Risk of bias of randomized controlled trials published in orthopaedic journals

Investigating the Effect of Addition of Cervical Proprioceptive Training to Conventional Physiotherapy on Visual, Vestibular and Proprioceptive Dependency of Postural Control in Patients with Chronic Non-Specific Neck Pain: A Randomized Controlled Clinical Trial

Objectives

While cervical proprioception deficit has been suggested as a contributing factor to clinical consequences of chronic non-specific neck pain (CNSNP), the effect of addressing such impairments on postural control strategies has remained unexplored. The aim of this study was to compare the response of the postural control system to alteration of sensory afferents in CNSNP with asymptomatic individuals. Furthermore, we examined whether proprioceptive training would yield superior outcomes to routine physiotherapy for improvement of postural control, pain and disability.

Methods

Center of pressure (CoP) variables of sixty CNSNP patients equally distributed in any of the proprioception-specific or conventional physiotherapy groups and 30 asymptomatic participants were evaluated under four standing conditions:1) normal, 2) foam, 3) cervical extension/eyes open and 4) cervical extension/eyes closed standing.

Results

CoP anteroposterior range and anteroposterior and mediolateral velocity in patients were significantly higher than the control group under condition 2 (P<0.05). Patients also demonstrated lower anteroposterior lyapunov exponent under conditions 2 and 4 (P<0.05). Both interventions significantly decreased anteroposterior range and anteroposterior velocity(P<0.05). Anteroposterior lyapunov exponent also increased under condition 2 (P<0.05).. After the interventions, CoP anteroposterior range and anteroposterior velocity were significantly lower in the proprioceptive exercise group than the conventional physiotherapy group (P<0.05). Anteroposterior lyapunov exponent was also significantly higher in the proprioceptive exercise group (P<0.05).This while there was no significant difference between these patients and control group participants in any of the CoP variables after intervention.

Conclusion

Our results rejected the hypothesis that impaired neck proprioception in the presence of CNSNP is compensated by overweighting other sources of sensory afferent information. The findings also revealed that while proprioceptive exercises successfully returned postural strategies of CNSNP patients to those in asymptomatic participants, they do not add to clinical recovery of these patients.

The Fragility of Statistical Significance in Sham Orthopaedic Surgery: A Systematic Review of Randomized Controlled Trials

OBJECTIVES

The purpose of this study was to determine the stability of statistical findings among sham surgery randomized controlled trials (RCTs) in orthopaedic surgery using fragility analysis.

METHODS

PubMed systematic review was conducted to include studies reporting dichotomous outcomes pertaining to sham surgery. The final review included eight RCTs involving only partial meniscectomies and vertebroplasties from 2009 to 2020. With a fixed sample size with dichotomous outcome measures (events versus non-events), the Total Fragility Index (TFI), which is composed of the fragility index (FI) and reverse fragility index (RFI), was calculated by altering the ratio of events to non-events in an iterative fashion until results were reversed from significant to nonsignificant findings (FI) or vice versa (RFI). The TFI, FI, and RFI were divided by their sample sizes to obtain the respective total fragility quotient, fragility quotient (FQ), and reverse fragility quotient. Median fragility indices and quotients were reported for all studies.

RESULTS

The eight RCTs included 50 dichotomous outcomes involving either partial meniscectomies or vertebroplasties, with a median TFI and total fragility quotient of 5 [interquartile range (IQR) 4 to 6] and 0.035 (IQR 0.028 to 0.048), respectively, indicating that a median of five total patients or 3.5 per 100 patients would need to experience a different outcome to reverse significant or insignificant findings for each of the eight trials. Among the 8 statistically significant ( P < 0.05) outcome events (16%), the respective FI and FQ were 2 (IQR 1 to 5) and 0.018 (IQR 0.010 to 0.044). Among the 42 statistically insignificant outcome events (84%), the respective RFI and reverse fragility quotient were 5 (IQR 4 to 6) and 0.04 (IQR 0.034 to 0.048). The median number of patients lost to follow-up was 1.5 (IQR 0.5 to 2).

CONCLUSION

The unstable findings in partial meniscectomy and vertebroplasty sham surgical RCTs undermine their study conclusions and recommendations. We recommend using fragility analysis in future sham surgical RCTs to contextualize statistical findings.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Assessment of 30 Years of Randomized Controlled Trials in The American Journal of Sports Medicine: 1990-2020

Background

Randomized controlled trials (RCTs) stand atop the evidence-based hierarchy of study designs for their ability to arrive at results with the lowest risk of bias. Even for RCTs, however, critical appraisal is essential before applying results to clinical practice.

Purpose

To analyze the quality of reporting of RCTs published in The American Journal of Sports Medicine (AJSM) from 1990 to 2020 and to identify trends over time and areas of improvement for future trials.

Study Design

Systematic review; Level of evidence, 1.

Methods

We queried the AJSM database for RCTs published between January 1990 and December 2020. Data pertaining to study characteristics were recorded. Quality assessments were conducted using the Detsky quality-of-reporting index and the modified Cochrane risk-of-bias (mROB) tool. Univariate and multivariable models were generated to establish factors with associations to study quality. The Fragility Index was calculated for eligible studies.

Results

A total of 277 RCTs were identified with a median sample size of 70 patients. A total of 19 RCTs were published between 1990 and 2000 (t₁); 82 RCTs between 2001 and 2010 (t₂); and 176 RCTs between 2011 and 2020 (t₃). From t₁ to t₃, significant increases were observed in the overall mean-transformed Detsky score (from 68.2% ± 9.8% to 87.4% ± 10.2%, respectively; P < .001) and mROB score (from 4.7 ± 1.6 to 6.9 ± 1.6, respectively; P < .001). Multivariable regression analysis revealed that trials with follow-up periods of <5 years clearly stated primary outcomes, and a focus on the elbow, shoulder, or knee were associated with higher mean-transformed Detsky and mROB scores. The median Fragility Index was 2 (interquartile range, 0-5) for trials with statistically significant. Studies with small sample sizes (<100 patients) were more likely to have low Fragility Index scores and less likely to have a statistically significant finding in any outcome.

Conclusion

The quantity and quality of published RCTs published in AJSM increased over the past 3 decades. However, single-center trials with small sample sizes were prone to fragile results.

Efficacy of nucleos(t)ide analogues(NAs) in preventing virus reactivation in oncology patients with HBV infection after chemotherapy or surgery: A network meta-analysis

Objective

In this study, we aimed to perform a network meta-analysis to compare the effectiveness of NAs in decreasing the reactivation of HBV, reducing chemotherapy disruption, and improving survival in oncology patients.

Methods

Relevant randomized controlled trials (RCT) evaluating the impact of NAs in HBV infected-related oncology patients were retrieved from electronic databases. The outcome indicators included reactivation rate, survival rate of 1 to 3 years after treatment, and chemotherapy disruption rate. The studies were evaluated for bias using the RCT risk of bias assessment tool recommended in the Cochrane Handbook. The risk ratio (RR) was used to compare the outcome indicators for the anti-viral treatment, and the surface under the cumulative ranking curves (SUCRA) was used to identify the optimal therapeutic regime.

Results

A total of 67 trials containing 5722 patients were included in this study. Regarding the reduction of reactivation rate, entecavir, lamivudine, adefovir alone were less effective than the combination of lamivudine and entecavir (94.9%), with RR values ranging from 3.16 to 3.73. However, based on SUCRA, the efficacy of telbivudine (80.3%) and the combination of lamivudine and adefovir dipivoxil (58.8%) were also acceptable. Entecavir (RR values ranging from 1.25 to 1.50) and lamivudine (RR values ranging from 1.27 to 1.35) can prolong the survival rate of patients at 1-3 years, and were better than adefovir dipivoxil in the comparison of 1-year survival rate. The RR values were 1.18 and 1.19, respectively. And entecavir 's ranking in SUCRA was more stable. Entecavir, lamivudine, and tenofovir all reduced chemotherapy interruption rates compared with no antiviral therapy, especially for tenofovir.

Conclusions

Current evidence shows that lamivudine combined with entecavir, telbivudine, and lamivudine combined with adefovir dipivoxil were the most effective in preventing virus reactivation in HBV infected-related cancer patients treated with chemotherapy. Entecavir had the most stable effect on survival, while tenofovir had the best impact on reducing the chemotherapy disruption rate. Due to limited quality and quantity of the included studies, more high-quality studies are required to verify the above conclusions.

Systematic review registration

PROSPEROI [https://www.crd.york.ac.uk/PROSPERO/index.php], identifier CRD4202250685.

Robust Randomized Controlled Data Is Lacking in Total Joint Arthroplasty

INTRODUCTION

 Randomized controlled trials (RCTs)are regarded as highest level of scientific evidence. There is belief that while prospective randomized control trials (PRCTs) are the gold standard for evaluating efficacy of interventions, there are very few conducted on lower extremity joint arthroplasty. However, there was a more than adequate amount (n=197) of published RCTs in knee arthroplasty during the 2021 calendar year. Therefore, we studied RCTs on knee arthroplasties for 2021 and assessed them for overall study topic reasons (i.e., devices as well as prostheses, rehabilitation, pain control, blood loss [tranexamic acid], and other), which were then subcategorized by: (1) country of origin; (2) sample size; and (3)whether or not they were follow-up studies. After this, we specifically focused on the studies (n=26) concerning devices or prostheses.

