Harman Chaudhry

The etiology of femoroacetabular impingement: what we know and what we don't.

Context: Several risk factors may cause femoroacetabular impingement (FAI). Knowledge of causation would identify patients for early intervention, prior to the development of painful intra-articular damage. Data Sources: PubMed, MEDLINE, EMBASE, and related article reference lists were screened for relevant studies published between January 2000 and December 2013. Study Selection: Inclusion criteria were (1) etiology of FAI, (2) original FAI clinical data, and (3) English language. Case reports of fewer than 3 patients were excluded. Study Design: Systematic review. Level of Evidence: Level 4. Results: In all, 754 studies were screened, with 18 meeting the eligibility criteria. There were 13 comparative observational studies and 5 case series. The studies pertained to intrinsic patient factors (n = 2), activity/developmental factors (n = 8), hip disease (n = 5), postsurgical changes (n = 2), and malunion after hip fracture (n = 1). Conclusion: A combination of intrinsic patient and developmental factors, activities involving repetitive hip motion, pediatric hip disease, and hip-related surgical procedures may contribute to the development of FAI.

How good is the orthopaedic literature

Randomized trials constitute approximately 3% of the orthopaedic literature Concerns regarding quality of the orthopaedic literature stem from a widespread notion that the overall quality of the surgical literature is in need of improvement. Limitations in surgical research arises primarily from two pervasive issues: 1) A reliance on low levels of evidence to advance surgical knowledge, and 2) Poor reporting quality among the high level surgical evidence that is available. The scarcity of randomized trials may be largely attributable to several unique challenges which make them difficult to conduct. We present characteristics of the orthopaedic literature and address the challenges of conducting randomized trials in surgery.

Cognitive dysfunction in hip fracture patients.

Hip fractures represent a widespread morbidity among the geriatric population. In North America, more than 320,000 hip fractures are sustained annually, a number that is expected to increase dramatically as the population continues to age. Disorders of cognition, primarily dementia and delirium, also have a higher-than-average incidence and prevalence among the geriatric population. The co-occurrence of cognitive dysfunction and hip fracture is an important entity for orthopedic surgeons and other clinicians involved in hip fracture care to recognize. This article provides an overview of the currently available evidence regarding cognitive dysfunction, specifically dementia and delirium, in patients with hip fractures.

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.

Design and execution of clinical trials in orthopaedic surgery

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.

Open Tibial Fractures: Updated Guidelines for Management

Fractures of the tibial diaphysis represent the most common major long-bone fractures that currently confront practicing orthopaedic surgeons1,2. The overall incidence has been estimated to be seventeen to twenty-three fractures per 100,000 person-years, and it is young males in particular who carry the highest risk of sustaining these fractures, with a reported incidence of thirty-nine fractures per 100,000 person-years in males from ten to nineteen years of age3,4. Unfortunately, up to 24% (a total of …

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.

Checklists to improve the quality of the orthopaedic literature

Several checklists have been developed in an effort to help journals and researchers improve the quality of reporting in research. The CONSORT statement and the CLEAR NPT evaluate randomized trials. The MOOSE and QUOROM checklists evaluate meta-analyses. The STROBE checklists assists readers in evaluating observational studies and the STARD checklist was developed for diagnostic test evaluation. The checklists presented here provide an invaluable source of guidance to authors, journal editors and readers who are seeking to prepare and evaluate reports. As evidence-based medicine continues to establish itself as the new paradigm by which medicine is practiced, the need for good reporting for all research designs must also become commonplace as opposed to the exception.

Cochrane in CORR®: Continuous Passive Motion Following Total Knee Arthroplasty in People With Arthritis (Review)

T otal knee arthroplasty (TKA) effectively reduces pain and improves function in most patients. It is also one of the most commonly performed orthopaedic procedures [7]; one projection suggests that in the United States alone, more than 1.3 million TKAs will be performed per year by 2020 [12]. However, knee stiffness complicates approximately 1.3% of TKAs, severely limiting patients’ function [11], reducing quality of life, and resulting in early revision [13]. Continuous Passive Motion (CPM) refers to the use of a motorized device that is applied to a patient’s lower extremity, and continuously moves the patient’s knee through a predefined arc of motion [8]. This device is typically used during the immediate postoperative period, and it has been theorized that early passive range-of-motion (ROM) can prevent the formation of adhesions that cause joint stiffness [15]. However, the cost of CPM devices can be high, and the efficacy of CPM is uncertain. This Cochrane systematic review and metaanalysis evaluated the efficacy of CPM in patients undergoing primary TKA [8]. Based on evidence from 24 randomized trials (pooled n = 1445), the authors concluded that there is very little advantage of using CPM after TKA.

Variability in the Approach to Total Hip Arthroplasty in Patients With Displaced Femoral Neck Fractures

The aim of this study was to determine the degree of variability in implants, approaches, and associated complication rates in randomized controlled trials (RCTs) evaluating primary total hip arthroplasty (THA) as an intervention for displaced femoral neck fractures. We searched 2 medical databases for RCTs involving THA for femoral neck fractures published between June 2000 and June 2010. All analyses were descriptive. Nine RCTs met our inclusion criteria. We identified variability in both the surgical approach and choice of prosthesis. Trials generally standardized to head sizes of 28 mm or greater and cemented prostheses. Surgical experience varied across studies. Dislocation rates varied from 0% to 22%. There is considerable variability in RCTs evaluating THA for femoral neck fractures. Standardization toward optimal outcomes for femoral neck fractures is needed.