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Evaniew N, Khan M, Drew B, Peterson D, Bhandari M, Ghert M. Intrawound vancomycin to prevent infections after spine surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:533-42. [DOI: 10.1007/s00586-014-3357-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 04/27/2014] [Accepted: 04/27/2014] [Indexed: 10/25/2022]
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Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1903-17. [PMID: 24760463 DOI: 10.1007/s00586-014-3284-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 12/22/2013] [Accepted: 03/22/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS. METHODS A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings. RESULTS 744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27%, uncertain in 41% and inappropriate in 31%. Frank panel disagreement was low (7% scenarios). Face validity was shown by the logical relationship between each variable's subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely (p < 0.0001) to be components of scenarios rated "appropriate" were: severe disability, no yellow flags, and severe neurological deficit. CONCLUSION This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated "appropriately" have better clinical outcomes.
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HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER): a multicenter comparative observational study. BMC Musculoskelet Disord 2014; 15:39. [PMID: 24517194 PMCID: PMC3922994 DOI: 10.1186/1471-2474-15-39] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/06/2014] [Indexed: 02/08/2023] Open
Abstract
Background Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery. Methods/design The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective. Discussion Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture. Trial registration The trial is registered at the Netherlands Trial Register (NTR3617).
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Evaniew N, Nuttall J, Farrokhyar F, Bhandari M, Ghert M. What are the levels of evidence on which we base decisions for surgical management of lower extremity bone tumors? Clin Orthop Relat Res 2014; 472:8-15. [PMID: 24081669 PMCID: PMC3889455 DOI: 10.1007/s11999-013-3311-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 09/19/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Benign and malignant lower extremity primary bone tumors are among the least common conditions treated by orthopaedic surgeons. The literature supporting their surgical management has historically been in the form of observational studies rather than prospective controlled studies. Observational studies are prone to confounding bias, sampling bias, and recall bias. QUESTIONS/PURPOSES (1) What are the overall levels of evidence of articles published on the surgical management of lower extremity bone tumors? (2) What is the overall quality of reporting of studies in this field based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist? (3) What are the most common pitfalls in reporting that authors might improve on? METHODS All studies describing the surgical management of lower extremity primary bone tumors from 2002 to 2012 were systematically reviewed. Two authors independently appraised levels of evidence. Quality of reporting was assessed with the STROBE checklist. Pitfalls in reporting were quantified by determining the 10 most underreported elements of research study design in the group of studies analyzed, again using the STROBE checklist as the reference standard. Of 1387 studies identified, 607 met eligibility criteria. RESULTS There were no Level I studies, two Level II studies, 47 Level III studies, 308 Level IV studies, and 250 Level V studies. The mean percentage of STROBE points reported satisfactorily in each article as graded by the two reviewers was 53% (95% confidence interval, 42%-63%). The most common pitfalls in reporting were failures to justify sample size (2.2% reported), examine sensitivity (2.2%), account for missing data (9.8%), and discuss sources of bias (14%). Followup (66%), precision of outcomes (64%), eligibility criteria (55%), and methodological limitations (53%) were variably reported. CONCLUSIONS Observational studies are the dominant evidence for the surgical management of primary lower extremity bone tumors. Numerous deficiencies in reporting limit their clinical use. Authors may use these results to inform future work and improve reporting in observational studies, and treating surgeons should be aware of these limitations when choosing among the various options with their patients.
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Affiliation(s)
- Nathan Evaniew
- />Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7 Canada
| | - James Nuttall
- />Division of Orthopaedics, Department of Surgery, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3 Canada
| | - Forough Farrokhyar
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, 39 Charlton Ave.East, Hamilton, ON L8N 1Y3 Canada
| | - Mohit Bhandari
- />Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7 Canada
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7 Canada
| | - Michelle Ghert
- />Division of Orthopaedics, Department of Surgery, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3 Canada
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Peinemann F, Tushabe DA, Kleijnen J. Using multiple types of studies in systematic reviews of health care interventions--a systematic review. PLoS One 2013; 8:e85035. [PMID: 24416098 PMCID: PMC3887134 DOI: 10.1371/journal.pone.0085035] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 11/23/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A systematic review may evaluate different aspects of a health care intervention. To accommodate the evaluation of various research questions, the inclusion of more than one study design may be necessary. One aim of this study is to find and describe articles on methodological issues concerning the incorporation of multiple types of study designs in systematic reviews on health care interventions. Another aim is to evaluate methods studies that have assessed whether reported effects differ by study types. METHODS AND FINDINGS We searched PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Methodology Register on 31 March 2012 and identified 42 articles that reported on the integration of single or multiple study designs in systematic reviews. We summarized the contents of the articles qualitatively and assessed theoretical and empirical evidence. We found that many examples of reviews incorporating multiple types of studies exist and that every study design can serve a specific purpose. The clinical questions of a systematic review determine the types of design that are necessary or sufficient to provide the best possible answers. In a second independent search, we identified 49 studies, 31 systematic reviews and 18 trials that compared the effect sizes between randomized and nonrandomized controlled trials, which were statistically different in 35%, and not different in 53%. Twelve percent of studies reported both, different and non-different effect sizes. CONCLUSIONS Different study designs addressing the same question yielded varying results, with differences in about half of all examples. The risk of presenting uncertain results without knowing for sure the direction and magnitude of the effect holds true for both nonrandomized and randomized controlled trials. The integration of multiple study designs in systematic reviews is required if patients should be informed on the many facets of patient relevant issues of health care interventions.