METHODS

 A search of PubMed on "knee arthroplasty" specifying "RCT" using their search function and dates between January 1, 2021 to December 24, 2021 resulted in the analyzed reports. A total of 17.3% reports analyzed rehabilitation methods while 28.4% studied pain control. A total of 20.3% examined blood loss topics and 20.8% investigated other topics.

RESULTS

 We found that 26 studies (13.2%) involved prosthetic design and implantation. Overall, only 15% knee arthroplasty RCTs were conducted in the United States, the mean total final sample size was 133±146 patients, and 7% were follow-up studies. None of the prostheses studies were performed in the United States, and the mean total final sample size of all of these studies was 86±54 patients, and 23% were follow-up studies. Total knee arthroplasty prospective RCTs were not performed in the United States.

CONCLUSION

 The authors believe that other study designs, such as database or registry analyses, are also appropriate in this rapidly advancing field of joint arthroplasty for the continuing evaluation and approval of new prostheses and techniques, while we await more PRCTs in our field.

Comparison of prognosis among patients with colorectal cancer liver metastases treated by surgical resection, radiofrequency ablation and HIFU: A protocol for network meta-analysis

BACKGROUND

Colorectal cancer is a malignant tumor second only to lung and breast cancer in the West. The liver is the main target organ for colorectal cancer metastasis, affecting the prognosis and survival. Surgical treatment has made great progress in colorectal cancer liver metastasis , including radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU) ablation.

OBJECT

Clinical treatments for colorectal cancer liver metastases are not the same. In order to clarify the impact of surgical resection, RFA and HIFU, we provided a decision-making basis for the clinical treatment of colon cancer liver metastasis through systematic reviews and network meta-analysis (NMA).

METHODS

We systematically searched the Chinese and English databases: PubMed, Embase, CENTRAL, CINAHL, Web of Science, CNKI, CBM, VIP, Wan Fang. Literature screening, data extraction, and quality evaluation were carried out by two researchers, and finally, use Stata to carry out meta-analysis.

RESULTS

This study is ongoing and the results will be submitted to a peer-reviewed journal for publication.

PROTOCOL REGISTRATION NUMBER

INPLASY202150044.

Reporting and transparent research practices in sports medicine and orthopaedic clinical trials: a meta-research study

OBJECTIVES

Transparent reporting of clinical trials is essential to assess the risk of bias and translate research findings into clinical practice. While existing studies have shown that deficiencies are common, detailed empirical and field-specific data are scarce. Therefore, this study aimed to examine current clinical trial reporting and transparent research practices in sports medicine and orthopaedics.

SETTING

Exploratory meta-research study on reporting quality and transparent research practices in orthopaedics and sports medicine clinical trials.

PARTICIPANTS

The sample included clinical trials published in the top 25% of sports medicine and orthopaedics journals over 9 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Two independent reviewers assessed pre-registration, open data and criteria related to scientific rigour, like randomisation, blinding, and sample size calculations, as well as the study sample, and data analysis.

RESULTS

The sample included 163 clinical trials from 27 journals. While the majority of trials mentioned rigour criteria, essential details were often missing. Sixty per cent (95% confidence interval (CI) 53% to 68%) of trials reported sample size calculations, but only 32% (95% CI 25% to 39%) justified the expected effect size. Few trials indicated the blinding status of all main stakeholders (4%; 95% CI 1% to 7%). Only 18% (95% CI 12% to 24%) included information on randomisation type, method and concealed allocation. Most trials reported participants' sex/gender (95%; 95% CI 92% to 98%) and information on inclusion and exclusion criteria (78%; 95% CI 72% to 84%). Only 20% (95% CI 14% to 26%) of trials were pre-registered. No trials deposited data in open repositories.

CONCLUSIONS

These results will aid the sports medicine and orthopaedics community in developing tailored interventions to improve reporting. While authors typically mention blinding, randomisation and other factors, essential details are often missing. Greater acceptance of open science practices, like pre-registration and open data, is needed. As these practices have been widely encouraged, we discuss systemic interventions that may improve clinical trial reporting.

Efficacy of antimicrobial washes before shoulder surgery against Cutibacterium: a systematic review and meta-analysis

Background

Cutibacterium acnes is a commensal intradermal microorganism that is commonly isolated at revision shoulder arthroplasty. Standard practice chlorhexidine gluconate (CHG) skin preparation agents have limited effectiveness at eradicating C. acnes in the dermis. Benzoyl peroxide (BPO) has demonstrated effectiveness against C. acnes. This meta-analysis compares the efficacy of at-home shoulder decolonization before surgery using CHG vs. BPO to reduce shoulder C. acnes burden.

Methods

This was a Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review. PubMed and MEDLINE databases were searched for studies evaluating the effects of CHG and BPO in reducing C. acnes at the shoulder. Trial results were extracted and pooled using a random effects model, separating data from randomized controlled trials (RCTs) and non-RCTs. Methodologic quality of studies was assessed using the Cochrane Risk of Bias Assessment Tools.

Results

Ten studies (589 patients) were included. RCTs showed that both BPO and CHG led to significant reductions in culture positivity compared with negative controls (risk ratio [RR] with 95% confidence interval [CI] = 0.20 [0.13, 0.30], P < .0001 and 0.46 [0.37, 0.57], P < .0001, respectively). Non-RCT data demonstrated similar results comparing BPO and CHG to the control (RR with 95% CI = 0.34 [0.21, 0.57], P < .0001 and 0.31 [0.20, 0.49], P < .0001, respectively). Comparing BPO and CHG, RCT data showed a significant reduction in culture positivity with BPO (RR with 95% CI = 0.46 [0.27, 0.77], P < .009). Of RCTs, 5 were low and one was of moderate risk of bias. Of non-RCTs, 3 had low risk of bias, whereas one had moderate risk of bias.

Conclusion

This review demonstrated that preoperative CHG and BPO can reduce C. acnes at the shoulder. However, BPO exhibits greater efficacy than CHG, potentially because of the compound's ability to penetrate the dermis. BPO is a simple and economical agent that may reduce joint exposure to C. acnes in shoulder surgery.

Network meta-analysis: What is its purpose in Orthopaedic literature?

Systematic reviews, of level-I primary literature, are the gold standard for the formation of Clinical Practice Guidelines in Orthopaedic Surgery. When systematic reviews have multiple groups of data, meta-analyses can be conducted to analyse the direct comparison of the data points (pairwise meta-analysis). Over recent years, statisticians have created a new statistical model called network meta-analyses that can be applied to systematic reviews. network meta-analyses allow for comparison of different treatment outcomes that may or may not have been directly assessed through level-I primary studies. network meta-analyses are appearing more and more in Orthopaedic Surgery literature; therefore, in this article, we discuss what a Network Meta-analysis is and its application in Orthopaedics.

Faculty appointment and promotion in Taiwan's medical schools, a systematic analysis

BACKGROUND

A rigorous faculty appointment and promotion (FAP) system is vital for the success of any academic institution. However, studies examining the FAP system in Asian universities are lacking. We surveyed the FAP policies of Taiwan's medical schools and identified an overreliance on the CJA score (manuscript Category, Journal quality, and Author order). The potential shortcomings of this metric and recommendations for refinement were discussed.

METHODS

We obtained the FAP documents from all 12 medical schools in Taiwan, and analyzed their use of traditional versus non-traditional criteria for FAP according to a published methodology. The influence of the journal impact factor (JIF) on the FAP process was quantified by comparing its relative weight between papers with two extreme JIFs. To better understand the research impact and international standing of each school, we utilized the public bibliographic database to rank universities by the number of papers, and the proportions of papers within the top 10% or 50% citation.

RESULTS

Compared with other countries, Taiwan's medical schools focus more on the quantifiable quality of the research, mostly using a "CJA" score that integrates the category, JIF or ranking, and authorship of a paper, with the JIF being the most influential factor. The CJA score for an article with a JIF of 20 can be up to three times the threshold for promotion to Assistant Professor. The emphasis on JIF is based on a presumed correlation between JIF and citation counts. However, our analysis shows that Taiwan's medical schools have lower-than-average citation counts despite a competitive rank in the number of publications.

CONCLUSIONS

The JIF plays an unrivaled role in determining the outcome of FAP in Taiwan's medical schools, mostly via the CJA system. The questionable effectiveness of the current system in elevating the international standing of Taiwan's higher-education institutions calls for a re-examination of the FAP system. We recommend a reduction in the relative importance of CJA score in the FAP system, adopting more rigorous metrics such as the h-index for evaluating research quality, and supporting more research aimed at improving the FAP system.

