development of a nonunion and risk for reoperation in tibial shaft fractures. In addition, our study supports the predictive value of a previous prognostic index, which inform discussion of prognosis following operative management of tibial fractures.

Anterior Cervical Discectomy with Arthroplasty versus Arthrodesis for Single-Level Cervical Spondylosis: A Systematic Review and Meta-Analysis

Objective To estimate the effectiveness of anterior cervical discectomy with arthroplasty (ACDA) compared to anterior cervical discectomy with fusion (ACDF) for patient-important outcomes for single-level cervical spondylosis. Data sources Electronic databases (MEDLINE, EMBASE, Cochrane Register for Randomized Controlled Trials, BIOSIS and LILACS), archives of spine meetings and bibliographies of relevant articles. Study selection We included RCTs of ACDF versus ACDA in adult patients with single-level cervical spondylosis reporting at least one of the following outcomes: functionality, neurological success, neck pain, arm pain, quality of life, surgery for adjacent level degeneration (ALD), reoperation and dysphonia/dysphagia. We used no language restrictions. We performed title and abstract screening and full text screening independently and in duplicate. Data synthesis We used random-effects model to pool data using mean difference (MD) for continuous outcomes and relative risk (RR) for dichotomous outcomes. We used GRADE to evaluate the quality of evidence for each outcome. Results Of 2804 citations, 9 articles reporting on 9 trials (1778 participants) were eligible. ACDA is associated with a clinically significant lower incidence of neurologic failure (RR  = 0.53, 95% CI  = 0.37–0.75, p = 0.0004) and improvement in the Neck pain visual analogue scale (VAS) (MD  = 6.56, 95% CI  = 3.22–9.90, p = 0.0001; Minimal clinically important difference (MCID)  = 2.5. ACDA is associated with a statistically but not clinically significant improvement in Arm pain VAS and SF-36 physical component summary. ACDA is associated with non-statistically significant higher improvement in the Neck Disability Index Score and lower incidence of ALD requiring surgery, reoperation, and dysphagia/dysphonia. Conclusions There is no strong evidence to support the routine use of ACDA over ACDF in single-level cervical spondylosis. Current trials lack long-term data required to assess safety as well as surgery for ALD. We suggest that ACDA in patients with single level cervical spondylosis is an option although its benefits and indication over ACDF remain in question.

Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis

BACKGROUND We conducted a meta-analysis of randomized trials to compare delayed vs early motion therapy on function after arthroscopic rotator cuff repair. METHODS We searched 4 electronic databases (Medline, Embase, Cochrane, and Physiotherapy Evidence Database [PEDro]). The methodologic quality of the included studies was assessed, and the relevant data were extracted. Data were pooled for functional outcomes, rotator cuff tear recurrence, and shoulder range of motion. Complications were reported descriptively. RESULTS Three level I and 1 level II randomized trials were eligible and included. Pooled analysis revealed no statistically significant differences in American Shoulder and Elbow Surgeons scores between delayed vs early motion rehabilitation (mean difference [MD], 1.4; 95% confidence interval [CI], -1.8 to 4.7; P = .38, I(2) = 34%). The risk of retears after surgery did not differ statistically between treatment groups (risk ratio, 1.01; 95% CI, 0.63-1.64; P = .95). Early passive motion led to a statistically significant, although clinically unimportant, improvement in forward elevation between groups (MD, -1°; 95% CI, -2° to 0°; P = 0.04, I(2) = 0%). There was no difference in external rotation between treatment groups (MD, 1°; 95% CI, -2° to 4°; P = 0.63, I(2) = 0%). None of the included studies identified any cases of postoperative shoulder stiffness. CONCLUSIONS The current meta-analysis did not identify any significant differences in functional outcomes and relative risks of recurrent tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. A statistically significant difference in forward elevation range of motion was identified; however, this difference is likely clinically unimportant.

The association between avulsions of the reflected head of the rectus femoris and labral tears: A retrospective study

Background: The aim of this study was to investigate if an association existed between the reflected head of rectus femoris avulsion injuries and labral tears in pediatric patients referred for magnetic resonance arthrography (MRA) or magnetic resonance imaging (MRI) evaluation. Methods: Electronic medical records of the patients between the ages of 12 and 18 who were treated at the hospitals affiliated by McMaster University between June 2000 and November 2010 with a diagnosis of rectus femoris avulsion injuries were retrospectively identified and analyzed. Patients were included if they had magnetic resonance imaging or MRA images of their hip. Results: Nine patients with avulsion injuries of the rectus femoris muscle were identified. The patient population consisted of 4 females and 5 males (range, 8 to 17 y, mean age 14 y). All injuries occurred during sports activity, which included running and kicking during soccer, skating in hockey, and a squatting exercise. MRA examination of 7 of these patients demonstrated associated labral tears. All patients were initially treated conservatively. Five patients continued to sustain from residual pain in the 9 months after the initial injury. Two of these patients with significant refractory pain were subsequently treated with hip arthroscopy. Intraoperatively, 1 small labral tear and 1 labral avulsion were identified and treated. Conclusions: This study suggests that there may be an association between avulsion of the reflected head of rectus femoris and labral injuries and that there may be an underlying spectrum of traction injuries. Patients with rectus femoris avulsion injuries with persistent symptoms may be at risk for concurrent traumatic labral tears. Level of Evidence: Level 4, retrospective case series.

