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Thomson S, Ainsworth G, Selvanathan S, Kelly R, Collier H, Mujica-Mota R, Talbot R, Brown ST, Croft J, Rousseau N, Higham R, Al-Tamimi Y, Buxton N, Carleton-Bland N, Gledhill M, Halstead V, Hutchinson P, Meacock J, Mukerji N, Pal D, Vargas-Palacios A, Prasad A, Wilby M, Stocken D. Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rachel Kelly
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Talbot
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Tess Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Buxton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Martin Gledhill
- Department of Speech and Language Therapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Peter Hutchinson
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Meacock
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nitin Mukerji
- Department of Neurosurgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Debasish Pal
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Anantharaju Prasad
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Neradi D, Sodavarapu P, Jindal K, Kumar D, Kumar V, Goni V. Locked Plating Versus Retrograde Intramedullary Nailing for Distal Femur Fractures: a Systematic Review and Meta-Analysis. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:141-152. [PMID: 35655740 PMCID: PMC9117898 DOI: 10.22038/abjs.2021.53515.2656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/24/2021] [Indexed: 05/13/2023]
Abstract
Modern advances in techniques and implants have allowed for a better operative fixation for distal femoral fractures. Both locked plating and retromedullary nail have allowed surgeons to stabilize these fractures with minimal soft tissue dissection and preserve blood supply. Although both the implants have been used extensively for such types of fractures, the superiority of one implant over the other is still doubtful. Therefore, we conducted this meta-analysis to compare locked plating and retrograde intramedullary nailing in distal femoral fractures. Based on prisma guidelines, electronic databases, including PubMed, Embase, Scopus, and Ovid Medline were searched using a well-defined search strategy. Outcome measures which were studied included blood loss, implant failure, infection, knee range of motion, malunion, non-union, pain, surgical duration and union time Surgical duration (95% CI 2.90 to 17.13, p <0.01) and blood loss (95% CI 69.60 to123.18, p <0.01) favoured plating group and the difference is significant. But while analysing parameters like implant failure, knee range of motion, non-union and union time, our analysis favoured nailing group, but the difference is not significant. Overall, both locked plating and retrograde intramedullary nailing are comparable with respect to union and complications in distal femur fractures, but we need further larger and high quality randomized studies to evaluate the difference.
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Affiliation(s)
- Deepak Neradi
- Senior Resident, Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Praveen Sodavarapu
- Senior Resident, Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Karan Jindal
- Senior Resident, Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Deepak Kumar
- Assistant Professor, Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Vishal Kumar
- Assistant Professor, Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Vijay Goni
- Professor, Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Griffin XL, Costa ML, Phelps E, Parsons N, Dritsaki M, Png ME, Achten J, Tutton E, Lerner R, McGibbon A, Baird J. Retrograde intramedullary nail fixation compared with fixed-angle plate fixation for fracture of the distal femur: the TrAFFix feasibility RCT. Health Technol Assess 2020; 23:1-132. [PMID: 31549959 DOI: 10.3310/hta23510] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Fractures of the distal femur are an increasingly common injury; the optimal management of these injuries remains controversial. The two interventions used in UK practice are intramedullary fixation, with a locked retrograde nail, and extramedullary fixation, with a fixed angle plate. OBJECTIVES This study assessed the feasibility of a definitive trial and included a process evaluation to understand the generalisability and likely success of a future trial. DESIGN A multicentre, parallel, two-arm, randomised controlled feasibility trial with an embedded process evaluation. Treatment with a plate or nail was allocated in a 1 : 1 ratio, stratified by centre and chronic cognitive impairment. Surgeons were not blinded, but participants were not told their allocation. SETTING Seven NHS hospitals. PARTICIPANTS Patients aged ≥ 18 years with a fracture of the distal femur who the attending surgeon believed would benefit from internal fixation were potentially eligible. Patients were excluded if they had a loose arthroplasty requiring revision or a femoral deformity or arthroplasty that precluded nail fixation. The sample was recruited between 29 September 2016 and 31 August 2017. Consent was obtained from the patient or appropriate consultee before enrolment. INTERVENTIONS Patients were randomised to receive fixation of their distal femur fracture with either a proximally and distally locked retrograde nail that spanned the diaphysis of the femur or an anatomical distal femoral locking plate with at least one locked screw distal to the fracture. Reduction and supplemental fixation were at the surgeon's discretion. OUTCOMES The primary outcome measures for this study were the recruitment rate and the completion rate of the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), at 6 weeks and 4 months. Additional measurements included baseline characteristics, measures of social support and self-efficacy, disability rating index, dementia quality-of-life measures and a radiographical assessment of any malunion. Participants' and staff views were obtained, at interview, for the process evaluation. RESULTS The process evaluation showed that surgeon-related factors, principally confidence with both technologies and a lack of individual equipoise, were key barriers to recruitment. A total of 23 participants were randomised and analysed (nail, n = 11; plate, n = 12). The recruitment rate was estimated as 0.42 [95% confidence interval (CI) 0.27 to 0.62] participants per centre per month, lower than the prespecified feasibility threshold of 1.0 participants per centre per month. Data completeness of the EQ-5D-5L was estimated at 65% (95% CI 43% to 83%). CONCLUSIONS This feasibility study has challenged many of the assumptions that underpinned the development of proposed definitive trial protocol. A modified protocol is proposed that would be feasible given the recruitment rate observed here, which is equal to that reported in the similar FixDT trial [Health Technology Assessment (HTA) 11/136/04: Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess 2018;22(25)], which delivered to target and budget. FUTURE WORK A definitive trial with a modified design is recommended, including an internal pilot to confirm initial recruitment rate assumptions. REGISTRATION Current Controlled Trials ISRCTN92089567. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 51. See the NIHR Journals Library website for further project information. Funding was also supported by the NIHR Oxford Biomedical Research Centre.
