Levels of evidence

Etiology, Classification, Diagnostics, and Conservative Management of Osteochondral Lesions of the Talus. 2023 Recommendations of the Working Group "Clinical Tissue Regeneration" of the German Society of Orthopedics and Traumatology

METHODS

Peer-reviewed literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLTs) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available for a particular diagnostic or therapeutic concept, including the grade of recommendation. Besides the scientific evidence, all group members rated the statements to identify possible gaps between literature and current clinical practice.

CONCLUSION

In patients with minimal symptoms, OLT progression to ankle osteoarthritis is unlikely. Risk factors for progression are the depth of the lesion on MRI, subchondral cyst formation, and the extent of bone marrow edema. Conservative management is the adaptation of activities to the performance of the ankle joint. A follow-up imaging after 12 months helps not to miss any progression. It is impossible to estimate the probability of success of conservative management from initial symptoms and imaging. Cast immobilization is an option in OLTs in children, with a success rate of approximately 50%, although complete healing, estimated from imaging, is rare. In adults, improvement by conservative management ranges between 45% and 59%. Rest and restrictions for sports activities seem to be more successful than immobilization. Intra-articular injections of hyaluronic acid and platelet-rich plasma can improve pain and functional scores for more than 6 months. If 3 months of conservative management does not improve symptoms, surgery can be recommended.

What are the health consequences associated with differences in medical malpractice liability laws? An instrumental variable analysis of surgery effects on health outcomes for proximal humeral facture across states with different liability rules

BACKGROUND

States enacted tort reforms to lower medical malpractice liability, which are associated with higher surgery rates among Medicare patients with shoulder conditions. Surgery in this group often entails tradeoffs between improved health and increased risk of morbidity and mortality. We assessed whether differences in surgery rates across states with different liability rules are associated with surgical outcomes among Medicare patients with proximal humeral fracture.

METHODS

We obtained data for 67,966 Medicare beneficiaries with a diagnosis of proximal humeral fracture in 2011. Outcome measures included adverse events, mortality, and treatment success rates, defined as surviving the treatment period with < $300 in shoulder-related expenditures. We used existing state-level tort reform rules as instruments for surgical treatment and separately as predictors to answer our research question, both for the full cohort and for stratified subgroups based on age and general health status measured by Charlson Comorbidity Index and Function-Related Indicators.

RESULTS

We found a 0.32 percentage-point increase (p < 0.05) in treatment success and a 0.21 percentage-point increase (p < 0.01) in mortality for every 1 percentage-point increase in surgery rates among patients in states with lower liability risk. In subgroup analyses, mortality increased among more vulnerable patients, by 0.29 percentage-point (p < 0.01) for patients with Charlson Comorbidity Index >  = 2 and by 0.45 percentage-point (p < 0.01) among those patients with Function-Related Indicator scores >  = 2. On the other hand, treatment success increased in patients with lower Function-Related Index scores (< 2) by 0.54 percentage-point (p < 0.001). However, younger Medicare patients (< 80 years) experienced an increase in both mortality (0.28 percentage-point, p < 0.01) and treatment success (0.89 percentage-point, p < 0.01). The reduced-form estimates are consistent with our instrumental variable results.

CONCLUSIONS

A tradeoff exists between increased mortality risk and increased treatment success across states with different malpractice risk levels. These results varied across patient subgroups, with more vulnerable patients generally bearing the brunt of the increased mortality and less vulnerable patients enjoying increased success rates. These findings highlight the important risk-reward scenario associated with different liability environments, especially among patients with different health status.

Radiofrequency microtenotomy for plantar fasciitis: A systematic review and meta-analysis

BACKGROUND

Currently, there is limited evidence on outcomes for plantar fascia radiofrequency microtenotomy. An evidence-based systematic review and meta-analysis for outcomes of radiofrequency microtenotomy for the treatment of plantar fasciitis was conducted.

