Mohit Bhandari

Operative management of displaced femoral neck fractures in elderly patients: An international survey

BACKGROUNDnHip fractures occur in 280,000 North Americans each year. Although surgeons have reached consensus with regard to the treatment of undisplaced fractures of the hip, the surgical treatment of displaced fractures remains controversial. Identifying surgeons preferences in techniques, and the rationale for their choices, may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the operative treatment of displaced fractures of the femoral neck.nnnMETHODSnWe used a cross-sectional survey design and a sample-to-redundancy strategy to examine surgeons preferences in the treatment of displaced femoral neck fractures. We mailed this survey to members of the Orthopaedic Trauma Association and European-AO International-affiliated trauma centers.nnnRESULTSnOf 442 surgeons who received the questionnaire, 298 (67%) responded. The typical respondent was a North American man over the age of forty years who was in academic practice, supervised residents, had fellowship training in trauma, and worked in a low-volume center (<100 hip fractures per year), treating an equal proportion of displaced and undisplaced femoral neck fractures. Most surgeons believed that internal fixation was the procedure of choice in younger patients (those who are less than sixty years old) with a displaced fracture (Garden type III or IV). For patients over eighty years old with Garden type-III or IV fractures, almost all surgeons preferred arthroplasty. Respondents varied widely in their preferences for the treatment of patients who were sixty to eighty years old with a displaced fracture (Garden type III or IV) or active patients with a Garden type-III fracture. Many surgeons believed there was no difference between arthroplasty and internal fixation when considering mortality (45%), infection rates (30%), and quality of life (37%). Surgeons also revealed variable preferences in their choice of the optimal approach to arthroplasty for patients between sixty and eighty years old with a type-IV fracture (32% preferred unipolar; 41%, bipolar; and 17%, total hip arthroplasty) and in the optimal choice of implant for internal fixation.nnnCONCLUSIONSnWhile surgeons prefer internal fixation for younger patients and arthroplasty for older patients, they disagree about the optimal approach to the management of patients between sixty and eighty years old with a displaced fracture and active patients with a Garden type-III fracture. Surgeons also disagree on the optimal implants for internal fixation or arthroplasty.

Surgical Compared with Conservative Treatment for Acute Nondisplaced or Minimally Displaced Scaphoid Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUNDnThere is a current trend in orthopaedic practice to treat nondisplaced or minimally displaced fractures with early open reduction and internal fixation instead of cast immobilization. This trend is not evidence-based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute nondisplaced and minimally displaced scaphoid fractures, thus aiming to summarize the best available evidence.nnnMETHODSnA systematic literature search of the medical literature from 1966 to 2009 was performed. We selected eight randomized controlled trials comparing surgical with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures in adults. Data from included studies were pooled with use of fixed-effects and random-effects models with standard mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with calculation of the I(2) statistic.nnnRESULTSnFour hundred and nineteen patients from eight trials were included. Two hundred and seven patients were treated surgically, and 212 were treated conservatively. Most trials lacked scientific rigor. Our primary outcome parameter, standardized functional outcome, which was assessed for 247 patients enrolled in four trials, significantly favored surgical treatment (p < 0.01). With regard to our secondary parameters, we found heterogeneous results that favored surgical treatment in terms of satisfaction (assessed in one study), grip strength (six studies), time to union (three studies), and time off work (five studies). In contrast, we found no significant differences between surgical and conservative treatment with regard to pain (two studies), range of motion (six studies), the rates of nonunion (six studies) and malunion (seven studies), and total treatment costs (two studies). The rate of complications was higher in the surgical treatment group (23.7%) than in the conservative group (9.1%), although this difference was not significant (p = 0.13). There was a nearly significantly higher rate of scaphotrapezial osteoarthritis in the surgical treatment group (p = 0.05).nnnCONCLUSIONSnBased on primary studies with limited methodological quality, this study suggests that surgical treatment is favorable for acute nondisplaced and minimally displaced scaphoid fractures with regard to functional outcome and time off work; however, surgical treatment engenders more complications. Thus, the long-term risks and short-term benefits of surgery should be carefully weighed in clinical decision-making.