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Affiliation(s)
- Xavier L Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Emma Phelps
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Nicholas Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - May Ee Png
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.,Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robin Lerner
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | | | - Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK.,National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Phelps EE, Tutton E, Griffin X, Baird J. Facilitating trial recruitment: A qualitative study of patient and staff experiences of an orthopaedic trauma trial. Trials 2019; 20:492. [PMID: 31399134 PMCID: PMC6688236 DOI: 10.1186/s13063-019-3597-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Qualitative research has been used to explore patients’ and healthcare professionals’ experiences of surgical randomised controlled trials (RCTs). From this research, reasons why patients accept or decline participation and barriers to engaging clinicians in trials have been identified. In a trauma setting, recruitment to surgical trials can be particularly difficult as patients may require urgent treatment and their ability to consider their options, ask questions and reach a decision may be hindered by the impact of their injury. Little research, however, has explored patients’ and healthcare professionals’ experiences of surgical RCTs in a trauma setting. This study aimed to understand patients’ and staff’s experiences of an orthopaedic trauma trial. Methods We carried out semi-structured interviews with 11 patients and 24 staff (10 surgeons and 14 research associates) participating in a UK multi-centre feasibility trial comparing intramedullary nails versus distal locking plates for fractures of the distal femur (TrAFFix). Interviews explored patients’ experience of TrAFFix and their reason for participating and staffs' experience of recruiting to TrAFFix and trauma trials more generally. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed using thematic analysis. Results Three themes were identified. These were i) navigating research with patients after orthopaedic trauma, ii) knowing that it is the right decision and iii) making it work. These themes reflect: i) how research associates supported and guided patients through the consent process enabling them to participate, ii) the difficulty in engaging surgeons in a trial when individual equipoise and experience of the interventions are low despite the presence of community equipoise and iii) the way in which research teams worked together and encouraged the development of a research culture within the clinical teams in order to facilitate recruitment. Conclusions Our findings highlight the pivotal role of research associates (RAs) in facilitating trial recruitment. RAs supported patients to enable them to make a decision about participation and assisted in developing a research culture within the team by promoting studies and communicating research to clinical staff. Our findings also reinforce surgeons’ difficulty with equipoise and suggest that accepting community equipoise could facilitate recruitment.
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Affiliation(s)
- Emma Elizabeth Phelps
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Elizabeth Tutton
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK. .,Oxford University Hospitals NHS Foundation Trust, Oxford, UK. .,Warwick Research in Nursing, University of Warwick, Coventry, UK.
| | - Xavier Griffin
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Janis Baird
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
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5
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Griffin XL, Costa ML, Phelps E, Parsons N, Dritsaki M, Achten J, Tutton E, Lerner RG, McGibbon A, Baird J. Intramedullary nails versus distal locking plates for fracture of the distal femur: results from the Trial of Acute Femoral Fracture Fixation (TrAFFix) randomised feasibility study and process evaluation. BMJ Open 2019; 9:e026810. [PMID: 31061043 PMCID: PMC6502051 DOI: 10.1136/bmjopen-2018-026810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This feasibility study and process evaluation assessed the likely success of a definitive trial of intramedullary fixation with locked retrograde nails versus extramedullary fixation with fixed angle plates for fractures of the distal femur. DESIGN & SETTING A multicentre, parallel, two-arm, randomised controlled feasibility study with an embedded process evaluation was conducted at seven NHS hospitals in England. Treatment was randomly allocated in 1:1 ratio, stratified by centre and chronic cognitive impairment. Participants, but not surgeons or research staff, were blinded to the allocation. PARTICIPANTS Patients 18 years and older with a fracture of the distal femur, who their surgeon believed would benefit from internal fixation, were eligible to take part.Participants were allocated to receive either a retrograde intramedullary nail or an anatomical locking plate. OUTCOMES The primary outcomes for this feasibility study were the recruitment rate and completion rate of the EQ-5D-5L at 4 months post-randomisation. Baseline characteristics, disability rating index, quality of life scores, measurements of social support and self-efficacy, resource use and radiographic assessments were also collected. The views of patients and staff were collected during interviews. RESULTS Recruitment and data completion were lower than expected. 23 of 82 eligible patients were recruited (nail, 11; plate, 12). The recruitment rate was estimated as 0.42 (95% CI 0.27 to 0.62) participants per centre-month. Data completeness of the EQ-5D-5L at 4 months was 61 per cent (95% CI 43% to 83%). The process evaluation demonstrated that the main barriers to recruitment were variation in treatment pathways across centres, lack of surgeon equipoise and confidence in using both interventions and newly formed research cultures that lacked cohesion. CONCLUSIONS A modified trial design, with embedded recruitment support intervention, comparing functional outcome in cognitively intact adults who have sustained a fragility fracture of the distal femur is feasible. ETHICS APPROVAL The Wales Research Ethics Committee 5 approved the study (ref: 16/WA/0225). TRIAL REGISTRATION NUMBER ISRCTN92089567; Pre-results.
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Affiliation(s)
- Xavier L Griffin
- Oxford Trauma, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew L Costa
- Oxford Trauma, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emma Phelps
- Oxford Trauma, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Nicholas Parsons
- Statistics and Epidemiology Unit, University of Warwick, Coventry, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Juul Achten
- Oxford Trauma, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Elizabeth Tutton
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Robin Gillmore Lerner
- Kadoorie Centre, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | | | - Janis Baird
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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