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Baylor JL, Luciani AM, Tokash JS, Foster BK, Klena JC, Grandizio LC. Fifty Most-Cited Research Articles in Elbow Surgery: A Modern Reading List. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:630-637. [PMID: 37790825 PMCID: PMC10543795 DOI: 10.1016/j.jhsg.2023.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 03/07/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose Bibliometric analysis is a common method for evaluating current trends within a scientific field. The primary aim of this study was to define and analyze the 50 most frequently cited articles in the field of elbow surgery, both of all time and those published during the 21st century. Methods We searched the Journal Citation Report to identify articles related to elbow surgery within academic journals. Articles were sorted by total citations. The overall top 50 articles and those published since 2000 were identified, and data were collected, including title, journal of publication, publication year, country of publication, citation density, level of evidence, article type, institution, and sex of the lead and senior authors, and inclusion on the reference list for the Orthopaedic In-Training Examination within the last 5 years. Descriptive statistics were reported, and correlation analysis was performed using Spearman test. Results For the most-cited elbow surgery articles, "fracture" was overall the most reported topic, whereas "lateral epicondylosis" and "fracture" were equal for those published since 2000. The United States was the most represented overall and for articles published since 2000. Women comprised 1/50 (2%) of lead authors overall, increasing to 8/50 (16%) for articles published during the 21st century. Most articles in during both periods contained level IV evidence, with level I evidence appearing infrequently (4%). Six percent of the most-cited articles of all time had appeared on the reference list of the Orthopaedic In-Training Examination within the past 5 years. Conclusions The top 50 most-cited elbow surgery articles often assess fracture and lateral epicondylosis, most commonly originating from the United States. Level IV retrospective series comprises over half of the articles on this list. Women remain underrepresented as authors. Clinical Relevance This study provides a modern reading list for upper-extremity surgeons about impactful elbow surgery articles.
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Affiliation(s)
- Jessica L. Baylor
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - A. Michael Luciani
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Jeremy S. Tokash
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Brian K. Foster
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Joel C. Klena
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Louis C. Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
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Chen B, Floyd S, Jindal D, Chapman C, Brooks J. 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. BMC Health Serv Res 2022; 22:590. [PMID: 35505315 PMCID: PMC9063084 DOI: 10.1186/s12913-022-07839-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Brian Chen
- Department of Health Services Policy and Management, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC, 29208, USA.
| | - Sarah Floyd
- College of Behavioral, Social and Health Sciences, Clemson University, 116 Edwards Hall, Clemson, SC, 29634, USA
| | - Dakshu Jindal
- Department of Health Services Policy and Management, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC, 29208, USA
| | - Cole Chapman
- Department of Pharmacy Practice and Science, University of Iowa, 345 CPB, 180 South Grand Ave, Iowa City, IA, 52242, USA
| | - John Brooks
- Center for Effectiveness Research in Orthopaedics (CERortho), University of South Carolina, 915 Greene Street Suite 302, Columbia, SC, 29208, USA
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Chen B, Chapman C, Bauer Floyd S, Mobley J, Brooks J. State medical malpractice laws and utilization of surgical treatment for rotator cuff tear and proximal humerus fracture: an observational cohort study. BMC Health Serv Res 2021; 21:516. [PMID: 34049554 PMCID: PMC8161917 DOI: 10.1186/s12913-021-06544-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/13/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Brian Chen
- Department of Health Services Policy and Management, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC, 29205, USA.
