Selection bias results in misinterpretation of randomized controlled trials on arthroscopic treatment of patients with knee osteoarthritis

Low reproducibility of randomized clinical trials methodology related to sampling: a systematic methodological review

Objectives: The reporting of sampling methods in Randomized Clinical Trials (RCTs) allows for research quality assessment, determination of sampling bias, and assures the presence of details necessary for reproducibility in future trials. The purpose of this study was to: (1) determine if sampling methodology was reproducible in RCTs related to musculoskeletal physical therapy (MSKPT) interventions to treat non-specific low back pain (NSLBP) and (2) establish if there was a relationship between sample reproducibility and established measures of research quality.Methods: Data were collected through a systematic review by a professional librarian. The identified RCTs were assessed for methodological quality by two blinded individual reviewers. Data analysis was performed by a third, blinded researcher; additional comparisons were made based on Journal Impact Factor and PEDro score.Results: Ninety-nine published peer-reviewed RCTs were identified that met inclusion criteria. Only 29% of the articles were judged to be reproducible based on the reported sampling methodology. There were meaningful correlations between two out of ten of the sampling reporting criteria and the judgement made if the sample was reported in significant detail to allow for replication. There was no relationship between sampling reporting criteria, Journal Impact Factors (JIFs), and Physiotherapy Evidence Database (PEDro) scores.Discussion: The reporting of sampling methodology needs to be considered to ensure reproducibility and avoid sampling bias. Despite the proliferation of measures of research quality, the overall reporting quality of RCTs continues to be inadequate to allow widespread reproducibility of trials.Level of Evidence: 1a.

Editorial Commentary: Biomechanical Data Does Not Translate to Clinical Rerupture Rates After Shoulder Rotator Cuff Repair Using Different Suture Techniques

Biomechanical data does not translate to clinical re-rupture rates after shoulder rotator cuff repair using different suture techniques stratified by method of repair and tear size. Explanations include reporting and selection bias.

Evidence of no benefit from knee surgery for osteoarthritis led to coverage changes and is linked to decline in procedures

Patients and physicians may be reluctant to abandon widely used treatments that have been found to be ineffective. In 2002 and 2008 the New England Journal of Medicine published the results of clinical trials showing that arthroscopic debridement and lavage--surgical treatments to remove damaged tissue and debris--do not benefit patients with osteoarthritis of the knee. To determine whether the trials' publication was associated with changes in practice patterns, we examined ambulatory surgery data from Florida and found that the number of debridement and lavage procedures per 100,000 adults declined 47 percent between 2001 and 2010. The reduction translates into national savings of $82-$138 million annually. These reductions may be offset by increases in the use of other procedures. The results indicate that clinical trials of widely used therapies can lead to cost-saving changes in practice patterns.

Finnish Degenerative Meniscal Lesion Study (FIDELITY): a protocol for a randomised, placebo surgery controlled trial on the efficacy of arthroscopic partial meniscectomy for patients with degenerative meniscus injury with a novel 'RCT within-a-cohort' study design

INTRODUCTION

Arthroscopic partial meniscectomy (APM) to treat degenerative meniscus injury is the most common orthopaedic procedure. However, valid evidence of the efficacy of APM is lacking. Controlling for the placebo effect of any medical intervention is important, but seems particularly pertinent for the assessment of APM, as the symptoms commonly attributed to a degenerative meniscal injury (medial joint line symptoms and perceived disability) are subjective and display considerable fluctuation, and accordingly difficult to gauge objectively.

METHODS AND ANALYSIS

A multicentre, parallel randomised, placebo surgery controlled trial is being carried out to assess the efficacy of APM for patients from 35 to 65 years of age with a degenerative meniscus injury. Patients with degenerative medial meniscus tear and medial joint line symptoms, without clinical or radiographic osteoarthritis of the index knee, were enrolled and then randomly assigned (1 : 1) to either APM or diagnostic arthroscopy (placebo surgery). Patients are followed up for 12 months. According to the prior power calculation, 140 patients were randomised. The two randomised patient groups will be compared at 12 months with intention-to-treat analysis. To safeguard against bias, patients, healthcare providers, data collectors, data analysts, outcome adjudicators and the researchers interpreting the findings will be blind to the patients' interventions (APM/placebo). Primary outcomes are Lysholm knee score (a generic knee instrument), knee pain (using a numerical rating scale), and WOMET score (a disease-specific, health-related quality of life index). The secondary outcome is 15D (a generic quality of life instrument). Further, in one of the five centres recruiting patients for the randomised controlled trial (RCT), all patients scheduled for knee arthroscopy due to a degenerative meniscus injury are prospectively followed up using the same protocol as in the RCT to provide an external validation cohort. In this article, we present and discuss our study design, focusing particularly on the internal and external validity of our trial and the ethics of carrying out a placebo surgery controlled trial.

ETHICS AND DISSEMINATION

The protocol has been approved by the institutional review board of the Pirkanmaa Hospital District and the trial has been duly registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT00549172.

Practice patterns for arthroscopy of osteoarthritis of the knee in the United States

BACKGROUND

Knee arthroscopy is one of the most common orthopaedic procedures performed in the United States. The publication of a randomized controlled trial of arthroscopy versus sham surgery by Moseley et al in 2002 showed no efficacy and challenged the role of arthroscopy for the treatment of osteoarthritis.

HYPOTHESIS

(1) Knee arthroscopy for osteoarthritis has decreased after the publication of the study by Moseley et al, (2) arthroscopy as a percentage of orthopaedic cases has decreased, and (3) the average age of patients undergoing arthroscopy has decreased.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The authors examined the American Board of Orthopaedic Surgery (ABOS) database that includes 6-month case logs for each examinee sitting for the Part II board examination for 1999 to 2009. Knee arthroscopy cases were identified by CPT (Current Procedural Terminology) code and knee osteoarthritis diagnosis was defined by ICD-9 (International Classification of Diseases, 9th Revision) code. Piecewise linear regression was used to evaluate knee arthroscopy before and after the publication of the Moseley et al article in 2002.

RESULTS

The number of knee arthroscopy cases for patients with osteoarthritis had greatly decreased by 2009 after peaking in 2001 (1621 vs 966 total cases, 2.36 vs 1.40 cases per surgeon). Cases classified as chondroplasty also decreased from 10.0% to 5.8% of knee arthroscopies (P < .0001). In addition, the total number of knee arthroscopy cases per surgeon decreased from a high of 11.9 in 2003 to a low of 8.6 in 2009. As expected, knee arthroscopy as a percentage of total orthopaedic cases decreased from a high of 9.9% in 2003 to 6.6% in 2009 (P < .0001).

CONCLUSION

Knee arthroscopy for patients with osteoarthritis among orthopaedic surgeons during their ABOS examination case collection period has decreased after the publication of a highly publicized article demonstrating a lack of efficacy of this procedure. Further study is needed to determine if this change occurred in the orthopaedic community at large or if practice patterns only changed for surgeons during their board collection periods.

CLINICAL RELEVANCE

Randomized controlled trials can be effective in changing orthopaedic surgeon practice.