The Quality of Reporting of Orthopaedic Randomized Trials with Use of a Checklist for Nonpharmacological Therapies

BACKGROUNDnThe Consolidated Standards of Reporting Trials statement for the reporting of randomized controlled trials has been limited by its applicability to surgical trials. In response, a Checklist to Evaluate a Report of a Nonpharmacological Trial was recently developed by the Consolidated Standards of Reporting Trials group to address reporting issues in surgical trials. We aimed (1) to apply the checklist for nonpharmacological therapies to orthopaedic randomized controlled trials across multiple journals from 2004 through 2005, and (2) to survey authors when methodological safeguards itemized in the checklist were not reported to determine whether they actually had been performed. We hypothesized that lack of reporting of a methodological safeguard did not necessarily mean it had not been conducted.nnnMETHODSnWe searched for relevant orthopaedic randomized controlled trials across eight journals in the period from January 2004 through December 2005. We applied the Checklist to Evaluate a Report of a Nonpharmacological Trial to all eligible studies. We contacted authors to determine what methodological safeguards were actually used, especially when details remained unclear from the publication.nnnRESULTSnWe included eighty-seven randomized controlled trials from eighty-five scientific reports. In assessing the randomized controlled trials with the checklist for nonpharmacological therapies, seventy-three studies (84%) had unclear reporting of treatment allocation concealment. Only seventeen studies (20%) mentioned surgeon skill or experience. The blinding of patients, ward staff, rehabilitation staff, clinical outcome assessors, and nonclinical outcome assessors was unclear in forty-eight (55%), sixty-three (72%), sixty-four (74%), forty (46%), and thirty-three studies (38%), respectively. Authors from forty-three randomized controlled trials responded to our survey. The results of the survey showed that 41% (95% confidence interval, 25% to 58%) of the trials had adequate allocation concealment when this had been unclear from the report. Although the surgical experience of the investigators was rarely reported, most authors (70%) acknowledged that they had defined surgical expertise criteria such as minimum case criteria, specialized training, and clinical performance. The survey also showed that 28% to 40% of the trials had blinding of relevant groups despite the fact that the reporting of such blinding had been unclear in the publications.nnnCONCLUSIONSnThe quality of reporting in the orthopaedic literature was highly variable. Readers should not assume that bias-reducing safeguards that were not reported in a randomized controlled trial did not occur. Our study reinforces the need for the consistent use of a tool like the Checklist to Evaluate a Report of a Nonpharmacological Trial to assess the methodology of surgical trials.

Improving reliability in the classification of fractures of the acetabulum

Background. Plain radiographs of the pelvis are routinely used in the initial assessment of patients with suspected fractures of the acetabulum. It is necessary for orthopaedic resident trainees, emergency physicians as well as orthopaedic surgeons who infrequently treat trauma patients to be able to describe these fracture patterns reliably to traumatologist orthopaedic surgeons who ultimately take over the patient care. Our purpose was two-fold: (1) to determine the reliability of the component parts of the Letournel classification of acetabular fractures involving six anteroposterior (AP) radiographic lines, and (2) to examine whether the addition of oblique radiograph views (Judet views) would improve the reliability.nn Methods. Thirty sets of AP and oblique radiographs (Judet views) of the pelvis were selected from a hospital database to represent various types of acetabular fractures. Six reviewers (three orthopaedic trainees and three community orthopaedic surgeons) independently reviewed the radiographs. For each radiograph, the reviewer classified the acetabular fracture according to the Letournel classification. In addition, each reviewer utilized a simplified classification scheme using six radiographic lines on the AP pelvic radiograph. Interobserver reliabilities among reviewers were reported along with the intraclass correlation coefficient (ICC) and kappa values.nn Results. Agreement for the Letournel classification increased with increasing physician experience (trainees ICC=−0.14 and community surgeons ICC=0.56). Interobserver reliability between trainees and community surgeons improved when the six radiographic lines were used (range kappa=0.09–0.89). The oblique pelvic radiographs (Judet views) did not significantly improve reliability among physicians.nn Conclusions. In this study we report the following: (1) the reliability of the Letournel classification improves with level of training, (2) physicians with less experience with acetabular fractures have significantly better agreement in identifying fractures using the six radiographic lines on the AP film than the Letournel classification, and (3) agreement among the reviewers for the AP pelvic radiograph is not improved with additional oblique (Judet) views.

