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van de Kuit A, Krishnan RJ, Mallee WH, Goedhart LM, Lambert B, Doornberg JN, Vervest TMJS, Martin J. Surgical site infection after wound closure with staples versus sutures in elective knee and hip arthroplasty: a systematic review and meta-analysis. Arthroplasty 2022; 4:12. [PMID: 35241172 PMCID: PMC8896293 DOI: 10.1186/s42836-021-00110-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose This systematic review and meta-analysis aimed to study surgical site infection of wound closure using staples versus sutures in elective knee and hip arthroplasties. Methods A systematic literature review was performed to search for randomized controlled trials that compared surgical site infection after wound closure using staples versus sutures in elective knee and hip arthroplasties. The primary outcome was surgical site infection. The risk of bias was assessed with the Cochrane risk of bias assessment tool. The relative risk and 95% confidence interval with a random-effects model were assessed. Results Eight studies were included in this study, including 2 studies with a low risk of bias, 4 studies having ‘some concerns’, and 2 studies with high risk of bias. Significant difference was not found in the risk of SSI for patients with staples (n = 557) versus sutures (n = 573) (RR: 1.70, 95% CI: 0.94–3.08, I2 = 16%). The results were similar after excluding the studies with a high risk of bias (RR: 1.67, 95% CI: 0.91–3.07, I2 = 32%). Analysis of studies with low risk of bias revealed a significantly higher risk of surgical site infection in patients with staples (n = 331) compared to sutures (n = 331) (RR: 2.56, 95% CI: 1.20–5.44, I2 = 0%). There was no difference between continuous and interrupted sutures (P > 0.05). In hip arthroplasty, stapling carried a significantly higher risk of surgical site infection than suturing (RR: 2.51, 95% CI: 1.15–5.50, I2 = 0%), but there was no significant difference in knee arthroplasty (RR: 0.87, 95% CI: 0.33–2.25, I2 = 22%; P > 0.05). Conclusions Stapling might carry a higher risk of surgical site infection than suturing in elective knee and hip arthroplasties, especially in hip arthroplasty. Supplementary Information The online version contains supplementary material available at 10.1186/s42836-021-00110-7.
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Affiliation(s)
- A van de Kuit
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R J Krishnan
- Department of Anesthesia & Perioperative Medicine and Department of Epidemiology & Biostatistics, MEDICI Centre, University of Western Ontario, London, Canada
| | - W H Mallee
- Department of Orthopaedics, Joint Research, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - L M Goedhart
- Department of Orthopaedics, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands
| | - B Lambert
- Department of Orthopaedics, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands
| | - J N Doornberg
- Department of Orthopaedics, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands.
| | - T M J S Vervest
- Department of Orthopaedics, Tergooi Hospital, Hilversum, The Netherlands
| | - J Martin
- Department of Anesthesia & Perioperative Medicine and Department of Epidemiology & Biostatistics, MEDICI Centre, University of Western Ontario, London, Canada
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Geerdink TH, Uijterwijk BA, Meijer DT, Sierevelt IN, Mallee WH, van Veen RN, Goslings JC, Haverlag R. Adoption of direct discharge of simple stable injuries amongst (orthopaedic) trauma surgeons. Injury 2021; 52:774-779. [PMID: 33276960 DOI: 10.1016/j.injury.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The importance of routine follow-up of several relatively simple stable injuries (SSIs) is questionable. Multiple studies show that direct discharge (DD) of patients with SSIs from the Emergency Department results in patient outcomes and experiences comparable to 'standard care' with outpatient follow-up. The purpose of this study was to evaluate to which extent DD of SSIs has been adopted amongst trauma and orthopedic surgeons internationally, and to assess the variation in the management of these common injuries. METHODS An online survey was sent to members of an international trauma- and orthopaedic surgery collaboration. Participants, all trauma- or orthopaedic surgeons, were presented with eleven hypothetical cases of patients with simple stable injuries in which they were asked to outline their treatment plan regarding number of follow-up appointments and radiographs, physiotherapy and when to start functional movement. The primary outcome was the proportion of surgeons selecting direct discharge (i.e. zero scheduled appointments), per injury. Secondary outcomes included clinical agreement (>80% of respondents answering similarly) on total number of follow-up appointments (0, 1 or ≥2), radiographs (0, 1 or ≥2), routine physiotherapy referral (yes/no) and when to start functional movement (weeks). RESULTS 138 of 667 (20.7%) surgeons completed the survey. Adoption of direct discharge ranged from 4-45% of case examples. In 10 out of 11 cases, less than 25% of surgeons selected direct discharge. Clinical agreement regarding number of appointments and when to start functional movement was not reached for any of the injuries. There was clinical agreement on number of radiographs for one injury and for four injuries regarding routine referral to a physiotherapist. DISCUSSION Despite available evidence, DD of SSIs has not been widely adopted worldwide. Practice variation still exists even for these common injuries. This variation suggests inefficiency and consequently unnecessarily high healthcare costs. (Orthopaedic) trauma surgeons are encouraged to evaluate their current treatment protocols of SSIs.