Assessment of Risk of Bias in Osteosarcoma and Ewing's Sarcoma Randomized Controlled Trials: A Systematic Review

Aim: The aim of this study was to systematically assess the risk of bias in osteosarcoma and Ewing’s sarcoma (ES) randomized controlled trials (RCT) and to examine the relationships between bias and conflict of interest/industry sponsorship. Methods: An OVID-MEDLINE search was performed (1976–2019). Using the Cochrane Collaboration guidelines, two reviewers independently assessed the prevalence of risk of bias in different RCT design domains. The relationship between conflicts of interest and industry funding with the frequency of bias was examined. Results: 73 RCTs met inclusion criteria. Prevalence of low-risk bias domains was 47.3%, unclear-risk domains 47.8%, and 4.9% of the domains had a high-risk of bias. Domains with the highest risk of bias were blinding of participants/personnel and outcome assessors, followed by randomization and allocation concealment. Overtime, frequency of unclear-risk of bias domains decreased (χ² = 5.32, p = 0.02), whilst low and high-risk domains increased (χ² = 8.13, p = 0.004). Studies with conflicts of interest and industry sponsorships were 4.2 and 3.1 times more likely to have design domains with a high-risk of bias (p < 0.05). Conclusion: This study demonstrates that sources of potential bias are prevalent in both osteosarcoma and ES RCTs. Studies with financial conflicts of interest and industry sponsors were significantly more likely to have domains with a high-risk of bias. Improvements in reporting and adherence to proper methodology will reduce the risk of bias and improve the validity of the results of RCTs in osteosarcoma and ES.

Biomechanically superior treatments do not translate into improved outcomes in randomized controlled trials

PURPOSE

Significant time and resources are devoted to conducting orthopaedic biomechanics research; however, it is not known how these studies relate to their subsequent clinical studies. The purpose of the present study was to determine whether biomechanically superior treatments were associated with improved clinical outcomes as determined by analogous randomized controlled trials (RCTs).

METHODS

A systematic review was conducted to find RCTs that tested a research question based on a prior biomechanical study. PubMed and SCOPUS databases were queried for orthopaedic randomized controlled trials, and full text articles were reviewed to find RCTs which cited biomechanical studies with analogous comparison groups. A random-effects multi-level logistic regression model was conducted examining the association between RCT outcome and biomechanics outcome, adjusting for multiple outcomes nested within study.

RESULTS

In total, 20,261 articles were reviewed yielding 21 RCTs citing a total of 43 analogous biomechanical studies. In 7 instances (16.2%), the RCT and a cited biomechanical study showed concordant results (i.e. the superior treatment in the RCT was also the superior construct in the biomechanical study). RCT outcome was not associated with biomechanical outcome (β = -1.50, standard error = 0.78, p = .05).

CONCLUSION

This study assessed 21 orthopaedic RCTs with 43 corresponding biomechanical studies and found no association between superior biomechanical properties of a given orthopaedic treatment and improved clinical outcomes. Favourable biomechanical properties alone should not be the primary reason for selecting one treatment over another. Furthermore, RCTs based on biomechanical studies should be carefully designed to maximize the chance of providing clinically relevant insights.

The Fragility of Statistically Significant Findings From Randomized Controlled Trials in Hip and Knee Arthroplasty

BACKGROUND

The Fragility Index (FI) is a method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs) beyond the P value in trials with dichotomous outcomes. The FI is defined as the number of patients in one arm of a trial that would have to have a different outcome to change the results of the trial from statistically significant to nonsignificant. This review assessed the FI in arthroplasty RCTs.

METHODS

A systematic search was conducted in MEDLINE, Embase, and Web of Science for RCTs related to primary total joint arthroplasty (TJA) from 2010 to 2020. Trials with a statistically significant dichotomous primary outcome were included. The FI was calculated using Fisher's exact test to determine how many events would need to be reversed to change a study from statistically significant to nonsignificant.

RESULTS

A total of 34 RCTs were included. The median sample size was 103 patients (range 24-791). The median FI was 1 (range 0-45), meaning that reversing the outcome of just one patient in either treatment group of each trial would change it from a significant to a nonsignificant result.

CONCLUSION

Hip and knee arthroplasty RCTs with statistically significant dichotomous outcomes in TJA are fragile. The median FI in TJA is lower than the FI in any of the other previously reported orthopedic subspecialties. Fragility is another reason to be cautious when conducting or interpreting small trials, and to continue to strive toward large trials to answer important questions in TJA.

LEVEL OF EVIDENCE

Level I.

Intervention Reporting of Published Trials Is Insufficient in Orthopaedic Surgery Journals: Application of the Template for Intervention Description and Replication Checklist

Purpose

Outcomes of randomized controlled trials (RCTs) have been shown to influence clinical decision making. Thus, the quality and reliability of these outcomes are essential for both patients and medical care providers. To date, no study has assessed the quality of intervention reporting of RCTs in orthopaedics. The aim of this study was to evaluate the quality of intervention reporting of published RCTs in the field of orthopaedics using the Template for Intervention Description and Replication (TIDieR) checklist.

Methods

In this cross-sectional analysis, we applied the TIDieR checklist to assess the quality of intervention reporting in orthopaedic RCTs. Additionally, we evaluated the TIDieR checklist’s influence on intervention reporting by comparing overall adherence to checklist items in trials published before the TIDieR checklist’s release versus trials published after its release. Finally, we assessed whether certain factors were associated with the quality of intervention reporting.

Results

From a random sample of 300 publications in orthopaedic journals, 175 parallel-arm and cluster RCTs were identified. The overall rate of adherence to TIDieR items was 58.4%. Only 31.4% of orthopaedic RCTs adhered to at least 6 of the 12 TIDieR checklist items, whereas 0% adhered to all 12 items. We found no significant improvement in the quality of intervention reporting in studies published after the TIDieR checklist’s release compared with studies published before its release (P = .97). Additionally, preregistered trials were associated with more complete intervention reporting.

Conclusions

Our results suggest suboptimal reporting of orthopaedic RCT interventions. In addition, the TIDieR checklist’s intended effect—to better the quality of RCT intervention reporting—appears to have fallen short of its goal.

Clinical Relevance

Because outcomes of RCTs are used to guide clinical decision making, it is essential that orthopaedic surgeons and clinical practice guideline panels are equipped with high-quality published research. Increasing the accuracy of intervention reporting may lead to more accurate clinical application. Thus, adoption of more stringent reporting of trial interventions by researchers, authors, and journal editors may improve the quality of orthopaedic research, as well as improve patient outcomes.

European Guidelines for Obesity Management in Adults with a Very Low-Calorie Ketogenic Diet: A Systematic Review and Meta-Analysis

BACKGROUND

The very low-calorie ketogenic diet (VLCKD) has been recently proposed as an appealing nutritional strategy for obesity management. The VLCKD is characterized by a low carbohydrate content (<50 g/day), 1-1.5 g of protein/kg of ideal body weight, 15-30 g of fat/day, and a daily intake of about 500-800 calories.

OBJECTIVES

The aim of the current document is to suggest a common protocol for VLCKD and to summarize the existing literature on its efficacy in weight management and weight-related comorbidities, as well as the possible side effects.

METHODS

This document has been prepared in adherence with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Literature searches, study selection, methodology development, and quality appraisal were performed independently by 2 authors and the data were collated by means of a meta-analysis and narrative synthesis.

RESULTS

Of the 645 articles retrieved, 15 studies met the inclusion criteria and were reviewed, revealing 4 main findings. First, the VLCKD was shown to result in a significant weight loss in the short, intermediate, and long terms and improvement in body composition parameters as well as glycemic and lipid profiles. Second, when compared with other weight loss interventions of the same duration, the VLCKD showed a major effect on reduction of body weight, fat mass, waist circumference, total cholesterol and triglyceridemia as well as improved insulin resistance. Third, although the VLCKD also resulted in a significant reduction of glycemia, HbA1c, and LDL cholesterol, these changes were similar to those obtained with other weight loss interventions. Finally, the VLCKD can be considered a safe nutritional approach under a health professional's supervision since the most common side effects are usually clinically mild and easily to manage and recovery is often spontaneous.

CONCLUSIONS

The VLCKD can be recommended as an effective dietary treatment for individuals with obesity after considering potential contra-indications and keeping in mind that any dietary treatment has to be personalized. Prospero Registry: The assessment of the efficacy of VLCKD on body weight, body composition, glycemic and lipid parameters in overweight and obese subjects: a meta-analysis (CRD42020205189).

Financial Conflicts of Interest Among Systematic Review Authors Investigating Interventions for Achilles Tendon Ruptures

BACKGROUND

The primary aim of our study was to evaluate the effects of undisclosed financial conflicts of interest in Achilles tendon rupture repair-focused systematic reviews.

METHODS

Following a cross-sectional study design, we searched MEDLINE and Embase for Achilles tendon rupture repair systematic reviews. We performed screening and data extraction in a blind, triplicate fashion. Each systematic review was evaluated on the individual characteristics of the study, presence of undisclosed and disclosed conflicts of interest, favorability of results and conclusions, and the relationship between conflicts of interest and the favorability of results and conclusions.

RESULTS

Our search produced 172 total systematic reviews pertaining to Achilles tendon rupture repair; of those, only 12 were included in our study. Undisclosed conflicts of interest were found in half (6/12) of the included reviews. However, no significant association was found between conflict of interest and the favorability of results and conclusions.

