The changing landscape of product development and randomized trials

The need for state-of-the-art orthopedic surgical technology in low- to middle income countries : The case of distraction epiphyseolysis for limb lengthening in children with fibular hemimelia in Uzbekistan

INTRODUCTION

Amongst low- to middle income countries (LMIC), outdated and poorly documented orthopedic interventions may pose patients at risk for complications, serious adverse events (SAE) and unsatisfactory results, contradicting the World Health Organization's (WHO) Safe Surgery mandates. Use cases of conditions managed inadequately in LMIC environments are necessary to increase awareness of stakeholders and overcome deficiencies in collaboration with high-income countries (HIC).

MATERIALS AND METHODS

Methodological and clinical experts from the BG Kliniken and the Charité, Berlin, Germany, were invited to investigate established processes for musculoskeletal disorders and injuries in Tashkent, Uzbekistan. Congenital lower leg discrepancy due to fibular hemimelia was recognized as an illustrative example to prove the effectiveness of local treatment guidelines, still relying on distraction epiphyseolysis (chondrodiatasis) via an Ilizarov frame. Routine data from hospital records, images and outpatient follow-up examinations were compared to estimates from a review of studies of limb-lengthening by other techniques.

RESULTS

Data from 16 of 49 immature patients (10 males, 6 females, mean age at surgery, 4.2 ± 2.3 years) undergoing chondrodiatasis between 2017 and 2021 showed a mean limb elongation of 2.4 (95% confidence interval [CI], 1.9 to 2.9) cm after a median follow-up of 29 (range, 24 to 36) months. While no complications or SAE were noted, findings are compatible with a risk of 21% under an upper 97.5% confidence limit for null events. No reproducible classification of hemimelia, surgical or general complications, assessment of functional outcomes or health-related quality of life were available. The pooled average length gain from 21 studies on different other interventions with osteotomy enrolling 458 limbs was 5.1 (95% CI, 5.0 to 5.3) cm.

CONCLUSIONS OF THE USE CASE

Limb lengthening for hereditary fibular hemimelia in Uzbekistan revealed rather obsolete surgical algorithms, inadequate documentation, and unreliable outcome assessment. Resource limitations notwithstanding, knowledge transfer, implementation of current procedures and hardware, and international collaboration is vital to improve quality of care in this scenario and for the benefit of LMIC in general.

[Interpretation of systematic review articles and meta-analyses : Clinical trials in trauma surgery and orthopedics]

Clinical trials must be planned and interpreted in the context of current best clinical and scientific evidence, undoubtedly provided by systematic reviews and meta-analyses, especially Cochrane Reviews. While many clinicians feel overwhelmed by this complex data source, few visualElements (e.g., the traffic light system of the Cochrane risk of bias [RoB‑2] tool, forest plots, etc.), together with indices such as the I2 heterogeneity statistic, allow for a quick appraisal of all critical and necessary qualitative and quantitative information. The effectiveness of different treatment options can indirectly be assessed by methodological advancements like network meta-analyses.Point estimates of percentages are insufficient to describe the utility and value of a proposed novel intervention, which, in orthopedic and trauma surgery, often represents a step innovation. 95% confidence intervals and the so-called fragility index are helpful in determining the ultimate patient benefit.

[Clinical studies in trauma surgery and orthopedics: read, interpret and implement]

Für eine informierte, partizipative ärztliche Entscheidungsfindung müssen Sie neben Ihrem Erfahrungswissen aktuelle wissenschaftliche Daten berücksichtigen. Die digitale Informationsflut macht es im klinischen Alltag allerdings schwer, immer auf dem Stand des Wissens zu bleiben. Der Beitrag bietet einige Hilfen an, wie mit diesem Problem umgegangen werden kann. Ein grundlegendes Verständnis über Vor- und Nachwahrscheinlichkeiten sowie systematische Fehler (Bias) erleichtert die Abwägung zwischen Nutzen und Risiko z. B. einer (chirurgischen) Intervention im Vergleich zu einer nichtoperativen Therapie. Randomisierte Studien („randomized controlled trials“, RCT, mit allen modernen Modifikationen) liefern unverzerrte Ergebnisse, führen in Orthopädie und Unfallchirurgie evtl. zu einer stark selektierten, nichtrepräsentativen Stichprobe, und ihre Resultate müssen durch weitere, unabhängige RCT bestätigt oder widerlegt werden. Große beobachtende Datenmengen (z. B. aus Registern) können quasiexperimentell modelliert werden und RCT in der Gesundheitstechnologiebewertung flankieren.

