Sam Adie

Cryotherapy after total knee arthroplasty a systematic review and meta-analysis of randomized controlled trials.

Cryotherapy has theoretical and practical applications in the reduction of pain, swelling, and blood loss after trauma. We performed a systematic review and meta-analysis of randomized controlled trials on the efficacy of cryotherapy after total knee arthroplasty (TKA). Eleven studies involving 793 TKAs were included. There was considerable clinical and methodological heterogeneity. Cryotherapy resulted in small benefits in blood loss and discharge knee range of motion. There were no benefits in transfusion and analgesia requirements, pain, swelling, length of stay, and gains in knee range of motion after discharge. Despite some early gains, cryotherapy after TKA yields no apparent lasting benefits. Patient-centered outcomes remain underinvestigated. The current evidence does not support the routine use of cryotherapy after TKA.

CONSORT compliance in surgical randomized trials: are we there yet? A systematic review.

Objective: We performed a systematic review assessing the reporting quality of trials of surgical interventions, and explored associated trial level variables. Background: Randomized controlled trials (RCTs) provide clinicians with the best evidence for the effects of interventions, but may not be reported with necessary detail. Methods: In May 2009, 3 databases (MEDLINE, EMBASE, and CENTRAL) were searched for RCTs that assessed a surgical intervention using a comprehensive electronic strategy developed by the Cochrane Collaboration. The Consolidated Standards of Reporting Trials (CONSORT) checklist was used as a measure of reporting quality. An overall CONSORT score was calculated and expressed as a proportion. This was supplemented with domains related to external validity. We also collected data on characteristics hypothesized to improve reporting quality, and exploratory regression was performed to determine associations. Results: One hundred fifty recently published RCTs were included. The most commonly represented surgical subspecialties were general (29%), orthopedic (23%), and cardiothoracic (13%). Most (65%) were published in subspecialty surgical journals. Overall reporting quality was low, with only 55% of CONSORT items addressed. Less than half of trials described adequate methods for sample size calculation (45%), random sequence generation (43%), allocation concealment (45%), and blinding (37%). The strongest associations with reporting quality were adequate methods related to methodological domains, an author with an epidemiology/statistics degree, and a longer report length. Conclusions: There remains much room for improvement for the reporting of surgical intervention trials. Authors and journal editors should apply existing reporting guidelines, and guidelines specific to the reporting of surgical interventions should be developed.

Discordance Between Patient and Surgeon Satisfaction After Total Joint Arthroplasty

We surveyed 331 patients undergoing total hip or knee arthroplasty pre-operatively, and patients and surgeons were both surveyed 6 and 12 months post-operatively. We identified variables (demographic factors, operative factors and patient expectations) as possible predictors for discordance in patient-surgeon satisfaction. At 12 months, 94.5% of surgeons and 90.3% of patients recorded satisfaction with the outcome. The discordance between patient and surgeon satisfaction was mainly due to patient dissatisfaction-surgeon satisfaction. In an adjusted analysis, the strongest predictors of discordance in patient-surgeon satisfaction were unmet patient expectations and the presence of complications. Advice to potential joint arthroplasty candidates regarding the decision to proceed with surgery should be informed by patient reported outcomes, rather than the surgeons opinion of the likelihood of success.

Is discharge knee range of motion a useful and relevant clinical indicator after total knee replacement? Part 2.

OBJECTIVE Knee range of motion (ROM) at discharge from acute care is used as a clinical indicator following total knee replacement (TKR) surgery. This study aimed to assess the clinical relevance of this indicator by determining whether discharge knee ROM predicts longer-term knee ROM and patient-reported knee pain and function. METHODS A total of 176 TKR recipients were prospectively followed after discharge from acute care. Outcomes assessed included knee ROM and Oxford knee score post rehabilitation and 1 year post surgery. Discharge ROM and other patient factors were identified a priori as potential predictors in multiple linear regression modelling. RESULTS A total of 133 (76%) and 141 (80%) patients were available for follow-up post rehabilitation [mean postoperative week 8.1 (SD 2.7)] and at 1 year [mean postoperative month 12.1 (SD 1.4)], respectively. Greater discharge knee flexion was a significant (P < 0.001) predictor of greater post-rehabilitation flexion but not 1-year knee flexion (P < 0.083). Better discharge knee extension was a significant predictor of better post-rehabilitation (P = 0.001) and 1-year knee extension (P = 0.013). Preoperative Oxford score and post-rehabilitation knee flexion independently predicted post-rehabilitation Oxford score, and gender predicted 1-year Oxford score. Discharge ROM did not significantly predict Oxford score in either model. CONCLUSION The finding that early knee range predicts longer-term range provides clinical evidence favouring the relevance of discharge knee ROM as a clinical indicator. Although longer-term patient-reported knee pain and function were not directly associated with discharge knee ROM, they were associated with ROM when measured concurrently in the sub-acute phase. No causal effect has been demonstrated, but the findings suggest it may be important for physiotherapists to maximize range in the early and sub-acute periods.

Quality of conduct and reporting of meta-analyses of surgical interventions.