CONCLUSION

Undisclosed conflicts of interests were discovered in a large percentage of our sample. This lack of disclosure did not appear to increase the likelihood of the systematic review results or conclusions reporting favorability of the intervention being investigated.

LEVEL OF EVIDENCE

Level II.

The effect of peer review on the improvement of rejected manuscripts

Peer review is intended to improve the quality and clarity of scientific reports. Upon rejection, authors receive suggestions from knowledgeable field experts. It is unclear whether authors take full advantage of the peer review process to improve their work before publication in another journal. We identified all actionable suggestions in rejection letters of 250 randomly selected manuscripts from a prominent orthopedic journal in 2012. We searched PubMed and Google Scholar and compared the published text to the initial submission to determine if reviewer suggestions were addressed. Two hundred (80%) of the 250 rejected manuscripts were published in another journal by July 2018. Among the 609 substantive actionable queries, 205 (34%) were addressed in the published manuscripts. The suggestions most frequently addressed were in the title and abstract (48%). Our findings suggest that authors often disregard advice from peer reviewers after rejection. Authors may regard the peer review process as particular to a journal rather than a process to optimize dissemination of useful, accurate knowledge in any media. Specialty journalsmight consider collaborating by using a single manuscript submission site that allows peer reviews to be transferred to the next journal, which helps holding authors accountable for making the suggested changes.

Can the results of a randomized controlled trial change the treatment preferences of orthopaedic surgeons?

Aims

The aim of this study was to investigate surgeons' reported change of treatment preference in response to the results and conclusion from a randomized contolled trial (RCT) and to study patterns of change between subspecialties and nationalities.

Methods

Two questionnaires were developed through the Delphi process for this cross-sectional survey of surgical preference. The first questionnaire was sent out before the publication of a RCT and the second questionnaire was sent out after publication. The RCT investigated repair or non-repair of the pronator quadratus (PQ) muscle during volar locked plating of distal radial fractures (DRFs). Overall, 380 orthopaedic surgeons were invited to participate in the first questionnaire, of whom 115 replied. One hundred surgeons were invited to participate in the second questionnaire. The primary outcome was the proportion of surgeons for whom a treatment change was warranted, who then reported a change of treatment preference following the RCT. Secondary outcomes included the reasons for repair or non-repair, reasons for and against following the RCT results, and difference of preferred treatment of the PQ muscle between surgeons of different nationalities, qualifications, years of training, and number of procedures performed per year.

Results

Of the 100 surgeons invited for the second questionnaire, 74 replied. For the primary outcome, six of 32 surgeons (19%), who usually repaired the PQ muscle and therefore a change of treatment preference was warranted, reported a change of treatment preference based on the RCT publication. Of the secondary outcomes, restoring anatomy was the most common response for repairing the PQ muscle.

Conclusion

The majority of the orthopaedic surgeons, where a change of treatment preference was warranted based on the results and conclusion of a RCT, did not report willingness to change their treatment preference.Cite this article: Bone Joint Open 2020;1-9:549-555.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013

BACKGROUND

The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials.

METHODS

A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted.

RESULTS

A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment.

CONCLUSIONS

The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

A systematic review of the benefits of occupation-based intervention for patients with upper extremity musculoskeletal disorders

STUDY DESIGN

Systematic review of intervention studies (level 3a).

INTRODUCTION

Occupation-based intervention (OBI) uses daily activities as a treatment modality. Its growing use with patients diagnosed with upper extremity musculoskeletal disorders (UE MSK) has driven interest in its supporting body of evidence.

PURPOSE OF THE STUDY

The purpose of this study was to locate, appraise, and summarize current evidence of the effectiveness of OBI in treating patients with UE MSK.

METHODS

Searches of PubMed, CINAHL, the Cochrane Register for Controlled Trials, and PEDro databases were conducted using predetermined keywords. Studies included in this systematic review described the use of OBI in UE MSK. Two examiners independently reviewed and assessed the quality of each study using the PEDro scale.

RESULTS

Results of the database searches yielded 991 studies, 13 of which were deemed eligible to include in this review (6 randomized controlled trials, 4 pretreatment/post-treatment cohort or case series studies, and 3 single case reports). Quality of the studies varied, with 4 rated poor, 2 moderate, and 4 excellent. Overall, individuals receiving OBI showed superior benefits in patient-reported, performance, and physical measures assessing the upper extremity.

DISCUSSION

Findings of this review provide preliminary evidence for the use of OBI with patients with UE MSK, however, generalizability of the evidence was compromised due to heterogeneity in study subjects as well as conceptualization, dosage, and delivery of OBI.

CONCLUSIONS

The existing literature reflects promising trends in the use of OBI, underscoring its utility as a treatment option for UE MSK-related impairment, limitations, and restrictions. Nonetheless, scientific evidence concerning the effectiveness of OBI needs to be improved by conducting high-quality studies that clearly conceptualize this intervention and heighten understanding of its role in hand therapy practice.

Research priorities in children requiring elective surgery for conditions affecting the lower limbs: a James Lind Alliance Priority Setting Partnership

OBJECTIVE

To identify and prioritise research questions concerning the elective surgical management of children with conditions affecting the lower limb by engaging patients, carers and healthcare professionals.

DESIGN

A modified nominal group technique.

SETTING

UK.

PARTICIPANTS

388 individuals (29 patients, 155 parents/carers, 204 healthcare professionals) were recruited through hospital clinics, patient charities and professional organisations and participated in the initial prioritisation survey; 234 individuals took part in the interim prioritisation survey. 33 individuals (3 patients, 9 parents/carers, 11 healthcare professionals, 7 individuals representing the project's steering group and 3 James Lind Alliance (JLA) facilitators) attended the final face-to-face workshop to rank the top 10 research priorities.

INTERVENTIONS

Surveys were distributed using various media resources such as newsletters, internet messaging boards and the 'Paediatric Lower Limb Surgery Priority Setting Partnership (PSP) website. Printed copies of the questionnaire were also made available to families in outpatient clinics.

OUTCOME MEASURES

Survey results, top 10 and top 26 priority rankings RESULTS: The process took 18 months to complete (July 2017-January 2019); 388 people generated 1023 questions; a total of 801 research questions were classified as true uncertainties. Following the JLA methodology, 75 uncertainties were developed from the initial 801 questions. Twenty six of those were selected through a second survey and were taken to the final face-to-face workshop where the top 10 research priorities were selected. The top10 priorities included questions on cerebral palsy, common hip conditions (ie, Perthes' disease and developmental dysplasia of the hip) as well as rehabilitation techniques and methods to improve shared decision-making between clinicians and patients/families.

CONCLUSIONS

This is the first JLA PSP in children's orthopaedic surgery, a particularly under-researched and underfunded area. We have identified important research topics which will guide researchers and funders and direct their efforts in future research.

Effects of a proposal to alter the statistical significance threshold on previously published orthopaedic trauma randomized controlled trials

INTRODUCTION

A recent proposal suggests changing the threshold for statistical significance from a P value of .05 to .005 to minimize bias and increase reproducibility of future studies. P values less than .05 but greater than .005 would be reclassified as "suggestive", whereas P values less than .005 would be considered significant. The present study explores how lowering the P value threshold would affect the interpretation of previously published orthopaedic trauma randomized controlled trials (RCTs) and whether outcomes from these trials would maintain statistical significance under the proposed P value threshold.

METHODS

All RCTs published between January 01, 2016 and January 31, 2018 in the Journal of Orthopaedic Trauma, Injury, and Archives of Orthopaedic and Trauma Surgery were screened by at least 2 authors. Data from included trials were extracted in blinded and duplicate fashion. All P values for primary endpoints were included from each study.

RESULTS

We identified 124 primary endpoints from 48 trials: 39.5% (49/124) of endpoints had a P value less than .05 and 60.5% (75/124) had a P value greater than .05. Overall, 51.0% (25/49) of statistically significant primary endpoints were less than .005, while 49.0% (24/49) would be reclassified as suggestive.

CONCLUSION

Based on our results, adopting a lower threshold of significance would heavily alter the significance of orthopaedic trauma RCTs and should be further evaluated and cautiously considered when viewing the effect such a proposal on orthopaedic practice.

Immediate and short-term radiological changes after combining static stretching and transcutaneous electrical stimulation in adults with cavus foot: A randomized controlled trial

BACKGROUND

Cavus foot is a deformity represented by an increased and rigid medial longitudinal arch, and it is often associated with persistent pain and gait disturbances. None of the conservative conventional treatments for cavus foot have shown conclusive evidence of effectiveness, and so further is research needed to understand how to manage this condition better. This study aimed to assess the immediate and short-term radiological changes after combining static stretching and transcutaneous electrical stimulation of the plantar fascia in adults with idiopathic cavus foot.