True Transosseous Hybrid Rotator Cuff Repair

Transosseous repair has been used safely and effectively for primary and revision rotator cuff repair for decades; as a result, it is considered by many the historical gold standard of open repair techniques. Transosseous repair offers the advantage of excellent biology, double-row anatomic footprint reconstruction, and the ability to create multiple low-cost fixation points per surface area of tendon with high-strength suture, while avoiding anchor pullout, cyst formation, and imaging artifact. More recently, in arthroscopic applications, transosseous-equivalent anchor-based repairs have been introduced that have shown satisfactory clinical and biomechanical results; however, these attributes have been coupled with increased cost, nonbiologic burden to the healing interface of the tendon, and new catastrophic failure modes including tendon transection, anchor pullout, and bone voids. This article delineates a technique for arthroscopic true transosseous hybrid cuff repair that combines the use of anchors and transosseous techniques to maximize the benefits and minimize the detriments of both techniques. Level 1 (shoulder); level 2 (rotator cuff).

[Evidence-based trauma and orthopedic surgery : 20 years after Sackett]

The article "Evidence based medicine: what it is and what it isn't" published in the BMJ in 1996, is regarded as the foundation of the evidence-based medicine (EbM) movement. Approximately 5 years later David L. Sackett, one of the leaders of the movement, requested all experts to voluntarily abandon their position to make way for young researchers and fresh ideas. Since the term was first coined and the establishment of organizations and platforms fostering the idea, EbM has polarized clinicians and scientists around the world. Clinical and methodological developments during recent years have, however, overtaken the original principles of EbM. This review highlights the core concepts of EbM which have remained unchanged and valid for the current practice of trauma and orthopedic surgery and where revision is needed.

Comparison of Registered and Published Primary Outcomes in Randomized Controlled Trials of Orthopaedic Surgical Interventions

BACKGROUND

The selective reporting of a subset of the outcomes that had been originally reported to a registry is a potential threat to the validity of evidence-based medicine. The extent of selective reporting has not been described for randomized controlled trials (RCTs) assessing the effectiveness of orthopaedic surgical interventions. The objective of this study was (1) to determine the percentage of orthopaedic surgical RCTs published in high-impact orthopaedic journals that were reported to have been registered, (2) to evaluate the consistency between the primary outcome measures recorded in the registry and those reported in the article, and (3) to evaluate whether selective reporting favored statistically significant outcomes.

METHODS

We searched PubMed for articles on RCTs assessing orthopaedic surgical interventions indexed from January 2010 through December 2014 and published in the ten orthopaedic journals with the highest impact factors. For every article in which the authors reported registration of the RCT, we extracted the number and nature of the outcome measures from the article and the corresponding information from the registry. We then evaluated the consistency between the primary outcome measures reported in the registry and those reported in the published article. Moreover, we evaluated whether selective reporting favored statistically significant outcomes.

RESULTS

Of the 362 articles on orthopaedic surgical RCTs, ninety (24.9%) reported that the RCT had been registered and thirty-four (37.8%) of the ninety had been registered adequately (registered before the study end with a clear description of the primary outcome measure and its time frame, with no substantial change after the study end). Twenty-six reports were eligible for our evaluation of the consistency between the registered primary outcome measures and those reported in the published article. This analysis identified one or multiple major discrepancies for fourteen articles, eight of which favored statistically significant results.

CONCLUSIONS

Few articles on orthopaedic surgical RCTs reported registration of the trial, and even fewer of these trials were registered adequately. Inconsistencies between registered primary outcome measures and those reported in the published articles, as well as selective outcome reporting favoring statistically significant outcomes, were prevalent.

CLINICAL RELEVANCE

Although trial registration is now the rule, it is currently far from optimal for orthopaedic surgical RCTs, and selective outcome reporting is prevalent. Full involvement of authors, editors, and reviewers is necessary to ensure publication of quality, unbiased results.

Strategies to improve clinical research in surgery through international collaboration

More than 235 million patients undergo surgery every year worldwide, but less than 1% are enrolled in surgical clinical trials--few of which are international collaborations. Several levels of action are needed to improve this situation. International research collaborations in surgery between developed and developing countries could encourage capacity building and quality improvement, and mutually enhance care for patients with surgical disorders. Low-income and middle-income countries increasingly report much the same range of surgical diseases as do high-income countries (eg, cancer, cardiovascular disease, and the surgical sequelae of metabolic syndrome); collaboration is therefore of mutual interest. Large multinational trials that cross cultures and levels of socioeconomic development might have faster results and wider applicability than do single-country trials. Surgeons educated in research methods, and aided by research networks and trial centres, are needed to foster these international collaborations. Barriers to collaboration could be overcome by adoption of global strategies for regulation, health insurance, ethical approval, and indemnity coverage for doctors.