Nonoperative Treatment for Acute Scaphoid Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUNDnRecommendations for cast immobilization of acute scaphoid fractures vary substantially. We reviewed data from randomized controlled trials comparing nonoperative treatment methods for acute scaphoid fractures to determine the best available evidence.nnnMETHODSnA systematic search of the medical literature from 1966 to 2010 was performed. Two authors independently screened titles and abstracts, reviewed articles, assessed methodological quality according to the Grading of Recommendations Assessment Development and Evaluation system, and extracted data. The primary outcome parameter was nonunion. Data were pooled using random-effects models with standard mean differences for continuous and risk ratios for dichotomous variables, respectively. Heterogeneity across studies was assessed with calculation of the I statistic.nnnRESULTSnThe search resulted in five potentially eligible trials of which four met our inclusion criteria. In total, 523 patients were included in four trials including two evaluating below-elbow casting versus above-elbow casting; one trial comparing below-elbow casting including the thumb versus excluding the thumb; and one trial comparing fractures with a below-elbow cast with the wrist in 20-degrees flexion to 20-degrees extension, with both types excluding the thumb. There were no significant differences in union rate, pain, grip strength, time to union, or osteonecrosis for the various nonoperative treatment methods.nnnCONCLUSIONSnThere is no evidence from randomized controlled trials on physician-based or patient-based outcome to favor any nonoperative treatment method for acute scaphoid fractures.

Predictors of the accuracy of quotation of references in peer-reviewed orthopaedic literature in relation to publications on the scaphoid

Using inaccurate quotations can propagate misleading information, which might affect the management of patients. The aim of this study was to determine the predictors of quotation inaccuracy in the peer-reviewed orthopaedic literature related to the scaphoid. We randomly selected 100 papers from ten orthopaedic journals. All references were retrieved in full text when available or otherwise excluded. Two observers independently rated all quotations from the selected papers by comparing the claims made by the authors with the data and expressed opinions of the reference source. A statistical analysis determined which article-related factors were predictors of quotation inaccuracy. The mean total inaccuracy rate of the 3840 verified quotes was 7.6%. There was no correlation between the rate of inaccuracy and the impact factor of the journal. Multivariable analysis identified the journal and the type of study (clinical, biomechanical, methodological, case report or review) as important predictors of the total quotation inaccuracy rate. We concluded that inaccurate quotations in the peer-reviewed orthopaedic literature related to the scaphoid were common and slightly more so for certain journals and certain study types. Authors, reviewers and editorial staff play an important role in reducing this inaccuracy.

Multiple testing in orthopedic literature: a common problem?

BackgroundPerforming multiple tests in primary research is a frequent subject of discussion. This discussion originates from the fact that when multiple tests are performed, it becomes more likely to reject one of the null hypotheses, conditional on that these hypotheses are true and thus commit a type one error. Several correction methods for multiple testing are available. The primary aim of this study was to assess the quantity of articles published in two highly esteemed orthopedic journals in which multiple testing was performed. The secondary aims were to determine in which percentage of these studies a correction was performed and to assess the risk of committing a type one error if no correction was applied.MethodsThe 2010 annals of two orthopedic journals (A and B) were systematically hand searched by two independent investigators. All articles on original research in which statistics were applied were considered. Eligible publications were reviewed for the use of multiple testing with respect to predetermined criteria.ResultsA total of 763 titles were screened and 127 articles were identified and included in the analysis. A median of 15 statistical inference results were reported per publication in both journal A and B. Correction for multiple testing was performed in 15% of the articles published in journal A and in 6% from journal B. The estimated median risk of obtaining at least one significant result for uncorrected studies was calculated to be 54% for both journals.ConclusionThis study shows that the risk of false significant findings is considerable and that correcting for multiple testing is only performed in a small percentage of all articles published in the orthopedic literature reviewed.

Making Decisions About Prognosis in Evidence-Based Practice

Prognostic studies are designed to investigate factors that impact the outcome of a disease or its treatment. These factors include, but are not limited to, inherent patient characteristics, the state of the disease, and severity of symptoms. The results of prognostic studies can be used to guide the treatment of patients with similar conditions and overall characteristics. It is the purpose of this paper to provide an outline of how to perform an unbiased appraisal of a prognostic study, allowing the physician to assess the applicability of the results to their patient and thereby assist with decision making in clinical practice.