METHODS

A randomized, single-blinded clinical trial was conducted. Sixty-eight participants with idiopathic cavus foot, as determined by an internal Moreau-Costa-Bertani angle (MCBA) less than 125° in a lateral weight-bearing foot radiograph, were equally distributed into a neuromuscular stretching group (NSG) or a control group (no intervention). The NSG underwent a single session, combining transcutaneous electrical nerve stimulation with static stretching of the plantar fascia. Primary measurements of 3 angles were taken using a lateral weight-bearing foot radiograph: the internal MCBA; the calcaneal pitch angle (CPA); and the first metatarsal declination angle (FMDA). Outcomes were collected at baseline, immediately postintervention, and 1 week after intervention.

RESULTS

Analysis of variance revealed a significant group effect for all angles (all, P < .05). NSG participants showed a significant increase in the internal MCBA (P = .03), and a significant decrease in the CPA (P = .01) and FMDA (P = .04) from baseline to immediately postintervention. These changes remained statistically significant 1 week after the intervention (all, P < .05).

CONCLUSION

The combination of static stretching and transcutaneous electrical stimulation of the plantar fascia, compared with no treatment, achieved immediate and short-term changes in the internal MCBA, the CPA, and the FMDA, which resulted in flattening the medial longitudinal plantar arch in adults with idiopathic cavus foot.

Effects of Osteopathic Visceral Treatment in Patients with Gastroesophageal Reflux: A Randomized Controlled Trial

Osteopathic manual treatment has been recommended as a non-pharmacological therapy for Gastroesophageal Reflux Disease (GERD). However, to date, no study has supported the effectiveness of this intervention with respect to the symptoms of the disease. Our goal was to assess the effect of an osteopathic manual technique for the lower esophageal sphincter on GERD symptoms, cervical mobility and on the C4 spinous process pressure pain threshold (PPTs).

METHODS

A randomized, double-blind placebo-controlled trial was performed. Sixty subjects suffering from GERD participated in this study and were randomly assigned to either an experimental group (EG) (n = 29), who received the osteopathic technique for the lower esophageal sphincter, or to a control group (CG) (n = 31), who received a manual contact, which mimicked the osteopathic technique without exerting any therapeutic force. Randomization was computer-generated, with allocation concealed by sequentially numbered, opaque, sealed envelopes. The GerdQ questionnaire was used to assess symptom changes the week after intervention. Cervical Range of Motion (CROM) and algometer were used to evaluate cervical mobility and PPTs before and after both treatments. Before-after between groups comparison (t-test) was used for statistical analysis of the outcome, with two measurement points (GerdQ), while repeated-measures ANOVA was used for those outcomes with four measurement points (CROM and PPT).

RESULTS

The application of the osteopathic manual treatment in subjects with GERD produced a significant improvement in symptoms one week after the intervention (p = 0.005) with a between-groups difference of 1.49 points in GerdQ score (95% CI: 0.47-2.49). PPT C4 improved in the EG after the treatment (p = 0.034; η² = 0.048) (between-groups difference 8.78 Newton/cm²; 95% CI: 0.48-17.09). CROM also increased in the EG compared to the CG (p < 0.001; η² = 0.108) (between-groups difference 33.89 degrees; 95% CI: 15.17-52.61).

CONCLUSIONS

The manual osteopathic technique produces an improvement in GERD symptoms one week after treatment, cervical mobility, and PPTs. This may mean that osteopathic treatment is useful for improving symptoms of GERD.

Local and Widespread Pressure Pain Hyperalgesia Is Not Side Specific in Females with Unilateral Neck Pain that Can Be Reproduced during Passive Neck Rotation

Current evidence for widespread hyperalgesia in non-specific neck pain (NSNP) is unclear. It is currently recommended to group NSNP patients according to pain-provoking movements. The aim of this study was to investigate local and widespread pain sensitivity in females with unilateral NSNP that is reproducible during passive neck rotation compared with matched controls, and to compare the side specific effect of pain location on pressure pain sensitivity among females with unilateral NSNP. Thirty-six females with unilateral NSNP evoked during passive ipsilateral (n = 20) or contralateral (n = 16) rotation toward the painful side were compared with 20 controls. Participants reported their pain intensity at rest and during passive neck rotation and completed the Neck Disability Index. Pressure pain thresholds (PPTs) were assessed bilaterally over the anterior scalene; the sternocleidomastoid; the levator scapulae; lateral to the spinous process of C6; the median, ulnar, and radial nerves; and the tibialis anterior. The ANOVA revealed lower PPTs in females with unilateral NSNP compared with the controls (all at p < 0.001), but no differences were found between the sides, nor was there any Group × side interaction. Among females with NSNP, those with higher pain intensity during ipsilateral rotation toward the painful side showed lower PPTs over the anterior scalene, median nerve, ulnar nerve, and tibialis anterior (all, p < 0.05) than females with higher pain intensity during contralateral rotation toward the painful side. These findings demonstrated bilateral local and widespread pressure pain hyperalgesia in females with unilateral NSNP that was reproducible during passive neck rotation compared with controls. There was no side specific effect of pain location on PPTs among females with unilateral NSNP.

Use of the Journal Impact Factor in academic review, promotion, and tenure evaluations

We analyzed how often and in what ways the Journal Impact Factor (JIF) is currently used in review, promotion, and tenure (RPT) documents of a representative sample of universities from the United States and Canada. 40% of research-intensive institutions and 18% of master’s institutions mentioned the JIF, or closely related terms. Of the institutions that mentioned the JIF, 87% supported its use in at least one of their RPT documents, 13% expressed caution about its use, and none heavily criticized it or prohibited its use. Furthermore, 63% of institutions that mentioned the JIF associated the metric with quality, 40% with impact, importance, or significance, and 20% with prestige, reputation, or status. We conclude that use of the JIF is encouraged in RPT evaluations, especially at research-intensive universities, and that there is work to be done to avoid the potential misuse of metrics like the JIF.

[Treatment of degenerative meniscal lesions : From eminence to evidence-based medicine]

BACKGROUND

The treatment of degenerative meniscal lesions has received increased attention since the publication of several Level 1 studies over the last few years. The following review of literature including the consensus statement given by ESSKA reports on the management of patients with degenerative meniscal lesions.

MATERIAL AND METHODS

The analysis includes the literature of Level 1 to 4 studies and the statement of the consensus group of ESSKA concerning the surgical or conservative management of these patients.

RESULTS

Meniscal lesions cause progression in osteoarthritis. Patients presenting a combination of degenerative meniscal lesion and osteoarthritis show inferior clinical outcome. The average clinical outcome after surgical treatment was 70 points based on the Lysholm score. Level 1 studies show no difference in clinical outcome. However, over 30% of these patients require arthroscopy at the second stage after an interval of 3 to 6 months. Patients presenting a flap tear or complaining about mechanical symptoms show poor outcome after conservative treatment.

DISCUSSION

Level 1 studies have focused on very selected patients. These patients do not represent the daily practice of orthopaedic surgeons. The findings of the level 1 studies should, therefore, not be generalized. According to the consensus statement of ESSKA, the treatment of degenerative meniscal lesions should start with conservative management. In the case of persistent symptoms, surgery should be considered after 3 months. In the case of mechanical symptoms, arthroscopy might be indicated earlier. Arthroscopy in advanced osteoarthritic knees is not indicated due to inferior clinical outcome.

An Evaluation of Publication Bias in High-Impact Orthopaedic Literature

Background:

Statistical analysis of systematic reviews allows the results of previous studies to be combined and synthesized to assess the overall health effect of the intervention in question. Systematic reviews can also be used to guide the creation of clinical practice guidelines and are considered to have a high level of evidence. Thus, it is important that their methodological quality is of the highest standard. Publication bias presents 2 problems: (1) studies with significant results may be overrepresented in systematic reviews and meta-analyses (“false positives”) and (2) studies without significant results may not be included in systematic reviews and meta-analyses (“false negatives”) because each study, on its own, was underpowered, meaning that some treatment options that may have clinical benefit will not be adopted.

Methods:

We performed a study to evaluate the techniques used by authors to report and evaluate publication bias in the top 10 orthopaedic journals as well as 3 orthopaedic-related Cochrane groups. Two authors independently screened the titles and abstracts to identify systematic reviews and meta-analyses. We assessed publication bias in the systematic reviews that did not assess publication bias themselves.

Results:

Our final sample included 694 systematic reviews or meta-analyses that met our inclusion criteria. Our review included 502 studies (72%) that focused on clinical outcomes, with the majority of the remaining studies focused on predictive and prognostic accuracy (20%) or diagnostic accuracy (5%). Publication bias was discussed in 295 (42.5%) of the included studies and was assessed in 135 (19.5%). Of the studies that assessed publication bias, 31.9% demonstrated evidence of publication bias. Only 43% and 22% of studies that involved use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines discussed and assessed publication bias, respectively.

Conclusions:

Publication bias is infrequently discussed and assessed in the high-impact orthopaedic literature. Furthermore, nearly one-third of the studies that assessed for publication bias demonstrated evidence of publication bias. In addition to these shortcomings, fewer than half of these studies involved use of the PRISMA guidelines and yet only one-fourth of the studies assessed for publication bias.