| | - Cole Chapman
- Department of Pharmacy Practice and Science, University of Iowa, 345 CPB, 180 South Grand Ave, Iowa City, IA, 52242, USA
| | - Sarah Bauer Floyd
- College of Behavioral, Social and Health Sciences, Clemson University, 116 Edwards Hall, Clemson, SC, 29634, USA
| | - John Mobley
- University of South Carolina School of Medicine Greenville , 607 Grove Rd, SC, 29605, Greenville, USA
| | - John Brooks
- Department of Health Services Policy and Management, University of South Carolina, 915 Greene Street Suite 302, Columbia, SC, 29205, USA
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Livingstone A, Asaid R, Moaveni AK. Is routine distal clavicle resection necessary in rotator cuff repair surgery? A systematic review and meta-analysis. Shoulder Elbow 2019; 11:39-45. [PMID: 31019561 PMCID: PMC6463380 DOI: 10.1177/1758573217741124] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/14/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The objective of the present study was to perform a systematic review and meta-analysis of randomized controlled trials looking at the effect of distal clavicle resection in patients undergoing rotator cuff repair (RCR). METHODS A systematic literature search was undertaken to identify randomized controlled trials looking at RCR +/- distal clavicle resection. Primary clinical outcome measures included in the meta-analysis were American Shoulder Elbow Society (ASES) score, pain on visual analogue scale and range of motion in forward elevation. RESULTS The systematic review identified three studies with a total of 203 participants. Those who underwent distal clavicle resection in conjunction with RCR had worse pain and acromioclavicular joint tenderness at 3-month follow-up. This difference, however, was not observed at the 24-month follow-up. The mean difference (95% confidence interval) for the ASES score was 0.45 (-3.67 to 4.58) and pain on visual analogue scale was - 0.27 (-0.70 to 0.16). CONCLUSIONS Routine distal clavicle resection in the setting of rotator cuff repair does not result in improved outcomes for patients with no difference being observed at 24 months post surgery. The results of our systematic review and meta-analysis do not support routine distal clavicle resection when performing RCR.
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Affiliation(s)
| | - Rafik Asaid
- Alfred Hospital, Melbourne, VIC, Australia,Rafik Asaid, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Austrailia.
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Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus. J Orthop Surg Res 2019; 14:22. [PMID: 30665430 PMCID: PMC6341604 DOI: 10.1186/s13018-018-1052-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/27/2018] [Indexed: 11/29/2022] Open
Abstract
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.
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Wright JG. Small Simple Trials: A Strategy for Orthopaedic Randomized Trials. J Bone Joint Surg Am 2018; 100:e95. [PMID: 30020133 DOI: 10.2106/jbjs.17.01107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James G Wright
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Hickey BA, Watson U, Cleves A, Alikhan R, Pugh N, Nokes L, Perera A. Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis. Foot Ankle Surg 2018; 24:19-27. [PMID: 29413769 DOI: 10.1016/j.fas.2016.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 06/24/2016] [Accepted: 06/29/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with below knee cast or splint. Our secondary aim was to report major bleeding events. METHODS MEDLINE and EMBASE databases were searched for randomized controlled trials from inception to 1st June 2015. RESULTS Seven studies were included. All focused on low molecular weight heparin (LMWH). None found a statistically significant symptomatic DVT reduction individually. At meta-analysis LMWH was protective against symptomatic DVT (OR 0.29, 95% CI 0.09-0.95). Symptomatic pulmonary embolism affected 3/692 (0.43%). None were fatal. 86 patients required LMWH thromboprophylaxis to prevent one symptomatic DVT event. The overall incidence of major bleeding was 1 in 886 (0.11%). CONCLUSIONS Low molecular weight heparin reduces the incidence of symptomatic VTE in adult patients with foot or ankle trauma treated with below knee cast or splint.
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Affiliation(s)
- Ben A Hickey
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK.
| | - Ultan Watson
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Andrew Cleves
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Raza Alikhan
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Neil Pugh
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Len Nokes
- Cardiff University, Cardiff, Wales, UK
| | - Anthony Perera
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
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The effect of active toe movement (AToM) on calf pump function and deep vein thrombosis in patients with acute foot and ankle trauma treated with cast - A prospective randomized study. Foot Ankle Surg 2017; 23:183-188. [PMID: 28865588 DOI: 10.1016/j.fas.2016.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/17/2016] [Accepted: 04/18/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with foot and ankle trauma treated with cast are advised to perform toe movements to prevent venous thromboembolism (VTE). Our aim was to determine the effect of active toe movement on asymptomatic deep vein thrombosis (DVT) and venous calf pump function. METHODS Patients aged 18-60 years with acute foot and ankle trauma requiring below knee non weight bearing cast were randomized to intervention (regular active toe movement) or control groups (n=100). Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic. Patients requiring chemical thromboprophylaxis were excluded. RESULTS 78 completed the study. 27% sustained asymptomatic DVT, with no statistically significant difference in calf pump function or DVT incidence between groups. All DVT's occurred in the injured lower limb. CONCLUSION Active toe movement is not a viable strategy for thromboprophylaxis in patients with acute foot and ankle trauma treated with cast.
