Design and execution of clinical trials in orthopaedic surgery

Teaching Science to the Next Generation

Teaching science to the next generation begins with foundations laid in podiatric medical school. Interest and immersion in research continues to develop through residency as trainees prepare for cases, participate in journal clubs, present posters and articles, and attend conferences. Having adequate training is essential to production of quality research. Although challenges and barriers exist, numerous resources are available at all levels of practice to guide those who are interested in contributing to the body of literature that supports the profession. Ensuring a robust pipeline of future clinician scientists is critical to the future of the profession.

Acetabular cup fixation with and without screws following primary total hip arthroplasty: migration evaluated by radiostereometric analysis

BACKGROUND

Early cup migration after total hip arthroplasty (THA) is correlated to late revision due to aseptic loosening. However, the use of screws for increased cup stability remains unclear and debated. The purpose of this study is to assess acetabular migration between cups fixated with and without the use of screws.

METHODS

Patients underwent primary THA using either a direct anterior (DA) or a direct lateral (DL) approach. The DA surgeon routinely supplemented cup fixation with 1 or 2 screws while the DL surgeon used no screws. At 7 follow-up visits up to 2 years post operation, patients underwent radiostereometric analysis (RSA) imaging for implant migration tracking. The primary outcome was defined as proximal cup migration measured with model-based RSA.

RESULTS

68 patients were assessed up to 2 years post operation, n = 43 received screws and n = 25 did not. The use of screws had a significant effect on cup migration (p = 0.018). From 2 weeks to 2 years post operation, the total mean migration was 0.403 ± 0.681 mm and 0.129 ± 0.272 mm (p = 0.319) for cups with and without screws, respectively. The number of screws used also had a significant impact, with cups fixated with 1 screw migrating more than cups fixated with 2 (p = 0.013, mean difference 0.712 mm).

CONCLUSIONS

Acetabular cups fixated with only 1 screw resulted in greater migration than cups with no screws or 2 screws, though the mean magnitude was well under the 1.0 mm threshold for unacceptable migration. However, 3 of the 24 patients who received only 1 screw exceeded the 1.0 mm threshold for unacceptable migration. Ultimately, the results of this study show that the use of 2 screws to supplement cup fixation can provide good implant stability that is equivalent to a secure press-fit component with no screws.Clinical trial registration: ClinicalTrials.gov (NCT03558217).

Assessment and trends in the methodological quality of the top 50 most cited articles in shoulder arthroplasty

INTRODUCTION

Shoulder arthroplasty is increasingly frequent, and the associated literature is abundant. Citation rate is often considered a good means of assessing impact and scientific value. However, analysis of methodological quality is also essential in evidence-based medicine.

OBJECTIVES

(1) To identify the 50 most cited articles on shoulder arthroplasty, and (2) to assess the correlation between citation rate and methodological quality. The study hypothesis was that there is no correlation between citation rate and methodological quality.

METHOD

Articles were retrieved from PubMed and Google Scholar, identifying the 50 most cited articles on shoulder arthroplasty via the keywords "shoulder joint replacement", "shoulder arthroplasty", "anatomic shoulder prothesis", "reverse shoulder prothesis", and "glenohumeral arthritis". Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS) were calculated.

RESULTS

Mean citation rate for the 50 articles was 312.4±169.5 (range, 151-841.5), with a mean citation density of 18.8±10.6 (range, 4.7-46.7). 56% of the studies (28/50) were retrospective case series with level of evidence IV. There was no correlation between citation rate and methodological quality.

DISCUSSION

The 50 most cited articles on shoulder arthroplasty mostly showed low levels of methodological quality. There was no correlation between citation rate and methodological quality: the literature needs to be read with a critical eye.

LEVEL OF EVIDENCE

IV.

Impact of Large Database Studies on Orthopedic Surgery Literature: Are We Advancing the Field?