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Affiliation(s)
- Frank Peinemann
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Children's Hospital, University of Cologne, Cologne, Germany
- * E-mail:
| | - Doreen Allen Tushabe
- University of Birmingham, Department of Public Health, Epidemiology & Biostatistics, Birmingham, United Kingdom
| | - Jos Kleijnen
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Kleijnen Systematic Reviews Ltd, York, United Kingdom
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Tepass A, Rolauffs B, Weise K, Bahrs SD, Dietz K, Bahrs C. Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009. Patient Saf Surg 2013; 7:34. [PMID: 24268107 PMCID: PMC4176190 DOI: 10.1186/1754-9493-7-34] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 11/05/2013] [Indexed: 12/16/2022] Open
Abstract
Background The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns. Methods The databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test. Results Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)]. The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores. Discussion Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.
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Affiliation(s)
- Alexander Tepass
- Department of Radiology, Eberhard-Karls University, Tübingen, Germany.
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Abstract
Comparative effectiveness research evaluates treatments as actually delivered in routine clinical practice, shifting research focus from efficacy and internal validity to effectiveness and external validity ("generalizability"). Such research requires accurate assessments of the numbers of patients treated and the completeness of their followup, their clinical outcomes, and the setting in which their care was delivered. Choosing measures and methods for clinical outcome research to produce meaningful information that may be used to improve patient care presents a number of challenges. WHERE ARE WE NOW?: Orthopaedic surgery research has many stakeholders, including patients, providers, payers, and policy makers. A major challenge in orthopaedic surgery outcome measurement and clinical research is providing all of these users with valid information for their respective decision making. At present, no plan exists for capturing data on such a broad scale and scope. WHERE DO WE NEED TO GO?: Practical challenges include identifying and obtaining resources for widespread data collection and merging multiple data sources. Challenges of study design include sampling to obtain representative data, timing of data collection in the episode of care, and minimizing missing data and study dropout. HOW DO WE GET THERE?: Resource limitations may be addressed by repurposing existing clinical resources and capitalizing on technologic advances to increase efficiencies. Increasing use of rigorous, well-designed observational research designs can provide information that may be unattainable in clinical trials. Such study designs should incorporate methods to minimize missing data, to sample multiple providers, facilities, and patients, and to include evaluation of potential confounding variables to minimize bias and allow generalization to broad populations.
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Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement to assess reporting of observational trials in hand surgery. J Hand Surg Am 2013; 38:1584-9.e2. [PMID: 23845586 PMCID: PMC3989883 DOI: 10.1016/j.jhsa.2013.05.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 05/07/2013] [Accepted: 05/07/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To use the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist to critically evaluate the change in quality of observational trial reporting in the Journal of Hand Surgery American between 2005 and 2011. METHODS A cross-sectional analysis of observational studies published in the Journal of Hand Surgery American was designed to sample 2 6-month periods of publication (March 2005 to August 2005 and June 2011 to November 2011). Fifty-one items were extracted from the STROBE statement for evaluation. Overall STROBE compliance rates for articles and specific checklist items were determined. Final compliance percentages from each period were compared by Student t-testing. Changes in item compliance over time were quantified. RESULTS Overall compliance with the STROBE statement was 38% (range, 10%-54%) in 2005 and 58% (range, 39%-85%) for 2011 manuscripts representing a significant improvement. Seventy-five percent or greater of articles (2005/2011) provided the explicit reporting of background (100%/97%), follow-up time (85%/94%), overall interpretation of data (100%/94%), and results of similar studies (95%/89%). Twenty-five percent or less of articles provided the study design in the abstract (10%/20%), a clear description of the study's setting (10%/23%), the handling of missing data (0%/6%), the potential directions of bias (5%/11%), and the use of a power analysis (0%/17%). Eighty-six percent (44/51) of items were more frequently satisfied in 2011 articles than in 2005 publications. Absolute increases in compliance rates of 40% or greater were noted in 10 items (20%) with no worsening in compliance for an individual item over 6%. CONCLUSIONS The overall quality of the reporting of observational trials in the Journal of Hand Surgery American improved from 2005 to 2011. Current observational trials in hand surgery could still benefit from increased reporting of methodological details including the use of power analyses, the handling of missing data, and consideration of potential bias. LEVEL OF EVIDENCE Diagnostic III.