Clinical Relevance:

By understanding the degree to which publication bias is discussed and presented in high-impact orthopaedic literature, changes can be made by journals and researchers alike to improve the overall quality of research produced and reported.

How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials

Purpose

To assess the effectiveness of surgery on all tendinopathies by comparing it to no treatment, sham surgery and exercise-based therapies for both mid-term (12 months) and long-term (> 12 months) outcomes.

Methods

Our literature search included EMBASE, Medline, CINAHL and Scopus. A combined assessment of internal validity, external validity and precision of each eligible study yielded its overall study quality. Results were considered significant if they were based on strong (Level 1) or moderate (Level 2) evidence.

Results

12 studies were eligible. Participants had the following types of tendinopathy: shoulder in seven studies, lateral elbow in three, patellar in one and Achilles in one. Two studies were of good, four of moderate and six of poor overall quality. Surgery was superior to no treatment or placebo, for the outcomes of pain, function, range of movement (ROM) and treatment success in the short and midterm. Surgery had similar effects to sham surgery on pain, function and range of motion in the midterm. Physiotherapy was as effective as surgery both in the midterm and long term for pain, function, ROM and tendon force, and pain, treatment success and quality of life, respectively.

Conclusion

We recommend that healthcare professionals who treat tendinopathy encourage patients to comply with loading exercise treatment for at least 12 months before the option of surgery is seriously entertained.

Overview of randomised controlled trials in orthopaedic research: search for significant findings

BACKGROUND

The majority of recent orthopaedics randomised controlled trials (RCTs) have been non-inferiority trials with no significant clinical or statistical differences between treatment groups. The aim of this study was to evaluate randomised trials for significant findings in the orthopaedic literature based on the main elective procedures undertaken across different subspecialties.

METHODS

We evaluated the following procedures: anterior cervical discectomy and fusion (ACDF), subacromial decompression (SAD), carpal tunnel decompression (CTD), total hip replacement (THR), anterior cruciate ligament reconstruction (ACLR), total knee replacement (TKR) and hallux valgus correction (HVC). Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 1), Ovid MEDLINE (1946 to 12 January 2018) and Embase (1980 to 12 January 2018). Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings.

RESULTS

We included 1078 RCTs across seven most commonly performed elective procedures. Of those, only 16% (172/1078) reported significant findings [ACDF 26/77 (33.8%); SAD 2/22 (9%); CTD 11/72 (15.3%); THR 52/281 (18.5%); ACLR 21/239 (8.8%); TKR 55/357 (15.4%); HVC 5/30 (16.7%)]. The number of RCTs per year of publication has increased dramatically particularly since early 2000s-with over 100 RCTs of those seven procedures published in 2017 alone.

CONCLUSIONS

This is the first study to undertake a comprehensive review of orthopaedic RCTs in elective practice. The number of RCTs in orthopaedic research is steadily increasing. However, only 16% of trials reports significant differences between interventions.

CLINICAL RELEVANCE

For trials comparing different surgical techniques, this evidence provides treating surgeons with the flexibility to utilise available resources and infrastructure to deliver patients care without compromising clinical outcomes. Further, for trials comparing different treatment modalities, this study helps to inform the shared decision-making process when counselling patients on the effectiveness of surgical interventions.

Outcome Selection and Methodological Quality of Major and Minor Shoulder Surgery Studies: A Scoping Review

BACKGROUND

Core outcome sets aim to select and standardize the choice of important outcomes reported in clinical trials to encourage more effective data synthesis, increase the reliability of comparing results, and minimize reporting bias. A core outcome set for elective shoulder surgery has yet to be defined, and therefore a systematic assessment of outcomes and methodology is necessary to inform the development of a core outcome set.

QUESTIONS/PURPOSES

The purpose of this study was to examine randomized controlled trials (RCTs) of patients having elective major or minor shoulder surgery to (1) identify the outcome domains reported; (2) determine specific outcome measurement tools that were utilized; and (3) assess the work for methodological quality and risk of bias.

METHODS

We conducted a scoping review (a review that identifies the nature and extent of research evidence) to explore the reported outcome domains, outcome tools, and methodological quality from RCTs conducted in shoulder surgery. We considered both major shoulder surgery (defined as arthroplasty, rotator cuff repair, stabilization procedures, biceps tenodesis, or Bankart repairs) and minor shoulder surgery (simple arthroscopy, capsular plication, lateral clavicular excisions, or subacromial decompression). We queried 10 electronic databases for studies published between January 2006 and January 2015. Studies were included if they were prospective, randomized controlled, clinical trials enrolling patients who received an elective shoulder surgical intervention. We extracted data relating to trial characteristics, primary outcomes, tools used to measure these outcomes as well as methodological quality indicators. We assessed indicators of methodological quality by exploring (1) the reproducibility of power analyses; and (2) whether the primary outcomes were powered to minimum clinically important differences. Risk of bias was also assessed with the Jadad score with scores between 0 (very high risk of bias) and 5 (very low risk). Findings were qualitatively analyzed and reported according to systematic and scoping review guidelines. We included 315 studies involving 30,232 patients; 266 studies investigated anesthetic, analgesic, or surgical interventions.

RESULTS

Of the 315 studies included, the most common outcome domains evaluated were analgesic (n = 104), functional (n = 87), anesthetic (n = 56), and radiologic (n = 29) outcomes, with temporal patterns noted. Studies of major shoulder surgery most commonly reported functional primary outcome domains, whereas minor shoulder surgery studies most frequently reported analgesic primary outcome domains. There were 85 different primary outcome tools utilized, which included 20 functional, 20 anesthetic, 13 analgesic, and 12 radiologic. A methodological quality assessment revealed that 24% of studies had reproducible power analyses, 13% were powered to minimum clinically important differences, and risk of bias assessment demonstrated a median (interquartile range [range]) Jadad score of 4 (3-5 [1-5]).

CONCLUSIONS

A wide range of outcome domains and outcome assessment tools are in common use in contemporary trials of patients undergoing elective surgery. Although some diversity is important to allow the assessment of patient populations that may have different goals, the large number of tools in common use may impair the ability of future meta-analyses to pool results effectively or even for systematic reviews to synthesize what is known. The limitations of methodological quality in RCTs may be improved by researchers following standard guidelines and considering the minimum clinically important differences in their trials to be of greater use to clinicians and their patients.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Are Neonatal Trials Better Conducted and Reported over the Last 6 Decades? An Analysis on Their Risk-of-Bias Status in Cochrane Reviews

BACKGROUND

The introduction of Neonatology as a subspecialty in 1960 has stimulated an enormous amount of neonatal research. A large proportion of neonatal randomized-controlled trials (RCTs) have been included in the Cochrane reviews, within which methodological quality or risk-of-bias (ROB) assessment is an integral feature.

OBJECTIVES

We described the ROB profile of neonatal RCTs published since the 1950s.

METHODS

We analyzed individual studies within the Cochrane Neonatal reviews published up to December 2016. We extracted the reviewers' judgments on the ROB domains including random sequence generation, allocation concealment, blinding, incomplete outcome data, and selective reporting. We evaluated blinding of personnel in trials in which blinding was considered feasible.

RESULTS

We assessed 1980 RCTs published between 1952 and 2016 from 294 Cochrane Neonatal systematic reviews, with full ROB assessments performed in 848 trials (42.8%). Among the ROB domains, the highest proportion of trials (73%) were judged as satisfactory ("low risk") in handling incomplete outcome data, while fewest trials achieved blinding of outcome assessor (38.4%). In the last 6 decades, a progressive increase has been observed in the proportion of trials that were rated as low risk in random sequence generation, allocation concealment, and selective reporting. However, blinding was achieved in less than half of the trials with no clear improvement across decades (23-44% since the 1980s).

CONCLUSIONS

Despite steady improvement in the overall quality of neonatal RCTs over the last 6 decades, blinding remained unsatisfactory in the majority of the trials.

Efficacy Evaluation of High-Dose Atorvastatin Pretreatment in Patients with Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials

Background

It is unclear whether high-dose atorvastatin pretreatment benefits acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). To clarify this issue, we performed a meta-analysis of the published literature.

Material/Methods

Randomized controlled trials (RCTs) assessing high-dose atorvastatin pretreatment in ACS patients undergoing PCI were enrolled. Short-term major adverse cardiac events (MACEs), changes in serum high-sensitivity C-reactive protein (hs-CRP), peak creatine kinase-myocardial band (CK-MB) level, and thrombolysis in myocardial infarction (TIMI) grade 3 flow after PCI were studied as clinical outcomes.

Results

Seventeen RCTs including 10 072 patients were retrieved. High-dose atorvastatin showed greater benefits in reducing the incidence of short-term MACEs (OR 0.72; 95% CI: 0.56 to 0.94; P=0.01) and hs-CRP level (SMD −1.59; 95% CI: −2.38 to −0.80; P<0.0001) among ACS patients after PCI. No significant difference was found between the 2 groups in terms of peak CK-MB (SMD −0.34; 95% CI: −0.79 to 0.10; P=0.13) or final TIMI flow grade 3 (OR 1.31; 95% CI: 0.73 to 2.36; P=0.36) after PCI. High-dose atorvastatin therapy also was not associated with alanine aminotransferase (ALT) elevation (OR 1.95; 95% CI: 0.95 to 4.03; P=0.07).