Background: While database studies have become more prevalent in the literature, there is concern over their value. In addition, the questions they are suitable to answer are limited. Questions/Purposes: We sought to determine the incidence of database studies in the orthopedic literature and in each subspecialty. In addition, we wanted to assess the impact of database studies on the literature by determining whether citations and Altmetric Attention Scores (AAS) varied by study type (studies using internal or external databases and those not using databases). Methods: We searched PubMed for articles published in impactful orthopedic surgery journals in the year 2018. All articles were discoverable on the Altmetric explorer portal database. Impact was determined by journal impact factor. Study design, subspecialty, number of citations, and AAS were obtained. Univariable analyses were conducted between study type, demographic variables, and the outcome of either citation count or AAS. Multivariable analyses were performed to identify independent predictors of the primary outcomes. Subgroup analyses were performed to differentiate the impact of external and internal database studies compared with non-database studies. Results: A total of 2684 total articles were eligible for inclusion. Of these, 366 studies (13.6%) were database studies. Hip and knee articles had the greatest incidence of database studies. Database studies had significantly more citations (5.9 vs 4.0) and significantly higher AAS (12.8 vs 11.3) compared with non-database studies. External database studies had significantly more citations (6.7 vs 4.8) and significantly higher AAS (14.0 vs 10.7) than internal database studies. Internal database studies had higher traditional citation counts but similar AAS to non-database studies. Conclusions: In 2018, database studies in well-reputed orthopedic journals had a greater number of citations but similar AAS compared with non-database studies. Further studies are warranted.

Propensity Scores: Confounder Adjustment When Comparing Nonrandomized Groups in Orthopaedic Surgery

Many studies in arthroplasty research are based on nonrandomized, retrospective, registry-based cohorts. In these types of studies, patients belonging to different treatment or exposure groups often differ with respect to patient characteristics, medical histories, surgical indications, or other factors. Consequently, comparisons of nonrandomized groups are often subject to treatment selection bias and confounding. Propensity scores can be used to balance cohort characteristics, thus helping to minimize potential bias and confounding. This article explains how propensity scores are created and describes multiple ways in which they can be applied in the analysis of nonrandomized studies. Please visit the following (https://www.youtube.com/watch?v=sqgxl_nZWS4&t=3s) for a video that explains the highlights of the paper in practical terms.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review

BACKGROUND

Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions.

AIM

To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures.

METHODS

We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published.

RESULTS

Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes.

CONCLUSION

The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.

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.

Assessment of Characteristics and Methodological Quality of the Top 50 Most Cited Articles on Platelet-Rich Plasma in Musculoskeletal Medicine

Background:

The wide range of clinical applications and controversial scientific evidence associated with platelet-rich plasma (PRP) therapy in musculoskeletal medicine requires an examination of the most commonly cited studies within this field.

Purpose:

To identify the 50 most cited articles on PRP, assess their study design, and determine any correlations between the number of citations and level of evidence (LoE) or methodological quality.

Study Design:

Cross-sectional study.

Methods:

The Web of Science database was queried to identify the top 50 most cited articles on PRP in orthopaedic surgery. Bibliometric characteristics, number of citations, and LoE were recorded. Methodological quality was evaluated using the Modified Coleman Methodology Score (MCMS), Methodological Index for Non-randomized Studies (MINORS), and Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO). The Pearson correlation coefficient and Spearman correlation coefficient (r_S) were used to determine the degree of correlation between the number of citations or citation density and LoE, MCMS, MINORS score, and MIBO score. Student t tests were performed for 2-group comparisons.

Results:

The top 50 articles were published between 2005 and 2016 in 21 journals. The mean number of citations and citation density were 241 ± 94 (range, 151-625) and 23 ± 8, respectively, and the mean LoE was 2.44 ± 1.67, with 15 studies classified as LoE 1. The mean MCMS, MINORS score, and MIBO score were 66.9 ± 12.6, 16 ± 4.7, and 12.4 ± 3.7, respectively. No correlation was observed between the number of citations or citation density and LoE, MCMS, MINORS score, and MIBO score. A significant difference (P = .02) was noted in LoE in articles from the United States (3.56 ± 1.7) versus outside the United States (2 ± 1.5). Seven of the 8 in vivo studies were published between 2005 and 2010, whereas 19 of the 25 clinical outcome investigations were published between 2011 and 2016. Studies that were published more recently were found to significantly correlate with number of citations (r_S = –0.38; P = .01), citation density (r_S = 0.36; P = .01), and higher LoE (r_S = 0.47; P = .01).