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Abstract
Enhancing patient safety and the quality of care continues to be a focus of considerable public and professional interest. We have made dramatic strides in our technical ability to care for children with pediatric orthopaedic problems, but it has become increasingly obvious that there are also significant opportunities to improve the quality, safety, and value of the care we deliver. The purpose of this article is to introduce pediatric orthopaedic surgeons to the rationale for and principles of quality improvement and to provide an update on quality, safety, and value projects within Pediatric Orthopaedic Society of North America.
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Vemulakonda VM, Jones J. Barriers to participation in surgical randomized controlled trials in pediatric urology: A qualitative study of key stakeholder perspectives. J Pediatr Urol 2016; 12:180.e1-7. [PMID: 26455638 DOI: 10.1016/j.jpurol.2015.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Randomized controlled trials (RCTs) are considered the gold standard for assessing treatment efficacy. However, pediatric surgical RCTs have been limited in their ability to recruit patients. The purpose of this study was to identify barriers and motivators to pediatric participation in surgical RCTs. METHODS We conducted a series of two focus groups with parents and one focus group with urology providers for children aged <2 years of age with a diagnosis of Society for Fetal Urology grade 3 or 4 hydronephrosis. We then administered a survey to referring pediatricians based on the initial analysis of focus group findings. Theme analysis was used for all qualitative transcribed text data obtained from focus groups and open-ended survey questions using team-based inductive approaches. Descriptive statistics were obtained for the remainder of the provider survey. RESULTS Using qualitative text from stakeholders (n = 38) we identified four key themes across the data: responsibility to my child; responsibility to my patient; responsibility to the field; and irreversibility of surgery. Participants felt there was an obligation to be informed of relevant scientific research within a clinic research culture. However, there remains a disconnect for parents between randomized research studies that may ultimately benefit their child, depending on their age and concern their child is being treated as a 'guinea pig'. Some parents were willing to participate in RCTs but all were more open to participate in an observational study where the treatment decisions were felt to be under their control even when there was no "right answer" or multiple equivalent options for treatment. There was mixed opinion across the parents and providers whether research trial education and enrollment should be provided by the pediatrician or urologist. Active physician decisions were seen as critical within the context of a long term clinical relationship and provision of information of risks and benefits without pressure were considered essential for ethical research by both parents and providers. CONCLUSION While some parents are open to participation in surgical RCTs, providers and parents of children with hydronephrosis feel discomfort with the element of chance in surgical randomized trials. Parents and providers are more likely to participate in observational studies where treatment decisions may be made jointly by the physician and the parent. These findings suggest that pragmatic trial strategies with the option for participation in an observational cohort may improve recruitment of pediatric patients into surgical clinical trials.