Conclusions

The results of this meta-analysis suggest that high-dose atorvastatin pretreatment reduces the incidence of short-term MACEs and hs-CRP level without increasing drug-induced hepatotoxicity in ACS patients after PCI.

"Publish or Perish" Promotes Medical Literature Quantity Over Quality

When it comes to medical research, incentives align to promote "publish or perish." This results in quantity over quality. A solution is to change the goal of medical scientist and clinician training from bolstering a curriculum vitae to mastering scientific research methods. In addition, the metric for scholarly authorship should be quality, for which validated measurement tools exist, rather than number of publications.

Quality of surgical randomized controlled trials in hand surgery: a systematic review

We assessed the quantity, quality and trends of randomized controlled trials comparing hand surgical interventions. Study characteristics were collected for 125 randomized controlled trials comparing hand surgical interventions. The Jadad scale (0-5), which assesses methodological quality of trials, was calculated. Logistic regressions were conducted to determine associations with the Jadad score. The studies were published between 1981 and 2015, with an increase over time, most often in Journal of Hand Surgery (European). Mean study size was 68 patients. Mean Jadad score was 2.1, without improvement over time. Thirty percent conducted a power analysis and 8% an intention-to-treat analysis. Studies conducted in the United Kingdom and with smaller sample sizes, power analysis and intention-to-treat analysis were associated with a higher Jadad score. The quantity of trials has increased over time while methodological quality has remained low, indicating a need to improve quality of trials in hand surgery literature.

The Robustness of Trials That Guide Evidence-Based Orthopaedic Surgery

BACKGROUND

The fragility index (FI) may prove to be a powerful metric of trial robustness. The FI is the minimum number of patient events that would need to become nonevents in order to nullify a significant result. The fragility quotient (FQ) is the FI divided by the total sample size. This study evaluates the robustness of the 20% of orthopaedic clinical trials that were cited as having strong evidence in the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines and that could be analyzed with these indices.

METHODS

From the AAOS recommendations with strong evidence, we extracted the randomized controlled trials that were cited as having supporting evidence that could be analyzed with the FI. Each trial's FI was calculated using the fragility calculator (http://www.fragilityindex.com). With use of the Cochrane Risk of Bias Tool 2.0, we evaluated the likelihood of bias. We also performed a post hoc power analysis of eligible studies.

RESULTS

The median FI for the 72 trials was 2 events, and the median FQ was 0.022. Of the 72 trials, only 3 (4.2%) were at a low risk of bias, and 35 (48.6%) were at a high risk of bias. Thirty-eight (53%) of the trials were underpowered. We identified a strong correlation between a trial's FI or FQ and the trial's power.

CONCLUSIONS

Our study found that trials that provided strong evidence for orthopaedic surgery guidelines were largely fragile, underpowered, and at risk of bias.

Effectiveness of an Osteopathic Abdominal Manual Intervention in Pain Thresholds, Lumbopelvic Mobility, and Posture in Women with Chronic Functional Constipation

OBJECTIVES

To assess the effect of an osteopathic abdominal manual intervention (AMI) on pressure pain thresholds (PPTs), mobility, hip flexibility, and posture in women with chronic functional constipation.

DESIGN

Randomized, double-blind placebo-controlled trial.

SETTING/LOCATION

Subjects were recruited for the study by referral from different gastroenterology outpatient clinics in the city of Madrid (Spain).

SUBJECTS

Sixty-two patients suffering from chronic functional constipation according to the guidelines of the Congress of Rome III.

INTERVENTIONS

The experimental group (n = 31) received an osteopathic AMI, and the control group (n = 31) received a sham procedure.

OUTCOME MEASURES

PPTs at different levels, including vertebral levels C7, T3, T10, T11, and T12, trunk flexion range of motion (ROM), hip flexibility, and posture, were measured before and immediately after the intervention. A comparison between the difference between the pre- and postintervention values using the Student's t test for independent samples or nonparametric U-Mann-Whitney test depending on the distribution normality of the analyzed variables was perfomed.

RESULTS

In the intergroup comparison, statistically significant differences were found in PPT at T11 (p = 0.011) and T12 (p = 0.001) and also in the trunk flexion ROM (p < 0.05). Moreover, women showed no adverse effects with acceptable pain tolerance to the intervention.

CONCLUSION

The application of an osteopathic AMI is well tolerated and improves pain sensitivity in areas related to intestinal innervation, as well as lumbar flexion.

An Evaluation of Reporting Guidelines and Clinical Trial Registry Requirements Among Orthopaedic Surgery Journals

BACKGROUND

The responsibility for ensuring that studies are adequately reported is primarily that of those conducting the study; however, journal policies may influence how thoroughly authors choose to report their research. The use of reporting guidelines and prospective trial registration are promising avenues for ensuring that published studies adhere to the highest methodological standards. The purpose of this study is to evaluate orthopaedic surgery journal policies regarding reporting guidelines and trial registration, and to evaluate the effects that these policies have on adherence to reporting.

METHODS

We conducted a cross-sectional survey of journal policies and "Instructions for Authors" to determine the journals' policies and guidance regarding use of reporting guidelines and study registration. We also examined whether trials published in journals referencing CONSORT (Consolidated Standards of Reporting Trials) had higher rates of compliance with publishing a CONSORT flow diagram and whether journals with trial registration policies were more likely to contain registered trials than journals without these requirements.

RESULTS

Of the 21 orthopaedic surgery journals, 6 (29%) did not mention a single guideline, and clinical trial registration was required by 11 (52%) orthopaedic surgery journals and recommended by 2 (10%). Of the 21 general medical journals, 3 (14%) did not mention a single guideline, and trial registration was required by 13 (62%) general medical journals and recommended by 5 (24%) others. Furthermore, journals that referenced CONSORT were more likely to publish trials with a CONSORT flow diagram. Journals with trial registration policies were more likely to publish registered trials.

CONCLUSIONS

Reporting guidelines and trial registration are suboptimally required or recommended by orthopaedic surgery journals. These 2 mechanisms may improve methodology and quality, and should be considered for adoption by journal editors in orthopaedic surgery.

CLINICAL RELEVANCE

Because orthopaedic surgeons rely on high-quality research to direct patient care, measures must be taken to ensure that published research is of the highest quality. The use of reporting guidelines and prospective clinical trial registration may improve the quality of orthopaedic research, thereby improving patient care.

Systematic review of bone marrow stimulation for osteochondral lesion of talus - evaluation for level and quality of clinical studies

AIM

To clarify the quality of the studies indicating lesion size and/or containment as prognostic indicators of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

Two reviewers searched the PubMed/MEDLINE and EMBASE databases using specific terms on March 2015 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Predetermined variables were extracted for all the included studies. Level of evidence (LOE) was determined using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was evaluated using the Modified Coleman Methodology Score.

RESULTS

This review included 22 studies. Overall, 21 of the 22 (95.5%) included studies were level IV or level III evidences. The remaining study was a level II evidence. MQOE analysis revealed 14 of the 22 (63.6%) included studies having fair quality, 7 (31.8%) studies having poor quality and only 1 study having excellent quality.

CONCLUSION

The evidence supporting the use of lesion size and containment as prognostic indicators of BMS for OLTs has been shown to be of low quality.

Better early functional outcome after short stem total hip arthroplasty? A prospective blinded randomised controlled multicentre trial comparing the Collum Femoris Preserving stem with a Zweymuller straight cementless stem total hip replacement for the treatment of primary osteoarthritis of the hip

OBJECTIVES

Primary aim was to compare the functional results at 3 months and 2 years between short and conventional cementless stem total hip arthroplasty (THA). Secondary aim was to determine the feasibility of a double-blind implant-related trial.

DESIGN

A prospective blinded randomised controlled multicentre trial in patients with osteoarthritis of the hip. All patients, research assistants, clinical assessors, investigators and data analysts were blinded to the type of prosthesis.

POPULATION

150 patients between 18 and 70 years with osteoarthritis of the hip, 75 in the short stem and 75 in the conventional stem group. Mean age: 60 years (SD 7).

INTERVENTIONS

the Collum Femoris Preserving short stem versus the Zweymuller Alloclassic conventional stem.

MAIN OUTCOME MEASURES

The Dutch version of the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes measures: Harris Hip Score, the Physical Component Scale of the SF12, the Timed Up and Go test, Pain and the EQ-5D. Feasibility outcomes: continued blinding, protocol adherence and follow-up success rate.

RESULTS

No significant difference between the two groups. Mean HOOS total score in the short stem group increased 32.7 points from 36.6 (95% CI 32.9 to 40.2) preoperatively to 69.3 (95% CI 66.4 to 72.1) at 3 months follow-up. Mean HOOS total score in the conventional straight stem group increased 36.3 points from 37.1 (95% CI 33.9 to 40.3) preoperatively to 73.4 (95% CI 70.3 to 76.4) at 3 months follow-up. 91.2% of patients remained blinded at 2 years follow-up. Both protocol adherence and follow-up success rate were 98%.