METHODS

A comprehensive evidence-based literature review of PubMed and Cochrane Databases was conducted in March 2019, which identified 11 relevant articles assessing the efficacy of plantar fascia radiofrequency microtenotomy. The studies were then assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against endoscopic plantar fascia release. Meta-analysis was performed for 7 of the studies that measured AOFAS scores.

RESULTS

Based on the results of this evidence-based review, there was fair (grade B) evidence to support plantar fascia radiofrequency microtenotomy. There was a statistically significant mean increase of 40.9 in AOFAS scores post procedure.

CONCLUSION

There was fair (grade B) evidence to recommend radiofrequency microtenotomy for plantar fasciitis. There is a need for more high quality level I randomized controlled trials with validated outcome measures to allow for stronger recommendations to be made.

LEVEL OF EVIDENCE

Level II, systematic review of level II studies.

State medical malpractice laws and utilization of surgical treatment for rotator cuff tear and proximal humerus fracture: an observational cohort study

Background

How much does the medical malpractice system affect treatment decisions in orthopaedics? To further this inquiry, we sought to assess whether malpractice liability is associated with differences in surgery rates among elderly orthopaedic patients.

Methods

Medicare data were obtained for patients with a rotator cuff tear or proximal humerus fracture in 2011. Multivariate regressions were used to assess whether the probability of surgery is associated with various state-level rules that increase or decrease malpractice liability risks.

Results

Study results indicate that lower liability is associated with higher surgery rates. States with joint and several liability, caps on punitive damages, and punitive evidence rule had surgery rates that were respectively 5%-, 1%-, and 1%-point higher for rotator cuff tears, and 2%-, 2%- and 1%-point higher for proximal humerus fractures. Conversely, greater liability is associated with lower surgery rates, respectively 6%- and 9%-points lower for rotator cuff patients in states with comparative negligence and pure comparative negligence.

Conclusions

Medical malpractice liability is associated with orthopaedic treatment choices. Future research should investigate whether treatment differences result in health outcome changes to assess the costs and benefits of the medical liability system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06544-8.

Robotic Surgery Research in Urology: A Bibliometric Analysis of Field and Top 100 Articles

Introduction: There has been a surge in robotic surgery research publications over the past 20 years. However, to date, there has been no characterization of urology's contribution to the robotic field, and there is a lack of bibliometric literature to guide future investigation. We conducted this bibliometric analysis to characterize the distributions and characteristics of robotic surgery research in the urologic field, with subanalysis of the top 100 articles. Materials and Methods: The Web of Science Core Collection of the ISI Web of Science was searched and analyzed to determine distributions and characteristics of robotic urologic surgery research. The top 100 articles were categorized by urologic subfield and organ of pathology, with a level of evidence rating system applied (adapted from the Centre of Evidence-Based Medicine). Results: The total number of articles retrieved was 1294 from 1999 to 2018. The number of articles published in the last decade has increased by 845.75%, with 153 articles published in the preceding decade. The United States leads countries in publication with 699 (54.02%) articles across the field, and 71 within the top 100 articles. The Journal of Endourology published most articles (n = 292, 22.57%) within the field, while European Urology published most (n = 36) within the top 100 articles. Top 100 articles where generally associated with cancer (n = 76), with prostate cancer dominating literature (n = 38). The most common level of evidence for top 100 articles was that of a level 3 study (n = 31). Conclusions: This analysis of research activity has the potential to guide future robotic surgery research trends in the field of urology. There has been an explosion in robotic surgery urologic research activity over the last decade, with level 3 evidence dominating the top 100 articles of the field.

Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size

INTRODUCTION

Evidence on penile enhancement interventions is lacking. Nonetheless, many non-evidence-based solutions are readily available.

AIM

To investigate enhancement and nonenhancement interventions in men without penile abnormalities seeking to increase penis size.

METHODS

We performed a systematic review with no time restrictions adhering to the PRISMA guidelines. Studies with fewer than 10 cases or including men with organic penile pathologies or previous penile surgeries were excluded.