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Matre K, Havelin LI, Gjertsen JE, Espehaug B, Fevang JM. Intramedullary nails result in more reoperations than sliding hip screws in two-part intertrochanteric fractures. Clin Orthop Relat Res 2013; 471:1379-86. [PMID: 23224796 PMCID: PMC3586046 DOI: 10.1007/s11999-012-2728-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 11/26/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sliding hip screws (SHSs) and intramedullary (IM) nails are well-documented implants for simple two-part intertrochanteric fractures; however, there is no consensus regarding which type of implant is better. QUESTIONS/PURPOSES We asked whether patients with simple two-part intertrochanteric fractures treated with IM nailing had (1) a lower reoperation rate and (2) less pain and better quality of life than patients treated with SHSs. METHODS We used data from the Norwegian Hip Fracture Register on 7643 operations for simple two-part intertrochanteric fractures (AO/OTA Type A1) treated with an SHS (n=6355) or an IM nail (n=1288) between 2005 and 2010. Kaplan-Meier analysis was used to assess reoperation percentages and a Cox regression model was used to assess the risk of reoperation. Questionnaires regarding pain and quality of life were answered by the patients at 4, 12, and 36 months postoperatively. RESULTS We found an increased risk of reoperation after IM nailing within 1 postoperative year: 2.4% and 4.2% for SHS and IM nails, respectively. The difference persisted with time: 4.5% and 7.1% at 3 years. We also found minor differences for pain and quality of life which we judged clinically unimportant. CONCLUSIONS Based on our findings and a critical review of the literature, we suggest an SHS is likely the preferred implant for simple two-part intertrochanteric fractures. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kjell Matre
- Department of Orthopaedic Surgery, Haukeland University Hospital, and Department of Surgical Sciences, University of Bergen, Jonas Lies Vei 65, 5021, Bergen, Norway.
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Affiliation(s)
- Per-Henrik Randsborg
- Department of Orthopaedic Surgery, Akershus University Hospital, NO-1478 Lørenskog, Norway.
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Sponsorship and design characteristics of trials registered in ClinicalTrials.gov. Contemp Clin Trials 2013; 34:348-55. [DOI: 10.1016/j.cct.2013.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 01/14/2013] [Accepted: 01/17/2013] [Indexed: 11/23/2022]
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de Moraes VY, Godin K, Tamaoki MJS, Faloppa F, Bhandari M, Belloti JC. Workers' compensation status: does it affect orthopaedic surgery outcomes? A meta-analysis. PLoS One 2012; 7:e50251. [PMID: 23227160 PMCID: PMC3515555 DOI: 10.1371/journal.pone.0050251] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/17/2012] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Previous reviews have demonstrated that patient outcomes following orthopaedic surgery are strongly influenced by the presence of Workers' Compensation. However, the variability in the reviews' methodology may have inflated the estimated strength of this association. The main objective of this meta-analysis is to evaluate the influence of Workers' Compensation on the outcomes of orthopaedic surgical procedures. METHODS We conducted a systematic search of the literature published in this area from 1992-2012, with no language restrictions. The following databases were used MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and Pubmed. We also hand-searched the reference sections of all selected papers. We included all prospective studies evaluating the effect of compensation status on outcomes in adult patients who had undergone surgery due to orthopaedic conditions or diseases. Outcomes of interest included disease specific, region specific and/or overall quality of life scales/questionnaires and surgeons' personal judgment of the results. We used an assessment tool to appraise the quality of all included studies. We used Review Manager to create forest plots to summarize study data and funnel plots for the assessment of publication bias. RESULTS Twenty studies met our eligibility criteria. The overall risk ratio for experiencing an unsatisfactory result after orthopaedic surgery for patients with compensation compared to non-compensated patients is 2.08 (95% CI 1.54-2.82). A similar association was shown for continuous data extracted from the studies using assessment scales or questionnaires (Standard Mean Difference = -0.70 95% CI -0.97- -0.43). CONCLUSIONS Among patients who undergo orthopaedic surgical procedures, those receiving Workers' Compensation experience a two-fold greater risk of a negative outcome. Our findings show a considerably lower estimate of risk compared to previous reviews that include retrospective data. Further research is warranted to determine the etiological explanation for the influence of compensation status on patient outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42012002121.