Conclusion:

The top 50 most cited articles on PRP consisted of high LoE and fair methodological quality. There was a temporal shift in research from in vivo animal studies toward investigations focused on clinical outcomes.

The rise of registry-based research: a bibliometric analysis

Background and purpose - The main purpose of arthroplasty registries is to collect information on patients, techniques, and devices to monitor and improve the outcome of the specific procedure. This study analyses the role played by registries in the orthopedic research community and describes publication trends, characteristics, and patterns of this field of research.Patients and methods - A descriptive-bibliometric review was conducted. Scopus was the database used for the research. All articles published from 1991 to December 2020 containing keywords related to registries and arthroplasty were considered. In particular, the following dimensions were analyzed in detail: (i) papers/year; (ii) journals; (iii) countries; (iv) research growth rate; (v) collaboration among countries. VOSviewer software was used to perform the bibliometric analysis. Finally, the 50 most cited papers of the last 10 years were briefly analyzed.Results - 3,933 articles were identified. There has been growing interest in the topic since 2010. Acta Orthopaedica ranked first for the number of articles published. The country with the largest number of articles citing registries was the United States, followed by the United Kingdom and Sweden. The relative number of articles per 100,000 inhabitants is 0.60 for Europe and 0.38 for the United States. The literature in this research area has an average yearly growth rate of 28%.Interpretation - The publication rate in the field of arthroplasty registries is constantly growing with a noteworthy impact in the evolution of this research and clinical area. The growth rate is significantly higher than that of arthroplasty literature (28% vs. 10%) and the collaboration among countries is strong and increasing with time.

Assessment and Trends of the Methodological Quality of the Top 50 Most Cited Articles on Patellar Instability

Background

Studies with a low level of evidence (LOE) have dominated the top cited research in many areas of orthopaedics. The wide range of treatment options for patellar instability necessitates an investigation to determine the types of studies that drive clinical practice.

Purpose

To determine (1) the top 50 most cited articles on patellar instability and (2) the correlation between the number of citations and LOE or methodological quality.

Study Design

Cross-sectional study.

Methods

The Scopus and Web of Science databases were assessed to determine the top 50 most cited articles on patellar instability between 1985 and 2019. Bibliographic information, number of citations, and LOE were collected. Methodological quality was calculated using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS). Mean citations and mean citation density (citations per year) were correlated with LOE, MCMS, and MINORS scores.

Results

Most studies were cadaveric (n = 10; 20.0%), published in the American Journal of Sports Medicine (n = 13; 26.0%), published between 2000 and 2009 (n = 41; 82.0%), and conducted in the United States (n = 17; 34.0%). The mean number of citations and the citation density were 158.61 ± 59.53 (range, 95.5-400.5) and 12.74 ± 5.12, respectively. The mean MCMS and MINORS scores were 59.62 ± 12.58 and 16.24 ± 3.72, respectively. No correlation was seen between mean number of citations or citation density versus LOE. A significant difference was found in the mean LOE of articles published between 1990 and 1999 (5.0 ± 0) versus those published between 2000 and 2009 (3.12 ± 1.38; P = .03) and between 2010 and 2019 (3.00 ± 1.10; P = .01).

Conclusion

There was a shift in research from anatomy toward outcomes in patellar instability; however, these articles demonstrated low LOE and methodological quality. Higher quality studies are necessary to establish informed standards of management of patellar instability.

Assessment and Trends in the Methodological Quality of the Top 50 Most Cited Articles in Shoulder Instability

Background:

Citation counts have often been used as a surrogate for the scholarly impact of a particular study, but they do not necessarily correlate with higher-quality investigations. In recent decades, much of the literature regarding shoulder instability is focused on surgical techniques to correct bone loss and prevent recurrence.

Purpose:

To determine (1) the top 50 most cited articles in shoulder instability and (2) if there is a correlation between the number of citations and level of evidence or methodological quality.

Study Design:

Cross-sectional study.

Methods:

A literature search was performed on both the Scopus and the Web of Science databases to determine the top 50 most cited articles in shoulder instability between 1985 and 2019. The search terms used included “shoulder instability,” “humeral defect,” and “glenoid bone loss.” Methodological scores were calculated using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS) score.

