Sheila Sprague

Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis.

BACKGROUND The optimal choice for the stabilization of displaced femoral neck fractures remains controversial, with alternatives including arthroplasty and internal fixation. Our objective was to determine the effect of arthroplasty (hemiarthroplasty, bipolar arthroplasty, and total hip arthroplasty), compared with that of internal fixation, on rates of mortality, revision, pain, function, operating time, and wound infection in patients with a displaced femoral neck fracture. METHODS We searched computerized databases for randomized clinical trials published between 1969 and 2002, and we identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic textbooks, and personal files. Of 140 citations initially identified, fourteen met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data, including information on revision and mortality rates. RESULTS Nine trials, which included a total of 1162 patients, provided detailed information on mortality rates over the first four postoperative months, which ranged from 0% to 20%. We found a trend toward an increase in the relative risk of death in the first four months after arthroplasty compared with the risk in the first four months after internal fixation (relative risk, 1.27). At one year, the relative risk of death was 1.04. The risk of death after arthroplasty appeared to be higher than that after fixation with a compression screw and side-plate but not higher than that after internal fixation with use of screws only (relative risk = 1.75 and 0.86, respectively; p < 0.05). Fourteen trials that included a total of 1901 patients provided data on revision surgery. The relative risk of revision surgery after arthroplasty compared with the risk after internal fixation was 0.23 (p = 0.0003). Pain relief and the attainment of overall good function were similar in patients treated with arthroplasty and those treated with internal fixation (relative risk, 1.12 for pain relief and 0.99 for function). Infection rates ranged from 0% to 18%, and arthroplasty significantly increased the risk of infection (relative risk, 1.81; p = 0.009). In addition, patients who underwent arthroplasty had greater blood loss and longer operative times than those who were treated with internal fixation. CONCLUSIONS In comparison with internal fixation, arthroplasty for the treatment of a displaced femoral neck fracture significantly reduces the risk of revision surgery, at the cost of greater infection rates, blood loss, and operative time and possibly an increase in early mortality rates. Only larger trials will resolve the critical question of the impact on early mortality.

Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis

Background: Guidelines exist for the surgical treatment of hip fracture, but the effect of early surgery on mortality and other outcomes that are important for patients remains unclear. We conducted a systematic review and meta-analysis to determine the effect of early surgery on the risk of death and common postoperative complications among elderly patients with hip fracture. Methods: We searched electronic databases (including MEDLINE and EMBASE), the archives of meetings of orthopedic associations and the bibliographies of relevant articles and questioned experts to identify prospective studies, published in any language, that evaluated the effects of early surgery in patients undergoing procedures for hip fracture. Two reviewers independently assessed methodologic quality and extracted relevant data. We pooled data by means of the DerSimonian and Laird random-effects model, which is based on the inverse variance method. Results: We identified 1939 citations, of which 16 observational studies met our inclusion criteria. These studies had a total of 13 478 patients for whom mortality data were complete (1764 total deaths). Based on the five studies that reported adjusted risk of death (4208 patients, 721 deaths), irrespective of the cut-off for delay (24, 48 or 72 hours), earlier surgery (i.e., within the cut-off time) was associated with a significant reduction in mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68–0.96, p = 0.01). Unadjusted data indicated that earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37–0.93, p = 0.02) and pressure sores (RR 0.48, 95% CI 0.34–0.69, p < 0.001). Interpretation: Earlier surgery was associated with a lower risk of death and lower rates of postoperative pneumonia and pressure sores among elderly patients with hip fracture. These results suggest that reducing delays may reduce mortality and complications.