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Affiliation(s)
- Vinícius Ynoe de Moraes
- Division of Hand and Upper Limb Surgery, Department of Orthopaedics and Trauma, Universidade Federal de São Paulo, São Paulo, Brazil.
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Abstract
Anterior cruciate ligament (ACL) injuries in skeletally immature individuals remain a challenge for the child, the parents, orthopaedic surgeons, and physical therapists. The main challenges are the potential risk of recurrent instability, secondary injuries following nonoperative treatment, and the risks involved with surgical treatment due to the vulnerability of the epiphyseal growth plates. We first present the physiological background for considerations that must be made when advising on treatment alternatives for skeletally immature individuals after ACL injury. The implications of continuous musculoskeletal development for treatment decisions are emphasized. No randomized controlled trials have been performed to investigate outcomes of different treatment algorithms. There is no consensus in the literature on clinical treatment decision criteria for whether a skeletally immature child should undergo transphyseal ACL reconstruction, physeal sparing ACL reconstruction, or nonoperative treatment. Additionally, well-described rehabilitation programs designed for either nonoperative treatment or postoperative rehabilitation have not been published. Based on the currently available evidence, we propose a treatment algorithm for the management of ACL injuries in skeletally immature individuals. Finally, we suggest directions for future prospective studies, which should include development of valid and reliable outcome measures and specific rehabilitation programs.
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Ligthelm RJ. Insulin analogues: how observational studies provide key insights into management of patients with type 2 diabetes mellitus. Curr Med Res Opin 2011; 27:2343-55. [PMID: 22047003 DOI: 10.1185/03007995.2011.630998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this commentary was to evaluate the current evidence regarding the use of synthetic insulin analogues in the 'real-world' clinic setting for the treatment of type 2 diabetes mellitus (T2DM). METHODS Relevant publications were searched on PubMed MEDLINE, EMBASE, Cochrane Register of Controlled Trials Google Scholar, NLM Gateway, Science Direct, Web of Science and OVID for the period of January 2007 to June 2010. Articles were included if they (a) provided specific study results on the use of insulin analogues in T2DM and (b) gave sufficiently clear methodology details to establish treatment strategies, diagnosis and diagnostic criteria using an observational study (OS) design. RESULTS Twenty one articles specifically addressing both type 2 diabetes management and the use of synthetic insulin analogues were identified. Results from recently published OS in patients with T2DM have shown, in the patient populations tested, the effective initiation, optimization and switch to use of insulin analogues in routine clinical settings (day-to-day common practice), with a good safety profile. CONCLUSIONS OS can provide clinicians with additional insights into the management of T2DM patients in their practices. However, the selection and initiation of insulin analogue regimens should be tailored to the individual patient and be one that the physician is comfortable using.
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Vaidya R. Observational therapeutics: Scope, challenges, and organization. J Ayurveda Integr Med 2011; 2:165-9. [PMID: 22253504 PMCID: PMC3255445 DOI: 10.4103/0975-9476.90764] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 11/15/2011] [Accepted: 11/22/2011] [Indexed: 01/21/2023] Open
Abstract
The importance of Observational Therapeutics in the progress of medicine has been neglected in the current era of the hierarchal position imparted to Randomized Controlled Trials (RCTs) for new drug discovery and practice of evidence-based medicine. There is a need to reflect on the reason for many new drugs being withdrawn during post marketing surveillance. There are several examples in literature where drug-discovery has originated initially from keen clinical and / or laboratory observations. The roots of these discoveries have often been from observations made by practitioners of traditional medicine including Ayurveda. The present article draws attention to the scope and challenges for observational therapeutics. There is an urgent need for the meticulous planning for a systematic organization of developing observational therapeutics, with a full understanding of its strengths and limitations.