Results:

The mean number of citations and mean citation density were 222.7 ± 123.5 (range, 124-881.5) and 16.0 ± 7.9 (range, 6.9-49.0), respectively. The most common type of study represented was the retrospective case series (evidence level, 4; n = 16; 32%) The overall mean MCMS, Jadad score, and MINORS score were 61.1 ± 10.1, 1.4 ± 0.9, and 16.0 ± 3.0, respectively. There were also no correlations found between mean citations or citation density versus each of the methodological quality scores.

Conclusion:

The list of top 50 most cited articles in shoulder instability comprised studies with low-level evidence and low methodological quality. Higher-quality study methodology does not appear to be a significant factor in whether studies are frequently cited in the literature.

Clinical Level of Evidence Presented at the Cervical Spine Research Society (CSRS) Annual Meeting Over 10 Years (2008-2017): A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

We systematically reviewed the level of clinical evidence presented at Cervical Spine Research Society annual meetings from 2008 through 2017.

SUMMARY OF BACKGROUND DATA

The Cervical Spine Research Society is dedicated to advancing knowledge of the cervical spine to promote evidence-based care. Research presented at these meetings impacts clinical practice.

METHODS

A total of 774 paper abstracts presented at Cervical Spine Research Society (CSRS) annual meetings were independently assessed by two reviewers. Reviewers designated a clinical level of evidence (LOE) to each included abstract from level I to level IV based on criteria set forth by the Oxford Centre for Evidence-Based Medicine. Reviewer agreement was assessed using Cohens Kappa coefficient (k) and disagreements were discussed until a consensus was reached. Wilcoxon rank sum test was used to assess for differences in LOE grades. Chi-squared testing was used to assess nonrandom changes in level of evidence and in excluded studies.

RESULTS

A total of 583 abstracts were included. Over the last 10 CSRS meetings, 5.15% of presentations were level I, 27.8% level II, 27.4% level III, and 39.6% level IV. The average LOE from 2008 to 2017 was 3.02 (median = 3). Additionally, 49.7% were therapeutic studies, 37.6% prognostic studies, and 12.7% diagnostic studies. When comparing the first 5 years (2008-2012) to the last 5 years (2013-2017), we observed a significant increase in Level II (P = 0.007) evidence and a corresponding decrease in level IV evidence (P < 0.001). The average LOE improved from 3.14 (2008-2012) to 2.91 (2013-2017); there was a significant improvement in LOE between the two periods (P = 0.001).

CONCLUSION

Emphasis on evidence-based medicine within cervical spine research has positively influenced the clinical level of evidence disseminated at CSRS annual meetings between 2008 and 2017. Continued focus on higher quality Level I studies is warranted.

LEVEL OF EVIDENCE

4.

Clinical Level of Evidence Presented at the Lumbar Spine Research Society (LSRS) Annual Meeting Over 10 Years (2008-2017): A Systematic Review

STUDY DESIGN

A systematic review.

OBJECTIVE

The Lumbar Spine Research Society (LSRS) is dedicated to advancing knowledge of the lumbar spine to promote evidence-based care. We sought to systematically review the level of clinical evidence presented at LSRS annual meetings from 2008 through 2017.

SUMMARY OF BACKGROUND DATA

Improvements in clinical evidence have been reported at similar bone and joint scientific meetings.

METHODS

A total of 458 paper abstracts presented at LSRS annual meetings were independently assessed by two reviewers. Only clinical studies being included for analysis. Reviewers designated a clinical level of evidence (LOE) to each included abstract from level I to level IV based on criteria set forth by the Oxford Centre for Evidence-Based Medicine. Reviewer agreement was assessed using Cohens Kappa coefficient (k). Student t test was used to assess for differences in mean LOE grades. Chi-squared testing was used to assess nonrandom changes in LOE.