Treatment of acute Achilles tendon ruptures a systematic overview and metaanalysis

A quantitative systematic review of randomized and quasirandomized trials was conducted to determine the effect of surgical versus conservative treatment of acute Achilles tendon ruptures on rates of rerupture. Secondary outcomes included deep infection rates, return to normal function, and minor complaints. A search of computerized databases was conducted to locate clinical studies published from 1969 to 2000. Additional studies were located through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files. Of the 273 citations initially identified, 11 proved potentially eligible, and six met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data. Among the studies, surgical repair revealed a significant reduction in the risk of rerupture when compared with conservative treatment. Alternatively, the risk of infection with surgical repair was significantly increased. Pooled analysis of studies did not reveal any difference in the risk of minor complaints or return to normal function between surgical repair and conservatively treated groups. Surgical treatment significantly reduces the risk of Achilles tendon rerupture, but increases the risk of infection, when compared with conservative therapy. Wide confidence intervals around the estimates of risk reduction suggest a large trial is needed to establish risks and benefits.

Barriers to full-text publication following presentation of abstracts at annual orthopaedic meetings.

Background: Oral presentations at national and international meetings offer an excellent forum for the dissemination of current research findings. However, publication rates of full-text articles after presentation of abstracts at international meetings have ranged from 11% to 78%, which suggests that at least 32% of the abstracts presented are never published as complete articles in peer-reviewed journals. In an effort to identify the reasons that surgeons had not had a paper published following presentation of their work at an international orthopaedic meeting, we conducted a survey of a cross section of authors of orthopaedic papers presented at a national meeting.Methods: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. A computerized Medline and PubMed search established whether the abstract had been subsequently published as a full-text article. The authors of the abstracts that had not been subsequently published were surveyed to identify the reasons for the failure to publish.Results: A total of 465 abstracts were presented at the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons in 1996. We surveyed the authors of 306 abstracts for which we were unable to locate a subsequent full-text publication on Medline. One hundred and ninety-nine investigators (65%) responded to the questionnaire. At the time of the survey, seventy-two manuscripts had been published, thirty-two had been submitted and rejected, fourteen were under consideration by journals, seven had been accepted for publication or were in press, and three were not recalled by the investigator. In addition, seventy-one abstracts (35.7%) of the 199 had not been submitted for publication. The authors of those abstracts were asked to indicate one or more reasons why they had not submitted a manuscript for publication. Thirty-three investigators (46.5%) indicated that they lacked sufficient time for research activities, twenty-two (31.0%) reported that the study presented at the meeting in 1996 was still in progress, fourteen (19.7%) believed that the responsibility for writing the manuscript belonged to someone else, and twelve (16.9%) reported that difficulties with co-authors who would not participate had impeded the completion of the manuscript. Nine investigators (12.7%) responded that the pursuit of publication was a low priority.Conclusions: In a survey of investigators who had not had a full-text article published after presenting the abstract at a national meeting, we found that the failure to publish was due to one of three main reasons: (1) they did not have enough time to prepare a manuscript for publication (the reason most frequently given); (2) almost one-third of the studies that had not been submitted for publication were ongoing; and (3) relationships with co-authors sometimes presented a barrier to final publication. Thorough preparation before the study and the establishment of stricter guidelines to limit the presentation of preliminary data at national and international meetings may improve publication rates.

The Quality of Reporting of Randomized Trials in The Journal of Bone and Joint Surgery from 1988 through 2000

Background: The purpose of this study was threefold: (1) to determine the scientific quality of published randomized trials in the American Volume of The Journal of Bone and Joint Surgery from 1988 through 2000, (2) to identify predictors of study quality, and (3) to evaluate inter-rater agreement in the scoring of study quality with use of a simple scale.Methods: Hand searches of The Journal of Bone and Joint Surgery were conducted in duplicate to identify randomized clinical trials. Of 2468 studies identified, seventy-two (2.9%) met all eligibility criteria. Two investigators each assessed the quality of the study under blinded conditions and abstracted relevant data.Results: The mean score (and standard error) for the quality of the seventy-two randomized trials was 68.1% ± 1.6%; 60% (forty-three) scored <75%. Drug trials had a significantly higher mean quality score than did surgical trials (72.8% compared with 63.9%, p < 0.05). Regression analysis revealed that cited affiliation with an epidemiology department and cited funding were associated with higher quality scores. Failure to conceal randomization, to blind outcome assessors, and to describe why patients were excluded resulted in significantly lower quality scores (p < 0.05), more than the 5% decrease expected by removal of each item. A priori calculations of sample size were rarely performed in the reviewed studies, and only 2% of the studies with negative results included a post hoc power analysis. The Detsky quality scale met accepted standards of interobserver reliability (kappa, 0.87; 95% confidence interval, 0.70 to 0.95).Conclusions: Few studies published in The Journal of Bone and Joint Surgery were randomized trials. More than half of the trials were limited by a lack of concealed randomization, lack of blinding of outcome assessors, or failure to report reasons for excluding patients. Application of standardized guidelines for the reporting of clinical trials in orthopaedics should improve quality.