Network Meta-analysis: Users’ Guide for Surgeons: Part I – Credibility

Conventional meta-analyses quantify the relative effectiveness of two interventions based on direct (that is, head-to-head) evidence typically derived from randomized controlled trials (RCTs). For many medical conditions, however, multiple treatment options exist and not all have been compared directly. This issue limits the utility of traditional synthetic techniques such as meta-analyses, since these approaches can only pool and compare evidence across interventions that have been compared directly by source studies. Network meta-analyses (NMA) use direct and indirect comparisons to quantify the relative effectiveness of three or more treatment options. Interpreting the methodologic quality and results of NMAs may be challenging, as they use complex methods that may be unfamiliar to surgeons; yet for these surgeons to use these studies in their practices, they need to be able to determine whether they can trust the results of NMAs. The first judgment of trust requires an assessment of the credibility of the NMA methodology; the second judgment of trust requires a determination of certainty in effect sizes and directions. In this Users’ Guide for Surgeons, Part I, we show the application of evaluation criteria for determining the credibility of a NMA through an example pertinent to clinical orthopaedics. In the subsequent article (Part II), we help readers evaluate the level of certainty NMAs can provide in terms of treatment effect sizes and directions.

Network Meta-analysis: Users' Guide for Surgeons: Part II - Certainty.

In the previous article (Network Meta-analysis: Users’ Guide for Surgeons—Part I, Credibility), we presented an approach to evaluating the credibility or methodologic rigor of network meta-analyses (NMA), an innovative approach to simultaneously addressing the relative effectiveness of three or more treatment options for a given medical condition or disease state. In the second part of the Users’ Guide for Surgeons, we discuss and demonstrate the application of criteria for determining the certainty in effect sizes and directions associated with a given treatment option through an example pertinent to clinical orthopaedics.

Future Perspectives: The Need for Large Clinical Trials

Fragility fractures represent a growing problem with large economic and patient burdens that are likely to increase as the population ages. The elderly patient with osteopenic bone presents a unique surgical challenge with appreciable risks associated with each surgical treatment option. As demonstrated in this supplement, the current evidence suggests that the best surgical treatment options for patients with fragility fractures remains largely unknown. Additional evidence, from large clinical trials, is required before definitive treatment recommendations can be made in many cases. In this article, we review the example of the femoral neck fracture to illustrate this point.

Musculoskeletal trauma and all-cause mortality in India: a multicentre prospective cohort study

BACKGROUND There is little data in low-income and middle-income countries (LMICs) quantifying the burden of fractures and describing current practices. The aim of the study was describe the severity of musculoskeletal injuries in LMICS and identify modifiable factors that predict subsequent early all-cause mortality. METHODS We did a multicentre, prospective, observational study of patients who presented to 14 hospitals across India for musculoskeletal trauma (fractures or dislocations). Patients were recruited during an 8-week period, between November, 2011, and June, 2012, and were followed for 30-days or hospital discharge, whichever occurred first. Primary outcome was all-cause mortality with secondary outcomes of reoperation and infection. Logistic regression analyses were conducted to identify factors associated with all-cause mortality. FINDINGS We enrolled 4822 patients, but restricted analyses to 4612 (96%) patients who had complete follow-up. The majority (56·2% younger than 40 years old) of trauma patients were young (mean age 40·9 years [SD 16·9]) and 3148 (68%) were men. 2344 (518%) patients sustained trauma as a result of a road traffic accident. The most common musculoskeletal injury was a fracture (4514 [98%]) and 707 patients (15%) incurred an open fracture. Less than a third of musculoskeletal trauma patients (1374 [29%]) were transported to hospital by ambulance, and one in six patients (18%) arrived at the hospital later than 24 h after sustaining their injury. Over a third (239 [35%] of 707) of open fractures were definitively stabilised later than 24 h. 30-day mortality was 1·7% (95% CI 1·4-2·2) for all patients and 2·1% (95% CI 1·5-2·7) among road traffic victims (p=0·005). Musculoskeletal trauma severity including the number of fractures (3·1 [95% CI 2·4-3·9]) and presence of an open fracture (2·1 [95% CI 1·2-3·4]) significantly increased the odds of all-cause mortality. INTERPRETATION Musculoskeletal trauma severity, particularly road related, is a key predictor of subsequent mortality. Improvement in road safety policies, and improvements in access to emergency medical services and timely orthopaedic care are critical to mitigate the burden of injury worldwide. FUNDING Regional Medical Associates, AO International, Hamilton Health Sciences Trauma Fund.

The Burden of Spine Fractures in India: A Prospective Multicenter Study

Study Design: Prospective cohort study. Objectives: The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma. Methods: In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model. Results: Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications. Conclusions: Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.

Introduction to Evidence-Based Medicine

The goal of evidence-based orthopedics (EBO) is to provide the most efficacious interventions to improve patient quality of life and surgical outcomes. The practice of EBO involves a triumvirate of best available evidence, surgical expertise, and patient preferences. To identify best available evidence one must have knowledge of the hierarchy of surgical evidence and appreciate the rationale for its structure. The development of several evaluative instruments and guidelines have helped surgeons by outlining the key elements of studies that impact the validity of evidence and its magnitude of effect on treatment recommendations. There has been a gradual improvement over the past decade in the methodological quality of the orthopedic literature which has been matched with a growing willingness of surgeons to utilize study results in their surgical decision-making. Thus, over a very short time-span, EBO has improved best practice and accountability of the field and continues to have a growing impact internationally.