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Affiliation(s)
| | - Jacqueline Jones
- University of Colorado College of Nursing, Anschutz Medical Campus, Aurora, CO, USA
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Cochrane in CORR(®): Surgical Versus Non-surgical Treatment for Thoracolumbar Burst Fractures Without Neurological Deficit. Clin Orthop Relat Res 2016; 474:619-24. [PMID: 25903942 PMCID: PMC4746176 DOI: 10.1007/s11999-015-4305-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 04/09/2015] [Indexed: 01/31/2023]
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Surgeon practices regarding infection prevention for growth friendly spinal procedures. J Child Orthop 2014; 8:245-50. [PMID: 24744235 PMCID: PMC4142892 DOI: 10.1007/s11832-014-0584-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/01/2014] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The rate of infection in patients having growth sparing surgery for early onset scoliosis has been reported up to 25 % during the course of treatment. A recent study demonstrated significant variability in the approach to infection prevention in adolescent and neuromuscular scoliosis. The purpose of this study is to conduct a similar survey in order to understand approaches used by experienced pediatric spinal surgeons with regard to infection prevention in growth friendly spinal procedures. MATERIALS AND METHODS After preliminary internal testing of a survey by the authors, a final 21-question survey was created and approved by the authors and electronically distributed to all members of the Chest Wall Spinal Deformity Study Group and the Growing Spine Study Group (n = 57). A total of 40 responses were obtained (70 %). RESULTS Significant variability in practice was demonstrated across the majority of the questions answered. Several of the questions demonstrated relative equipoise between practices, including preoperative MRSA screening, preoperative chlorhexidine baths, postoperative antibiotic duration after insertion, use of topical antibiotics, use of drains, use of IV gram negative coverage or vancomycin, and skin preparation. CONCLUSION Other studies have demonstrated that variability in practice may have a negative impact on clinical outcomes, so one could postulate that steps that can reduce variability in the current population may help improve outcomes in this population. Areas of clinical equipoise can be used to help design and direct multicenter studies with an ultimate goal of reducing infections in this population. LEVEL OF EVIDENCE Level V.
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Corona J, Miller DJ, Downs J, Akbarnia BA, Betz RR, Blakemore LC, Campbell RM, Flynn JM, Johnston CE, McCarthy RE, Roye DP, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, Sturm PF, Thompson GH, Yazici M, Vitale MG. Evaluating the extent of clinical uncertainty among treatment options for patients with early-onset scoliosis. J Bone Joint Surg Am 2013; 95:e67. [PMID: 23677368 DOI: 10.2106/jbjs.k.00805] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Literature guiding the management of early-onset scoliosis consists primarily of studies with a low level of evidence. Evaluation of clinical equipoise (i.e., when there is no known superiority among treatment modalities) allows for prioritization of research efforts. The objective of this study was to evaluate areas of clinical uncertainty among pediatric spine surgeons regarding the treatment of early-onset scoliosis. METHODS Fourteen experienced pediatric spine surgeons participated in semistructured interviews to identify clinical variables that influence decision making in the treatment of early-onset scoliosis. A series of case scenarios of 315 patients with idiopathic and neuromuscular early-onset scoliosis was then developed to be representative of those encountered in clinical practice. Using an online survey, eleven surgeons selected their choice of eight treatment options for each case scenario. Associations between case characteristics and treatment choices were assessed with chi-square and logistic regression analysis. Participants then reviewed the areas of treatment uncertainty identified in the survey, nominated additional research questions of interest, and ranked their interest to further explore the identified research questions. RESULTS Collective equipoise was identified in numerous scenarios in the survey spanning a range of ages and magnitudes of scoliosis, and additional questions were identified during the nominal group technique. Areas that had the greatest clinical uncertainty included the management of patients who have finished treatment with a growing-rod, timing of rod-lengthening intervals, and indications for spine-based and rib-based proximal instrumentation anchors. The use of rib anchors compared with spine-based anchors was ranked highly for consideration in future clinical trials. CONCLUSIONS Variability in decision making with regard to the optimum treatment of certain subsets of patients with early-onset scoliosis reflects gaps in the available evidence. Structured consensus methods identified priorities for higher levels of research in this area of scoliosis. Higher-level studies, including randomized trials, should focus on answering the questions highlighted in this report.
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Affiliation(s)
- Jacqueline Corona
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, 701 North First Street, Room D220, Springfield, IL 62702, USA
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Abstract
BACKGROUND AND PURPOSE Hip fractures are among the top causes of global disability. Conduction of high-quality studies such as randomized controlled trials to assess the effectiveness of interventions remains crucial. The geographic distribution of hip fracture studies is largely unknown. We wanted to make a global assessment of national contributions of randomized controlled trials on surgical interventions for hip fracture. METHODS We performed a systematic search for randomized controlled trials on surgical interventions for hip fracture that were published from May 1970 to May 2011. Study information including sample size and study location was abstracted. The number of trials and cumulative sample size of hip fracture clinical trials were analyzed with respect to geographic region (city, country, and continent). RESULTS We identified 199 randomized trials investigating surgical interventions. Sweden ranked highest with 50 trials (8,941 patients). The United Kingdom followed with 40 trials (7,589 patients). Other countries contributed substantially less. The United States and Canada together contributed only a tenth of the total number of trials contributed by European countries. INTERPRETATION Global contributions to randomized trials and the total number of patients recruited have been led by Scandinavian countries and the UK. Countries with few trials but a large burden of hip fractures have an opportunity to engage in high-quality research to resolve important surgical questions and improve the generalizability of study results.