RESULTS

A total of 299 abstracts met inclusion criteria. Over the last 10 LSRS meetings, 2.68% of the presentations were level I, 22.4% were level II, 37.1% were level III, and 37.8% were level IV. We found the average LOE from 2008 to 2017 to be 3.10 (median = 3). In addition, 63.9% presentations were Therapeutic Studies, 30.1% were Prognostic Studies, and 6.02% were Diagnostic studies. When comparing the first 5 years (2008-2012) to the last 5 years (2013-2017), we observed a significant increase in Level II (P < 0.05) and Level III (P < 0.05) evidence along with a corresponding decrease in level IV evidence (P < 0.01). The average LOE improved significantly from 3.28 (2008-2012) to 2.88 (2013-2017) (P < 0.001).

CONCLUSION

Emphasis on evidence-based medicine within spine surgery, specifically pertaining to the lumbar spine, has positively influenced the clinical LOE disseminated at LSRS annual meetings between 2008 and 2017.

LEVEL OF EVIDENCE

4.

Engineering Stem and Stromal Cell Therapies for Musculoskeletal Tissue Repair

Stem cells and tissue-derived stromal cells stimulate the repair of degenerated and injured tissues, motivating a growing number of cell-based interventions in the musculoskeletal field. Recent investigations have indicated that these cells are critical for their trophic and immunomodulatory role in controlling endogenous cells. This Review presents recent clinical advances where stem cells and stromal cells have been used to stimulate musculoskeletal tissue repair, including delivery strategies to improve cell viability and retention. Emerging bioengineering strategies are highlighted, particularly toward the development of biomaterials for capturing aspects of the native tissue environment, altering the healing niche, and recruiting endogenous cells.

Nonsteroidal Anti-Inflammatory Drugs and Bone-Healing: A Systematic Review of Research Quality

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often avoided by orthopaedic surgeons because of their possible influence on bone-healing. This belief stems from multiple studies, in particular animal studies, that show delayed bone-healing or nonunions associated with NSAID exposure. The purpose of this review was to critically analyze the quality of published literature that evaluates the impact of NSAIDs on clinical bone-healing.

METHODS

A MEDLINE and Embase search was conducted to identify all articles relating to bone and fracture-healing and the utilization of NSAIDs. All human studies, including review articles, were identified for further analysis. Non-English-language manuscripts and in vitro and animal studies were excluded. A total of twelve clinical articles and twenty-four literature reviews were selected for analysis. The quality of the clinical studies was assessed with a modified Coleman Methodology Score with emphasis on the NSAID utilization. Review articles were analyzed with regard to variability in the cited literature and final conclusions.

RESULTS

The mean modified Coleman Methodology Score (and standard deviation) was significantly lower (p = 0.032) in clinical studies that demonstrated a negative effect of NSAIDs on bone-healing (40.0 ± 14.3 points) compared with those that concluded that NSAIDs were safe (58.8 ± 10.3 points). Review articles also demonstrated substantial variability in the number of cited clinical studies and overall conclusions. There were only two meta-analyses and twenty-two narrative reviews. The mean number (and standard deviation) of clinical studies cited was significantly greater (p = 0.008) for reviews that concluded that NSAIDs were safe (8.0 ± 4.8) compared with those that recommended avoiding them (2.1 ± 2.1). Unanimously, all reviews admitted to the need for prospective randomized controlled trials to help clarify the effects of NSAIDs on bone-healing.

CONCLUSIONS

This systematic literature review highlights the great variability in the interpretation of the literature addressing the impact of NSAIDs on bone-healing. Unfortunately, there is no consensus regarding the safety of NSAIDs following orthopaedic procedures, and future studies should aim for appropriate methodological designs to help to clarify existing discrepancies to improve the quality of care for orthopaedic patients.

CLINICAL RELEVANCE

This systematic review highlights the limitations in the current understanding of the effects of NSAIDs on bone healing. Thus, withholding these medications does not have any proven scientific benefit to patients and may even cause harm by increasing narcotic requirements in cases in which they could be beneficial for pain management. This review should encourage further basic-science and clinical studies to clarify the risks and benefits of anti-inflammatory medications in the postoperative period, with the aim of improving patient outcomes.

Clinical research on postoperative trauma care: has the position of observational studies changed?

OBJECTIVE

The postoperative care regimes of ankle fractures are studied for over 30 years and recommendations have shifted only slightly in the last decades. However, study methodology might have evolved. The aim of this study was to evaluate the changes in time in the design, quality and outcome measures of studies investigating the postoperative care of ankle fractures.