MAIN OUTCOME MEASURES

When available, treatment efficacy was evaluated based on patient satisfaction, penile size increase, and complications.

RESULTS

We included 17 studies, assessing a total of 21 interventions in 1,192 men screened, with 773 followed up after nonsurgical (n = 248) or surgical (n = 525) treatment. The quality of the studies was poor in terms of methodology for patient selection and outcomes assessment. The vast majority of series reported normal penile size. Among nonsurgical treatments, extenders increased flaccid length (but by <2 cm), injectables increased girth but were associated with a high complication rate, and vacuum devices did not increase size. Surgical interventions included suspensory ligament incision (the most used method; n = 12), tissue grafting (autologous, n = 2; dermal fat, n = 3, ex vivo, n = 2), flaps (n = 2), and penile disassembly (n = 1). Some men reported a significant size increase; however, complications were not infrequent, and none of the techniques was externally validated. When provided, counseling was effective, with the majority of men coming to understand that their penis was normal and unwilling to undergo any further treatment.

CONCLUSION

Treatment of small penis in normal men is supported by scant, low-quality evidence. Structured counseling should be always performed, with extenders eventually used by those still seeking enhancement. Injectables and surgery should remain a last option, considered unethical outside of clinical trials. Marra G, Drury A, Tran L, et al. Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size. Sex Med Rev 2020;8:158-180.

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus

Background

Using a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached.

Methods

This was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level.

Results

Among patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles.

Conclusions

Persistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

Evidence-Based Analysis of Adjacent Segment Degeneration and Disease After LIF: A Narrative Review

STUDY DESIGN

Narrative review.

OBJECTIVES

The etiology of adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDz) after lumbar interbody fusion (LIF) remains controversial. The aim of this narrative review was to provide an evidence-based analysis of the peer-reviewed literature on clinical studies of ASDeg and ASDz after LIF.

METHODS

A review was performed utilizing Medline, Embase, and Cochrane databases. Two reviewers independently extracted relevant data from each included study. Statistical comparisons were made when appropriate.

RESULTS

Nine articles that matched the inclusion and exclusion criteria were included. All the studies were Level III and retrospective. MINORS scores ranged from 9.5 to 13. Clinical outcomes were assessed in all 9 studies, but only 6 studies used validated outcomes measures. Only 6 studies reported values for both ASDeg and ASDz. ASDeg alone was reported in 3 studies. Due to the variability in the criteria for designation as ASDz (different radiographic modalities) and ASDeg (different outcomes measures), we were unable to calculate frequency-weighted mean values or compare the various surgical techniques.

CONCLUSIONS

This review highlights the various limitations of the current literature on ASDeg and ASDz after lumbar fusion, specifically the absence of a rigorous definition and classification system and an extraordinary heterogeneity in methodology. There needs to be a fundamental shift in the current ASDeg and ASDz research landscape, toward a consensus, so that the high-level clinical research that is essential for treatment of spinal pathology may become available.

Bisphosphonate therapy and atypical fractures

Atypical femoral fractures have attracted a great deal of attention and controversy in the osteoporosis community because of their association with prolonged bisphosphonate therapy. The purpose of this article is to review the epidemiologic evidence linking bisphosphonates to atypical fractures and to highlight the potential pathologic mechanisms involved in such fractures. A management plan is provided based on the available evidence.

Beyond a reasonable doubt? Bisphosphonates and atypical femur fractures

In May 2011, we were privileged to debate on behalf of the ECTS and the ASBMR in a Clinical Debate hosted by the IBMS and the ECTS with the motion "Atypical femoral shaft fractures are a consequence of bisphosphonate therapy". The evidence presented for and against the motion is summarized and discussed in this joint commentary. The hypothetical chain of evidence between bisphosphonates, decreased toughness of bone, microcrack accumulation in man and atypical fractures is plausible but unproven. However, the combination of consistent clinical features (which may include a stress reaction at the site of maximum tensile load), a significant statistical association and a feasible biological mechanism gives grounds for caution especially as regards long term treatment in patients at low or moderate risk of osteoporotic fractures.