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Affiliation(s)
- Rama Vaidya
- ICMR Advanced Centre for Reverse Pharmacology in Traditional Medicine, Medical Research Centre – Kasturba Health Society, Mumbai, India
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Braga LH, Pemberton J, DeMaria J, Lorenzo AJ. Methodological Concerns and Quality Appraisal of Contemporary Systematic Reviews and Meta-Analyses in Pediatric Urology. J Urol 2011; 186:266-71. [DOI: 10.1016/j.juro.2011.03.044] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Indexed: 01/08/2023]
Affiliation(s)
- Luis H. Braga
- Department of Surgery (Urology), McMaster Children's Hospital and McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julia Pemberton
- Department of Surgery (Urology), McMaster Children's Hospital and McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jorge DeMaria
- Department of Surgery (Urology), McMaster Children's Hospital and McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Armando J. Lorenzo
- Department of Surgery (Urology), McMaster Children's Hospital and McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton and Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Butler M, Forte ML, Joglekar SB, Swiontkowski MF, Kane RL. Evidence summary: systematic review of surgical treatments for geriatric hip fractures. J Bone Joint Surg Am 2011; 93:1104-15. [PMID: 21776547 DOI: 10.2106/jbjs.j.00296] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is a growing body of literature on surgical treatments for elderly patients with a hip fracture and the effects of various surgical procedures on complications and postoperative outcomes. No single review has previously summarized the literature on the effects of surgical procedures on outcomes after treatment across all types of hip fractures. We conducted a comprehensive systematic literature review to organize the clinical evidence for patient-centered outcomes across all types of geriatric hip fractures. METHODS We searched MEDLINE, the Cochrane Database of Systematic Reviews, Scirus, and ClinicalTrials.gov for randomized clinical trials and observational studies published between 1985 and 2008. We also manually searched reference lists from relevant systematic reviews. RESULTS We found eighty-four [corrected] articles representing seventy-four [corrected] unique, randomized, controlled trials, including thirty-three [corrected] on femoral neck fractures, forty on intertrochanteric fractures, and one on subtrochanteric fractures. Nine observational studies addressed the link between patient characteristics and outcome variables by fracture type. Age, sex, prefracture functioning, and cognitive impairment are related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Mortality, pain, function, and quality of life did not differ by surgical implant class, or by implants within a class. Neither the randomized controlled trials nor the observational literature include the full complement of potential covariates that can impact treatment outcomes after treatment. CONCLUSIONS The broader questions about the relationship of patient factors, fracture type, and specific treatments to the outcomes of mortality, functional status, and quality of life cannot be addressed with the existing literature. Research should include comprehensive conceptual models that capture complete sets of important independent variables. Studies of musculoskeletal outcomes, including hip fracture, require well-defined patient groups and consistent use of validated outcome measures.
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Affiliation(s)
- Mary Butler
- Minnesota Evidence-based Practice Center, School of Public Health, University of Minnesota, 420 Delaware Street S.E., Minneapolis, MN 55455, USA
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Mithoefer K, Saris DB, Farr J, Kon E, Zaslav K, Cole BJ, Ranstam J, Yao J, Shive M, Levine D, Dalemans W, Brittberg M. Guidelines for the Design and Conduct of Clinical Studies in Knee Articular Cartilage Repair: International Cartilage Repair Society Recommendations Based on Current Scientific Evidence and Standards of Clinical Care. Cartilage 2011; 2:100-21. [PMID: 26069574 PMCID: PMC4300780 DOI: 10.1177/1947603510392913] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To summarize current clinical research practice and develop methodological standards for objective scientific evaluation of knee cartilage repair procedures and products. DESIGN A comprehensive literature review was performed of high-level original studies providing information relevant for the design of clinical studies on articular cartilage repair in the knee. Analysis of cartilage repair publications and synopses of ongoing trials were used to identify important criteria for the design, reporting, and interpretation of studies in this field. RESULTS Current literature reflects the methodological limitations of the scientific evidence available for articular cartilage repair. However, clinical trial databases of ongoing trials document a trend suggesting improved study designs and clinical evaluation methodology. Based on the current scientific information and standards of clinical care, detailed methodological recommendations were developed for the statistical study design, patient recruitment, control group considerations, study endpoint definition, documentation of results, use of validated patient-reported outcome instruments, and inclusion and exclusion criteria for the design and conduct of scientifically sound cartilage repair study protocols. A consensus statement among the International Cartilage Repair Society (ICRS) and contributing authors experienced in clinical trial design and implementation was achieved. CONCLUSIONS High-quality clinical research methodology is critical for the optimal evaluation of current and new cartilage repair technologies. In addition to generally applicable principles for orthopedic study design, specific criteria and considerations apply to cartilage repair studies. Systematic application of these criteria and considerations can facilitate study designs that are scientifically rigorous, ethical, practical, and appropriate for the question(s) being addressed in any given cartilage repair research project.