METHODS

The MEDLINE and EMBASE database were searched for both RCTs and cohort studies. The original studies were divided into decades of publication over the last 30 years. The methodological quality of the studies was assessed using the 'traditional' risk of bias assessment tool provided by The Cochrane Collaboration and the 'newer' MINORS criteria.

RESULTS

The percentage of RCTs on this subject declined from 67 to 38 % in the last decades. According to the Cochrane tool, the reported quality of RCTs has improved in the last three decades whereas the reported quality of observational studies has remained unchanged. However, when quality was evaluated with the MINORS criteria, equal improvement was observed for both RCTs and observational studies. In the 80s, 67 % of all studies used the range of motion as the primary outcome measure, which decreased to 45 % in the 90s. In the 00s, none of the studies used the range of motion as the primary outcome.

CONCLUSION

For postoperative care of ankle fractures, results of this study showed a relative decrease in the published number of RCTs. The overall quality of the published articles did not decline. In addition, a gradual shift from physician measured to patient-reported outcome variables was observed. However, it should be borne in mind that the findings are based on a small sample (n = 25).

The 50 Most Cited Articles in Orthopedic Cartilage Surgery

OBJECTIVE

To determine the 50 most cited articles in orthopedic cartilage surgery and their characteristics.

DESIGN

A systematic review of the Science Citation Index Expanded was performed for articles related to cartilage surgery published in the 66 journals under the category "Orthopedics." The 50 most cited articles were determined, and the following characteristics were analyzed for each article: authors, journal and year of publication, number of citations, geographic origin, article type (basic science or clinical), article subtype by study design, and level of evidence. Citation density (total number of citations/years since publication) was also computed.

RESULTS

The 50 most cited articles ranged from 989 to 172 citations, with citation density ranging from 71.5 to 4.1. The publication years spanned from 1968 to 2008, with the 2000s accounting for half (25) of the articles and the highest mean citation density (14.6). The 50 most cited articles were published in 11 journals. The majority of the articles (29) were clinical, with level IV representing the most common level of evidence (10). The remaining basic science articles were most commonly animal in vivo studies (14). Stronger level of evidence was correlated with overall number of citations (P = 0.044), citation density (P < 0.001), and year of publication (P = 0.003).

CONCLUSIONS

Articles with stronger levels of evidence are more highly cited, with an increasing trend as evidence-based practice has been emphasized. This article list provides clinicians, researchers, and trainees with a group of "citation classics" in orthopedic cartilage surgery.

Feasibility of individual patient data meta-analyses in orthopaedic surgery

BACKGROUND

The number of individual patient data meta-analyses published is very low especially in surgical domains. Our aim was to assess the feasibility of individual patient data (IPD) meta-analyses in orthopaedic surgery by determining whether trialists agree to send IPD for eligible trials.

METHODS

We performed a literature search to identify relevant research questions in orthopaedic surgery. For each question, we developed a protocol synopsis for an IPD meta-analysis and identified all related randomized controlled trials (RCTs) with results published since 2000. Corresponding authors of these RCTs were sent personalized emails that presented a project for an IPD meta-analysis corresponding to one of the research questions, with a link to the protocol synopsis, and asking for IPD from their RCT. We guaranteed patient confidentiality and secure data storage, and offered co-authorship and coverage of costs related to extraction.

RESULTS

We identified 38 research questions and 273 RCTs related to these questions. We could contact 217 of the 273 corresponding authors (79 %; 56 had unavailable or non-functional email addresses) and received 68/273 responses (25 %): 21 authors refused to share IPD, 10 stated that our request was under consideration and 37 agreed to send IPD. Four corresponding authors required authorship and three others asked for financial support to send the IPD. Overall, we could obtain IPD for 5,110 of 33,602 eligible patients (15 %). Among the 38 research questions, only one IPD meta-analysis could be potentially initiated because we could receive IPD for more than 50 % of participants.

CONCLUSION

The present study illustrates the difficulties in initiating IPD meta-analyses in orthopaedic surgery. Significant efforts must be made to improve data sharing.