An Observational Study of Orthopaedic Abstracts and Subsequent Full-Text Publications

Background: Research abstracts are frequently referenced in orthopaedic textbooks and influence orthopaedic care. However, little is known about the quality of information provided in the abstracts, the frequency of publication of complete papers after presentation of abstracts, or any discrepancies between abstracts and published papers. The objective of this study was to determine the quality of information provided in orthopaedic abstracts, rates of publication of full-text articles after presentation of abstracts, predictors of publication of full-text articles, and consistency between abstracts and full-text articles. Methods: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. For each abstract, we recorded the completeness of reporting and key features of the study design, conduct, analysis, and interpretation. A computerized Medline and PubMed search established whether the abstract had been followed by publication of a full-text article. Finally, we evaluated the consistency of reporting between abstracts and final publications. Results: The program included 465 abstracts, 66% of which were on prognostic studies. All abstracts described the study design, and 70.7% of the designs were observational. Key methodological issues were reported in less than half of the abstracts, and information on data analysis was reported in <15%. One hundred and fifty-nine (34%) of the 465 abstracts were followed by publication of a full-text article. The mean time to publication (and standard deviation) was 17.6 ±; 12 months (range, one to fifty-six months). Inconsistencies between the abstract and the full-text article included the primary outcome measure, which differed 14% of the time, and the results, which differed 19% of the time. Conclusions: Two-thirds of the orthopaedic abstracts in this sample were not followed by publication of a full-text paper. The overall quality of reporting in abstracts proved inadequate, and inconsistencies between the final published paper and the original abstract occurred frequently. The routine use of abstracts as a guide to orthopaedic practice needs to be reconsidered.

Predictors of reoperation following operative management of fractures of the tibial shaft.

Background Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors. Objective We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures. Design Retrospective observational study. Setting Level 1 trauma center. Methods We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure ≤1 year after the initial surgery that was aimed specifically at achieving bony union of the fracture, including bone grafts, implant exchanges, or débridement for infections). We chose a Cox proportion hazards model to conduct a survival analysis for time to reoperation and constructed a multivariable model to estimate the relative risk of reoperation and associated 95%confidence interval (CI) for each predictor variable. Main Outcome Measures Time to reoperation following the initial surgery. Results Complete follow-up information was available for 192 of 200 (96%) patients. Three variables predicted reoperation: the presence of an open fracture wound (relative risk 4.32, 95% CI 1.76 to 11.26), lack of cortical continuity between the fracture ends following fixation (relative risk 8.33, 95% CI 3.03 to 25.0), and the presence of a transverse fracture (relative risk 20.0, 95% CI 4.34 to 142.86). Conclusions We identified a set of three simple prognostic variables (open fracture, transverse fracture, and postoperative fracture gap) that can assist surgeons in predicting reoperation following operative treatment of tibial shaft fractures.