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Affiliation(s)
- Kai Mithoefer
- Harvard Vanguard Medical Associates, Harvard Medical School, Boston, MA, USA,Kai Mithoefer, Harvard Vanguard Medical Associates, 291 Independence Drive, Chestnut Hill, MA 02467
| | | | - Jack Farr
- OrthoIndy Knee Care Institute, Indianapolis, IN, USA
| | | | | | | | | | - Jian Yao
- Zimmer Orthobiologics, Austin, TX, USA
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69
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Affiliation(s)
- Chin-wern Chan
- Wasser Pain Management Center, Mount Sinai Hospital, Toronto, Ontario, Canada
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Corten K, Bourne RB, Charron KD, Au K, Rorabeck CH. What works best, a cemented or cementless primary total hip arthroplasty?: minimum 17-year followup of a randomized controlled trial. Clin Orthop Relat Res 2011; 469:209-17. [PMID: 20625950 PMCID: PMC3008892 DOI: 10.1007/s11999-010-1459-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 06/23/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Total hip arthroplasty (THA) has been associated with high survival rates, but debate remains concerning the best fixation mode of THA. QUESTIONS/PURPOSES We conducted a randomized controlled trial (RCT) with 250 patients with a mean age of 64 years between October 1987 and January 1992 to compare the results of cementless and cemented fixation. PATIENTS AND METHODS Patients were evaluated for revision of either of the components. One hundred twenty-seven patients had died (51%) and 12 (4.8%) were lost to followup. The minimum 17-year followup data (mean, 20 years; range, 17-21 years) for 52 patients of the cementless group and 41 patients of the cemented group were available for evaluation. RESULTS Kaplan-Meier survivorship analysis at 20 years revealed lower survival rates of cemented compared with cementless THA. The cementless tapered stem was associated with a survivorship of 99%. Age younger than 65 years and male gender were predictors of revision surgery. CONCLUSIONS The efficacy of future RCTs can be enhanced by randomizing patients in specific patient cohorts stratified to age and gender in multicenter RCTs. Including only younger patients might improve the efficacy of a future RCT with smaller sample sizes being required. A minimum 10-year followup should be anticipated, but this can be expected to be longer if the difference in level of quality between the compared implants is smaller. LEVEL OF EVIDENCE Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kristoff Corten
- London Health Sciences Centre, University Campus, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Robert B. Bourne
- London Health Sciences Centre, University Campus, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Kory D. Charron
- London Health Sciences Centre, University Campus, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Keegan Au
- London Health Sciences Centre, University Campus, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Cecil H. Rorabeck
- London Health Sciences Centre, University Campus, 339 Windermere Road, London, ON N6A 5A5 Canada
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Donahue A. Google Wave: Have CTSA-Minded Institutions Caught It? EVIDENCE BASED LIBRARY AND INFORMATION PRACTICE 2010; 5:70-82. [PMID: 21461135 PMCID: PMC3068201 DOI: 10.18438/b8fw48] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Google Wave was touted as the next big communication tool-combining e-mail, social networking, and chat within a single "wave"-with the potential to create a new world for collaboration. Information professionals who are knowledgeable of this tool and its capabilities could become uniquely situated to use it, evaluate it, and teach it. This seemed especially true for those working within Clinical and Translational Science Award (CTSA)-minded institutions, given the promise of interdisciplinary collaboration between investigators and the potential for creating new authorship models. This case study on Google Wave users who are affiliated with CTSA-minded institutions, was designed for and presented at the Evidence-Based Scholarly Communication Conference held by the University of New Mexico Health Sciences Library and Information Center. It provides an early evidence based evaluation of Google Wave's potential. METHODS: Two "waves" were created. The first consisted of five survey questions designed to collect demographic data on the respondents' roles, a general impression of Wave, the specific tools within Wave that might be useful, and potential collaborators with whom the respondents might use Wave. The second wave was a private, guided discussion on Wave's collaboration potential. Individuals from CTSA-minded institutions were invited to participate with messages on Twitter, forums, blogs, and electronic mail lists, although there were difficulties reaching out to these institutions as a group. RESULTS: By the conclusion of the study, only a small number of people (n=11, with a viable n=9) had responded to the survey. Given this small result set, it made sense to group the responses by the respondents' roles (CTSA staff and researchers, support staff, medical librarian, or general public) and to treat them as individual cases. Most of the respondents were librarians and support staff who felt that Wave might have potential for collaboration; there were no CTSA researcher respondents. For the second part of the study, the discussion wave, only one participant explicitly expressed interest in joining. All were invited to join, but there was no participation in the discussion wave at the conclusion of the study. CONCLUSIONS: The results of this study implied that Google Wave was not on the forefront of CTSA-minded institutions' communication strategies. However, it was being used, and it did demonstrate new collaboration and authorship capabilities. Being generally aware of these capabilities may be useful to information professionals who seek to be current and informed regarding developing technology and to those interested in scholarly communication practices. In addition, the difficulties encountered during this case study in attempting to reach out to CTSA-minded institutions raised the question of how members currently communicate with each other as institutions and as individuals. There was a lesson learned in the usefulness of doing case-study research to evaluate new technologies; the cost in terms of time was relatively low, and knowledge about the technology itself was gained while establishing a base level of evidence to potentially build on in the future.