BACKGROUND Meta-analyses are useful tools for summarizing surgical evidence as they aim to encompass multiple sources of information on a particular research question, but they may be prone to methodological and reporting biases. We evaluated the conduct and reporting of meta-analyses of surgical interventions. METHODS AND FINDINGS We performed a systematic review of 150 meta-analyses of randomized trials of surgical interventions published between January 2010 and June 2011. A comprehensive search strategy was executed using MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. Data were independently extracted by 2 authors using the PRISMA statement (preferred reporting items for systematic reviews and meta-analyses, a standardized quality of reporting guideline) and AMSTAR (a tool for methodological quality). Descriptive statistics were used for individual items, and as a measure of overall compliance, PRISMA and AMSTAR scores were calculated as the sum of adequately reported domains. A median of 8 trials (interquartile range = 8) was included in each meta-analysis. One third of all meta-analyses had an author with a background in epidemiology and/or statistics. Forty-four percent were published in PRISMA-endorsing journals with a median impact factor of 3.5. There was moderate compliance with PRISMA, with an average of 71% of items reported, but poorer compliance with AMSTAR, with 48% of items adequately described, on average. CONCLUSIONS Substantial gaps in the conduct and reporting of meta-analyses within the surgical literature exist, mainly in the specification of aims and/or objectives, the use of preplanned protocols, and the evaluation of potential bias at the review (rather than trial) level. Editorial insistence on using reporting guidelines would improve this situation.

Tourniquet application only during cement fixation in total knee arthroplasty: a double-blind, randomized controlled trial

Background:  The functional benefits of tourniquet application for short periods compared with standard duration applications during total knee arthroplasty surgery have not been well explored. We aimed to compare functional outcomes between tourniquet application of short duration (during cement fixation only) and tourniquet application of longer duration (from skin incision to just after cement fixation).

Pulsed electromagnetic field stimulation for acute tibial shaft fractures: a multicenter, double-blind, randomized trial.

BACKGROUND Tibial shaft fractures are sometimes complicated by delayed union and nonunion, necessitating further surgical interventions. Pulsed electromagnetic field stimulation is an effective treatment for delayed unions and nonunions, but its efficacy in preventing healing complications in patients with acute fractures is largely untested. The purpose of this pragmatic trial was to determine whether adjuvant pulsed electromagnetic field therapy for acute tibial shaft fractures reduces the rate of surgical revision because of delayed union or nonunion. METHODS In a double-blind randomized trial involving six metropolitan trauma hospitals, 259 participants with acute tibial shaft fractures (AO/OTA type 42) were randomized by means of external allocation to externally identical active and inactive pulsed electromagnetic field devices. Participants were instructed to wear the device for ten hours daily for twelve weeks. Management was otherwise unaltered. The primary outcome was the proportion of participants requiring a secondary surgical intervention because of delayed union or nonunion within twelve months after the injury. Secondary outcomes included surgical intervention for any reason, radiographic union at six months, and the Short Form-36 Physical Component Summary and Lower Extremity Functional Scales at twelve months. Main analyses were by intention to treat. RESULTS Two hundred and eighteen participants (84%) completed the twelve-month follow-up. One hundred and six patients were allocated to the active device group, and 112 were allocated to the placebo group. Compliance was moderate, with 6.2 hours of average daily use. Overall, sixteen patients in the active group and fifteen in the inactive group experienced a primary outcome event (risk ratio, 1.02; 95% confidence interval, 0.95 to 1.14; p = 0.72). According to per-protocol analysis, there were six primary events (12.2%) in the active, compliant group and twenty-six primary events (15.1%) in the combined placebo and active, noncompliant group (risk ratio, 0.97; 95% confidence interval, 0.86 to 1.10; p = 0.61). No between-group differences were found with regard to surgical intervention for any reason, radiographic union, or functional measures. CONCLUSIONS Adjuvant pulsed electromagnetic field stimulation does not prevent secondary surgical interventions for delayed union or nonunion and does not improve radiographic union or patient-reported functional outcomes in patients with acute tibial shaft fractures.

Resection of liver metastases from colorectal cancer: does preoperative chemotherapy affect the accuracy of PET in preoperative planning?

Background:  Preoperative scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of preoperative chemotherapy, which has marked biochemical and physical effects on the liver. Integrated fluoro‐deoxyglucose positron emission tomography and computed tomography (FDG‐PET/CT) has applications for detecting extrahepatic disease. The aim of the present study was to investigate FDG‐PET/CT as a preoperative planning tool for detecting liver lesions in patients with and without preoperative chemotherapy.

Randomised Trial Support for Orthopaedic Surgical Procedures

We investigated the proportion of orthopaedic procedures supported by evidence from randomised controlled trials comparing operative procedures to a non-operative alternative. Orthopaedic procedures conducted in 2009, 2010 and 2011 across three metropolitan teaching hospitals were identified, grouped and ranked according to frequency. Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) were performed to identify RCTs evaluating the most commonly performed orthopaedic procedures. Included studies were categorised as “supportive” or “not supportive” of operative treatment. A risk of bias analysis was conducted for included studies using the Cochrane Collaborations Risk of Bias tool. A total of 9,392 orthopaedic procedures were performed across the index period. 94.6% (8886 procedures) of the total volume, representing the 32 most common operative procedure categories, were used for this analysis. Of the 83 included RCTs, 22.9% (19/83) were classified as supportive of operative intervention. 36.9% (3279/8886) of the total volume of procedures performed were supported by at least one RCT showing surgery to be superior to a non-operative alternative. 19.6% (1743/8886) of the total volume of procedures performed were supported by at least one low risk of bias RCT showing surgery to be superior to a non-operative alternative. The level of RCT support for common orthopaedic procedures compares unfavourably with other fields of medicine.

Practice variation in common fracture presentations: A survey of orthopaedic surgeons

BACKGROUND Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation. MATERIALS AND METHODS A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored. RESULTS 358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures). CONCLUSIONS Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.