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Affiliation(s)
- Marco Yeung
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Sibai T, Carlisle H, Tornetta P. The darker side of randomized trials: recruitment challenges. J Bone Joint Surg Am 2012; 94 Suppl 1:49-55. [PMID: 22810448 DOI: 10.2106/jbjs.l.00240] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Randomized trials are thought to provide optimal evidence if carried out correctly. Their application to important questions is the best guide to clinical decision-making. However, these trials are expensive to complete and have a variety of challenges in design and application. This article will review some of the factors that affect our ability to recruit patients into randomized controlled trials for conditions that may be treated surgically by different methods or for conditions for which both nonsurgical and surgical treatments exist.
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Affiliation(s)
- Tarek Sibai
- Department of Orthopaedic Surgery, Boston University Medical Center, 850 Harrison Avenue, D2N, Boston, MA 02118, USA
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Abstract
Randomized controlled trials continue to be at the pinnacle of the evidence hierarchy. With this unique vantage point, they inform medical practice, clinical guidelines, health policy, and reimbursement. Prior to an emphasis on randomized controlled trials, traditional clinical research consisted primarily of uncontrolled case series and expert opinions. Randomized controlled trials are a true experiment in clinical practice and provide the most valid answers to clinical questions by reducing bias originating from patients, providers, and investigators. Riding on the coattails of other medical subspecialties, orthopaedic surgeons have recognized the importance of evidence-based medicine. From 1975 to 2005, the number of Level-I studies increased over fivefold and comprised >20% of studies published in The Journal of Bone and Joint Surgery (American Volume) (JBJS). With the emergence of comparative effectiveness research, the definition and methods of best evidence may continue to evolve. In conclusion, substantial improvements in both the quantity and the quality of randomized controlled trials in orthopaedic surgery have occurred, although unique considerations still limit their widespread use.
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Affiliation(s)
- S Samuel Bederman
- Department of Orthopaedic Surgery, University of California at Irvine, 101 The City Drive South, Pavilion III, Orange, CA 92868, USA.
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Dy CJ, Cross MB, Osbahr DC, Parks ML, Green DW. What opportunities are available for resident involvement in national orthopedic and subspecialty societies? Orthopedics 2011; 34:e669-73. [PMID: 21956064 DOI: 10.3928/01477447-20110826-13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
As physician involvement in health policy grows, there will be an increasing need for future leaders in orthopedics. Interested orthopedic residents may be unaware of opportunities for leadership involvement in professional and subspecialty organizations. This article investigates whether national and subspecialty organizations offer membership to residents, allow residents to participate in committees, and provide opportunities for scholarly activity and mentorship. The authors surveyed 20 national orthopedic professional and subspecialty societies to evaluate the availability and cost of resident membership, meeting attendance and participation, research funding, committee membership, and mentorship opportunities. Each society's Web site was reviewed, and societies were contacted by phone if further inquiry was needed. Of the 20 orthopedic societies surveyed, 11 allowed resident membership. Five of 20 societies allowed residents to serve on committees, with a total of 14 total positions for residents. Four organizations provided formalized mentorship programs to residents. Although opportunities for resident involvement in subspecialty and professional societies are available in the majority of groups surveyed, the Orthopaedic Trauma Association and American Society for Surgery of the Hand provided the most comprehensive collection of opportunities. Residents should also pursue involvement in other organizations that may be more readily accessible, such as local, state, and regional orthopedic and medical societies. Increased resident participation in these organizations may help in increasing the 14 nationally available committee positions for orthopedic residents. Our orthopedic profession and societies should encourage motivated residents to pursue involvement and leadership at the national level.
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