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Affiliation(s)
- Amy Donahue
- Special Projects Librarian University of Minnesota Bio-Medical Library St. Paul, Minnesota, United States of America
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Hendrick P, Milosavljevic S, Hale L, Hurley DA, McDonough S, Ryan B, Baxter GD. The relationship between physical activity and low back pain outcomes: a systematic review of observational studies. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 20:464-74. [PMID: 21053026 DOI: 10.1007/s00586-010-1616-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 10/01/2010] [Accepted: 10/20/2010] [Indexed: 10/18/2022]
Abstract
Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase, Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP.
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Affiliation(s)
- Paul Hendrick
- Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand.
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Abstract
BACKGROUND Improved patient care is related to validated outcome measures requiring the collection of three distinct data types: (1) demographics; (2) patient outcome measures; and (3) physician treatment. Previous impediments to widespread data collection have been: cost, office disruption, personnel requirements, physician motivation, data integration, and security. There are currently few means to collect data to be used for collaborative analysis. QUESTIONS/PURPOSES We therefore developed an inexpensive, patient-centric mechanism to reduce redundant data entry, limiting cost and personnel requirements. METHODS Using an intuitive touch-screen kiosk interface program, all data elements have been captured in a private practice setting since 2000. Developed for small to medium sized offices, this is scalable to larger organizations. Questionnaire navigation is patient driven, with demographics shared with EMR and billing systems. Integration of billing and EMR with outcomes minimizes cost and personnel time. Data are deidentified locally and may be centrally shared. Since data are entered by the patients, minimal personnel costs are incurred. Physician disincentives are minimized with cost reduction, time savings and ease of use. RESULTS To date, we have collected high level data on most total joint patients, with excellent patient compliance. CONCLUSIONS By addressing impediments to broad application, we may enable widespread local data collection in all practice settings. Data may be shared centrally, allowing comparative effectiveness research to become a reality. Future success will require broad physician participation, uniformity of data collected, and designation of a central site for receipt of data and its collaborative comparative analysis.
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Hendrick P, Te Wake AM, Tikkisetty AS, Wulff L, Yap C, Milosavljevic S. The effectiveness of walking as an intervention for low back pain: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1613-20. [PMID: 20414688 DOI: 10.1007/s00586-010-1412-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 03/08/2010] [Accepted: 04/11/2010] [Indexed: 11/29/2022]
Abstract
As current low back pain (LBP) guidelines do not specifically advocate walking as an intervention, this review has explored for the effectiveness of walking in managing acute and chronic LBP. CINAHL, Medline, AMED, EMBASE, PubMed, Cochrane and Scopus databases, as well as a hand search of reference lists of retrieved articles, were searched. The search was restricted to studies in the English language. Studies were included when walking was identified as an intervention. Four studies met inclusion criteria, and were assessed with a quality checklist. Three lower ranked studies reported a reduction in LBP from a walking intervention, while the highest ranked study observed no effect. Heterogeneity of study design made it difficult to draw comparisons between studies. There is only low-moderate evidence for walking as an effective intervention strategy for LBP. Further investigation is required to investigate the strength of effect for walking as a primary intervention in the management of acute and chronic LBP.