Evolution and development of the Advanced Trauma Life Support (ATLS) protocol: a historical perspective

The Advanced Trauma Life Support (ATLS) protocol is a successful course offered by the American College of Surgeons. Once based on didactic lectures and seminars taught by experts in the field, trauma training has evolved to become a set of standardized assessment and treatment protocols based on evidence rather than expert opinion. As the ATLS expands, indices to predict outcome, morbidity, and mortality have evolved to guide management and treatment based on retrospective data. This historical, perspective article attempts to tell the story of ATLS from its inception to its evolution as an international standard for the initial assessment and management of trauma patients.

Publication rate of abstracts presented at the Annual Congress of the German Society of Orthopaedics and Trauma Surgery

INTRODUCTION

The quality of abstracts presented at medical conferences reflects the scientific activity in the organisations involved. The aims of this study were to evaluate the publication rate of studies presented at the annual congress of the German Society of Orthopaedics and Trauma Surgery and to investigate predictive factors for publication. The results were to be compared with other international meetings.

METHOD

All 1,100 abstracts presented at the Congress of the German Society of Orthopaedics and Trauma Surgery in 2003 were assessed. The publication rate for the corresponding articles in peer-reviewed journals within 5 years was examined using a PubMed search. The consistency of the congress abstracts with the publications was studied. Factors influencing publication rates were investigated, including level of evidence (LoE) and type of study.

RESULTS

The publication rate was 36%, with a mean of 15 months between conference and publication (mean impact factor 1.50). No significant differences were observed between publication rates for oral presentations and posters. Experimental studies and those with LoE I and II had higher publication rates (47.1%; 55.2%; 39.8%) than clinical studies and those with LoE III and IV (30.8%; 29.2%; 28.0%). Abstracts of randomised studies and prospective studies showed publication rates of 43.2 and 35.6% and were published more often than abstracts of non-randomised studies and retrospective studies, with publication rates of 35.3 and 27.1%.

CONCLUSION

The publication rate was in the lower range of rates available for comparable conferences--e.g., the American Academy of Orthopaedic Surgeons, with rates between 34 and 55%--but lower than those of the Orthopaedic Trauma Association, at 52-67%. However, 64% of the abstracts remained unpublished, calling into question the acceptability of citing conference abstracts in the scientific literature and implementing them in clinical practice.

Advanced trauma life support, 8th edition, the evidence for change

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Levels of Evidence in the Urological Literature

PURPOSE

The concept of levels of evidence is one of the guiding principles of evidence based clinical practice. It is based on the understanding that certain study designs are more likely to be affected by bias than others. We provide an assessment of the type and levels of evidence found in the urological literature.

MATERIALS AND METHODS

Three reviewers rated a random sample of 600 articles published in 4 major urology journals, including 300 each in 2000 and 2005. The level of evidence rating system was adapted from the Center of Evidence Based Medicine. Sample size was estimated to detect a relative increase in the proportion of studies that provided a high level of evidence (I and II combined) from 0.2 to 0.3 with 80% power.

RESULTS

Of the 600 studies reviewed 60.3% addressed questions of therapy or prevention, 11.5% addressed etiology/harm, 11.3% addressed prognosis and 9.2% addressed diagnosis. The levels of evidence provided by these studies from I to IV were 5.3%, 10.3%, 9.8% and 74.5%, respectively. A high level of evidence was provided by 16.0% of studies in 2000 and by 15.3% in 2005 (p = 0.911).

CONCLUSIONS

This study suggests that a majority of studies in the urological literature provide low levels of evidence that may not be well suited to guide clinical decision making. We propose that editors of leading urology journals should promote awareness for this guiding principle of evidence based clinical practice by providing a level of evidence designation with each published study.