Surgeons' Preferences for the Operative Treatment of Fractures of the Tibial Shaft: An International Survey

There are more potential treatments for tibial fractures and more potential complications of those treatments than there are for any other type of fracture. The American Academy of Orthopaedic Surgeons recently reviewed malpractice claims to identify the procedures and diagnoses that have most commonly resulted in legal action. Among all orthopaedic conditions, fractures of the tibia and fibula ranked second with regard to the total number of patient malpractice claims, accounting for over thirty million dollars in indemnity1. The National Center for Health Statistics reported that more than 490,000 fractures of the tibia and fibula occur each year in the United States2. Although many tibial fractures may be managed nonoperatively, fractures for which nonoperative treatment has failed, open fractures, fractures with an associated compartment syndrome, and high-energy fractures require operative stabilization3. Surgical options include external fixation, plate fixation, and intramedullary nailing with or without reaming. Although there is a consensus among orthopaedic surgeons with regard to the optimal treatment of fractures of the femoral shaft, the appropriate treatment of closed and open tibial fractures remains controversial. Meta-analyses that include randomized trials provide the best evidence regarding the results of operative treatment of fractures of the tibial shaft4-7. In our meta-analysis6, one randomized trial8, involving fifty-six patients, showed a significant reduction in the rate of reoperation after external fixation compared with the rate after the use of plates (relative risk reduction, 87%; 95% confidence interval, 46% to 97%). Other trials showed that nailing without reaming resulted in a significant reduction in the risk of reoperation compared with the risk after external fixation (relative risk reduction, 49%; 95% confidence interval, 31% to 63%). Nailing with reaming reduced the risk of nonunion of closed and open fractures of the …

A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes.

Background: This study assessed the health-related quality of life experienced by breast reduction patients using four reliable and validated health-related quality-of-life measures. Methods: Consecutive patients with breast hypertrophy completed the Health Utilities Index Mark 2, the Health Utilities Index Mark 3, and the Breast Reduction Assessment Value and Outcomes instruments (the Short Form 36, the Multidimensional Body-Self Rating Questionnaire Appearance Assessment, and the Breast-Related Symptom Questionnaire) at 1 week and 1 day before surgery and at 1, 6, and 12 months after surgery. Results: For the 52 patients in the study, mean scores for all quality-of-life instruments increased from the preoperative assessments to the postoperative assessments. The mean quality-adjusted life years gained per patient because of the surgery was 0.12 during the 1-year follow-up period. There was a positive relationship (p < 0.001) between breast resection weight and body mass index. However, body mass index and tissue resection weight were not significantly associated with Health Utilities Index Mark 3 change scores (p > 0.05). Conclusions: Patients who undergo breast reduction experience an important improvement in health-related quality of life according to four established measures. The improvement is most noticeable between 1 day before surgery and 1 month after surgery, after which it stabilizes for up to 1 year. The health-related quality-of-life effect of the surgery translates into an expected lifetime gain of 5.32 quality-adjusted life years, which is equivalent to each patient living an additional 5.32 years in perfect health. The authors conclude that there is no justification for the ongoing restriction or denials of third-party payments based on body mass index.

Challenges to the practice of evidence-based medicine during residents' surgical training: a qualitative study using grounded theory.

Purpose. To examine surgical trainees’ barriers to implementing and adopting evidence-based medicine (EBM) in the day-to-day care of surgical patients. Method. In 2000, 28 surgical residents from various subspecialties at a hospital affiliated with McMaster University Faculty of Health Sciences in Ontario, Canada, participated in a focus group (n = 8) and semistructured interviews (n = 20) to explore their perceptions of barriers to the practice of EBM during their training. Additional themes were explored, such as definitions of EBM and potential strategies to implement EBM during training. The canons and procedures of the grounded theory approach to qualitative research guided the coding and content analysis of the data derived from the focus group and semistructured interviews. Results. Residents identified personal barriers, staff-surgeon barriers, and institutional barriers that limited their ability to apply EBM in their daily activities. Residents perceived their lack of education in EBM, time constraints, lack of priority, and fear of staff disapproval as major challenges to practicing EBM. Moreover, the lack of ready access to surgical EBM resource materials proved to be an important additional factor limiting EBM surgical practice. Residents identified several strategies to overcome these barriers to EBM, including hiring staff surgeons with EBM training, offering coursework in critical appraisal for all staff, improving interdepartmental communication, and providing greater flexibility for EBM training. Conclusions. Surgical residents identified a general lack of education, time constraints, lack of priority, and staff disapproval as important factors limiting incorporation of EBM. Curriculum reform and surgeon education may help overcome these barriers.