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Affiliation(s)
- P Hendrick
- Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand
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Bluhm R. The epistemology and ethics of chronic disease research: further lessons from ECMO. THEORETICAL MEDICINE AND BIOETHICS 2010; 31:107-122. [PMID: 20333473 DOI: 10.1007/s11017-010-9139-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Robert Truog describes the controversial randomized controlled trials (RCTs) of extracorporeal membrane oxygenation (ECMO) therapy in newborns. Because early results with ECMO indicated that it might be a great advance, saving many lives, Truog argues that ECMO should not have been tested using RCTs, but that a long-term, large-scale observational study of actual clinical practice should have been conducted instead. Central to Truog's argument, however, is the idea that ECMO is an unusual case. Thus, it is an open question whether Truog's conclusions can be extended to other areas of medical research. In this paper, I look at epistemological and ethical issues arising in the care of patients with chronic diseases, using ECMO as a starting point. Both the similarities and the dissimilarities of these two cases highlight important issues in biomedical research and support a conclusion similar to Truog's. Observational studies of clinical practice provide the best evidence to inform the treatment of patients with chronic disease.
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Affiliation(s)
- Robyn Bluhm
- Department of Philosophy and Religious Studies, Old Dominion University, Norfolk, VA 23529, USA.
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The changing face of quality in spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18 Suppl 3:277-8. [PMID: 19582486 DOI: 10.1007/s00586-009-1090-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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A comparison of outcomes of cervical disc arthroplasty and fusion in everyday clinical practice: surgical and methodological aspects. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 19:297-306. [PMID: 19882177 DOI: 10.1007/s00586-009-1194-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 08/27/2009] [Accepted: 10/12/2009] [Indexed: 10/20/2022]
Abstract
Randomised controlled trials (RCTs) of cervical disc arthroplasty vs fusion generally show slightly more favourable results for arthroplasty. However, RCTs in surgery often have limited external validity, since they involve a select group of patients who fit very rigid admission criteria and who are prepared to subject themselves to randomisation. The aim of this study was to examine whether the findings of RCTs are verified by observational data recorded in our Spine Center in association with the Spine Society of Europe Spine Tango surgical registry. Patients undergoing fusion/stabilisation or disc arthroplasty for degenerative cervical spinal disease were selected for inclusion. They completed a questionnaire pre-operatively and at 12 and 24 months follow-up (FU). The questionnaire comprised the multidimensional Core Outcome Measures Index (COMI; 0-10 scale) and, at FU, questions on global outcome and satisfaction with treatment (5-point scales, dichotomised to "good" and "poor"), re-operation and patient-rated complications. The surgeon completed a Spine Tango Surgery form. The outcome data from 266 (208 fusion, 58 arthroplasty) out of 284 eligible patients who had reached 12 months FU, and 169 (139 fusion, 30 arthroplasty) out of 178 who had reached 24 months FU, were included. Patients with cervical disc arthroplasty were younger [46 (SD 8) years vs 56 (SD 11) years for fusion; P < 0.05], had less comorbidity (P < 0.05), more often had only mono-segmental pathology (69% arthroplasty, 47% fusion) and only one type of degenerative pathology (69% arthroplasty, 46% fusion). Surgical complication rates were similar in each group (arthroplasty, 1.5%; fusion, 2.6%). The reduction in the COMI score was significantly greater in the arthroplasty group (at 12 months, 4.8 (SD 3.0) vs 3.7 (SD 2.9) points for fusion, and at 24 months 5.1 (SD 2.8) vs 3.8 (SD 2.9) points; each P < 0.05). In the arthroplasty group, a "good" global outcome was recorded in 90% patients (at 12 months) and 93% (at 24 months); in the fusion group the figures were 80 and 82%, respectively (group differences at each timepoint, P > 0.09). Satisfaction with treatment was similar in both groups (89-93%), at each timepoint. In multiple regression analysis, treatment group was of borderline significance as a unique predictor of the change in COMI at FU (P = 0.059 at 12 months, P = 0.055 at 24 months) in a model in which known confounders (age, comorbidity, number of affected levels) were controlled for. Being in the arthroplasty group was associated with an approximately 1-point greater reduction in the COMI score at FU. The results of this observational study appear to support those of the RCTs and suggest that, in patients with degenerative pathology of the cervical spine, disc arthroplasty is associated with a slightly better outcome than fusion. However, given the small size of the difference, its clinical relevance is questionable, especially in view of the a priori more favourable outcome expected in the arthroplasty group due to the more rigorous selection of patients.
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