CONCLUSIONS

Functional result at 3 months and 2 years after short stem THA is not superior to conventional cementless THA. There were more perioperative and postoperative complications in the short stem group. Direct comparison of two hip implants in a double-blinded randomised controlled trial is feasible.

TRIAL REGISTRATION NUMBER

NTR1560.

Misconceptions, Misuses, and Misinterpretations of P Values and Significance Testing

The interpretation and reporting of p values and significance testing in biomedical research are fraught with misconceptions and inaccuracies. Publications of peer-reviewed research in orthopaedics are not immune to such problems. The American Statistical Association (ASA) recently published an official statement on the use, misuse, and misinterpretation of statistical testing and p values in applied research. The ASA statement discussed 6 principles: (1) "P-values can indicate how incompatible the data are with a specified statistical model." (2) "P-values do not measure the probability that the studied hypothesis is true, or the probability that the data were produced by random chance alone." (3) "Scientific conclusions and business or policy decisions should not be based only on whether a p-value passes a specific threshold." (4) "Proper inference requires full reporting and transparency." (5) "A p-value, or statistical significance, does not measure the size of an effect or the importance of a result." (6) "By itself, a p-value does not provide a good measure of evidence regarding a model or hypothesis." The purpose of this article was to discuss these principles. We make several recommendations for moving forward: (1) Authors should avoid statements such as "statistically significant" or "statistically nonsignificant." (2) Investigators should report the magnitude of effect of all outcomes together with the appropriate measure of precision or variation. (3) Orthopaedic residents and surgeons must be educated in biostatistics, the ASA principles, and clinical epidemiology. (4) Journal editors and reviewers need to be familiar with and enforce the ASA principles.

Surgical Management of Degenerative Meniscus Lesions: The 2016 ESSKA Meniscus Consensus

Purpose  A degenerative meniscus lesion is a slowly developing process typically involving a horizontal cleavage in a middle-aged or older person. When the knee is symptomatic, arthroscopic partial meniscectomy has been practised for a long time with many case series reporting improved patient outcomes. Since 2002, several randomised clinical trials demonstrated no additional benefit of arthroscopic partial meniscectomy compared to non-operative treatment, sham surgery or sham arthroscopic partial meniscectomy. These results introduced controversy in the medical community and made clinical decision-making challenging in the daily clinical practice. To facilitate the clinical decision-making process, a consensus was developed. This initiative was endorsed by ESSKA.

Methods  A degenerative meniscus lesion was defined as a lesion occurring without any history of significant acute trauma in a patient older than 35 years. Congenital lesions, traumatic meniscus tears and degenerative lesions occurring in young patients, especially in athletes, were excluded. The project followed the so-called formal consensus process, involving a steering group, a rating group and a peer-review group. A total of 84 surgeons and scientists from 22 European countries were included in the process. Twenty questions, their associated answers and an algorithm based on extensive literature review and clinical expertise, were proposed. Each question and answer set was graded according to the scientific level of the corresponding literature.

Results  The main finding was that arthroscopic partial meniscectomy should not be proposed as a first line of treatment for degenerative meniscus lesions. Arthroscopic partial meniscectomy should only be considered after a proper standardised clinical and radiological evaluation and when the response to non-operative management has not been satisfactory. Magnetic resonance imaging of the knee is typically not indicated in the first-line work-up, but knee radiography should be used as an imaging tool to support a diagnosis of osteoarthritis or to detect certain rare pathologies, such as tumours or fractures of the knee.

Discussion  The present work offers a clear framework for the management of degenerative meniscus lesions, with the aim to balance information extracted from the scientific evidence and clinical expertise. Because of biases and weaknesses of the current literature and lack of definition of important criteria such as mechanical symptoms, it cannot be considered as an exact treatment algorithm. It summarises the results of the “ESSKA Meniscus Consensus Project” ( http://www.esska.org/education/projects ) and is the first official European consensus on this topic. The consensus may be updated and refined as more high-quality evidence emerges.

Level of Evidence  I.

The Fragility of Statistically Significant Findings From Randomized Trials in Sports Surgery: A Systematic Survey

BACKGROUND

High-quality, evidence-based orthopaedic care relies on the generation and translation of robust research evidence. The Fragility Index is a novel method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs). It is defined as the minimum number of patients in 1 arm of a trial that would have to change status from a nonevent to an event to alter the results of the trial from statistically significant to nonsignificant.

PURPOSE

To calculate the Fragility Index of statistically significant results from clinical trials in sports medicine and arthroscopic surgery to characterize the robustness of the RCTs in these fields.

METHODS

A search was conducted in Medline, EMBASE, and PubMed for RCTs related to sports medicine and arthroscopic surgery from January 1, 2005, to October 30, 2015. Two reviewers independently assessed titles and abstracts for study eligibility, performed data extraction, and assessed risk of bias. The Fragility Index was calculated using the Fisher exact test for all statistically significant dichotomous outcomes from parallel-group RCTs. Bivariate correlation was performed to evaluate associations between the Fragility Index and trial characteristics.

RESULTS

A total of 48 RCTs were included. The median sample size was 64 (interquartile range [IQR], 48.5-89.5), and the median total number of outcome events was 19 (IQR, 10-27). The median Fragility Index was 2 (IQR, 1-2.8), meaning that changing 2 patients from a nonevent to an event in the treatment arm changed the result to a statistically nonsignificant result, or P ≥ .05.

CONCLUSION

Most statistically significant RCTs in sports medicine and arthroscopic surgery are not robust because their statistical significance can be reversed by changing the outcome status on only a few patients in 1 treatment group. Future work is required to determine whether routine reporting of the Fragility Index enhances clinicians' ability to detect trial results that should be viewed cautiously.

Short-Term Changes in Algometry, Inclinometry, Stabilometry, and Urinary pH Analysis After a Thoracolumbar Junction Manipulation in Patients with Kidney Stones

OBJECTIVES

To determine the efficacy of a high-velocity low-amplitude manipulation of the thoracolumbar junction in different urologic and musculoskeletal parameters in subjects suffering from renal lithiasis.

DESIGN

Randomized, controlled blinded clinical study.

SETTINGS/LOCATION

The Nephrology departments of two hospitals and one private consultancy of physiotherapy in Valencia (Spain).

SUBJECTS

Forty-six patients suffering from renal lithiasis.

INTERVENTIONS

The experimental group (EG, n = 23) received a spinal manipulation of the thoracolumbar junction, and the control group (CG, n = 23) received a sham procedure.

OUTCOME MEASURES

Pressure pain thresholds (PPTs) of both quadratus lumborum and spinous processes from T10 to L1, lumbar flexion range of motion, stabilometry, and urinary pH were measured before and immediately after the intervention. A comparison between pre- and postintervention phases was performed and an analysis of variance for repeated measures using time (pre- and postintervention) as intrasubject variable and group (CG or EG) as intersubject variable.

RESULTS

Intragroup comparison showed a significant improvement for the EG in the lumbar flexion range of motion (p < 0.001) and in all the PPT (p < 0.001 in all cases). Between-group comparison showed significant changes in PPT in quadratus lumborum (p < 0.001), as well as in the spinous processes of all of the evaluated levels (p < 0.05). No changes in urinary pH were observed (p = 0.419).

CONCLUSION

Spinal manipulation of the thoracolumbar junction seems to be effective in short term to improve pain sensitivity, as well as to increase the lumbar spine flexion.

A Systematic Review of Measurement Properties of Patient-Reported Outcome Measures Used in Patients Undergoing Total Knee Arthroplasty

BACKGROUND

While clinical research on total knee arthroplasty (TKA) outcomes is prevalent in the literature, studies often have poor methodological and reporting quality. A high-quality patient-reported outcome instrument is reliable, valid, and responsive. Many studies evaluate these properties, but none have done so with a systematic and accepted method. The objectives of this study were to identify patient-reported outcome measures (PROMs) for TKA, and to critically appraise, compare, and summarize their psychometric properties using accepted methods.

METHODS

MEDLINE, EMBASE, SCOPUS, Web of Science, PsycINFO, and SPORTDiscus were systematically searched for articles with the following inclusion criteria: publication before December 2014, English language, non-generic PRO, and evaluation in the TKA population. Methodological quality and evidence of psychometric properties were assessed with the COnsensus-based standards for the selection of health Status Measurement INstruments (COSMIN) checklist and criteria for psychometric evidence proposed by the COSMIN group and Terwee et al.

RESULTS

One-hundred fifteen studies on 32 PROMs were included in this review. Only the Work, Osteoarthritis or joint-Replacement Questionnaire, the Oxford Knee Score, and the Western Ontario and McMaster Universities Arthritis Index had 4 or more properties with positive evidence.

CONCLUSION

Most TKA PROMs have limited evidence for their psychometric properties. Although not all the properties were studied, the Work, Osteoarthritis or joint-Replacement Questionnaire, with the highest overall ratings, could be a useful PROM for evaluating patients undergoing TKA. The methods and reporting of this literature can improve by following accepted guidelines.