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Affiliation(s)
- T H Geerdink
- Trauma Surgery, OLVG Amsterdam, The Netherlands.
| | | | - D T Meijer
- Resident Orthopaedic Surgery, Amsterdam UMC - Location AMC, The Netherlands
| | | | - W H Mallee
- Orthopaedic Surgery, OLVG Amsterdam, The Netherlands
| | | | | | - R Haverlag
- Trauma Surgery, OLVG Amsterdam, The Netherlands
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Kievit AJ, Dobbe JGG, Mallee WH, Blankevoort L, Streekstra GJ, Schafroth MU. Accuracy of cup placement in total hip arthroplasty by means of a mechanical positioning device: a comprehensive cadaveric 3d analysis of 16 specimens. Hip Int 2021; 31:58-65. [PMID: 31506002 PMCID: PMC7797610 DOI: 10.1177/1120700019874822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We tested whether a mechanical device (such as Hipsecure) to pinpoint the anterior pelvic plane (APP) as a guide can improve acetabular cup placement. To assess accuracy we asked: (1) is the APP an effective guide to position acetabular cup placement within acceptable ° of divergence from the optimal 40° inclination and 15° anteversion; (2) could a mechanical device increase the number of acetabular cup placements within Lewinnek's safe zone (i.e. inclination 30° to 50°; anteversion 5° to 25°)? METHODS 16 cadaveric specimens were used to assess the 3D surgical success of using a mechanical device APP to guide acetabular cup placement along the APP. We used the Hipsecure mechanical device to implant acetabular cups at 40° inclination and 15° anteversion. Subequently, all cadaveric specimens with implants were scanned with a CT and 3D models were created of the pelvis and acetabular cups to assess the outcome in terms of Lewinnek's safe zones. RESULTS The mean inclination of the 16 implants was 40.6° (95% CI, 37.7-43.4) and the mean anteversion angle was 13.4° (95% CI, 10.7-16.1). All 16 cup placements were within Lewinnek's safe zone for inclination (between 30° and 50°) and all but 2 were within Lewinnek's safe zone for anteversion (between 5° and 25°). CONCLUSION In cadaveric specimens, the use of a mechanical device and the APP as a guide for acetabular cup placement resulted in good positioning with respect to both of Lewinnek's safe zones.
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Affiliation(s)
- Arthur J Kievit
- Orthopaedic Research Centre Amsterdam, Department of Orthopaedics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands,Arthur J Kievit, Orthopaedic Research Centre Amsterdam, Department of Orthopaedics of the Amsterdam University Medical Centre, University of Amsterdam, Amsterdam 1105 AZ, The Netherlands.
| | - Johannes G G Dobbe
- Department of Biomedical Engineering and Physics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands
| | - Wouter H Mallee
- Orthopaedic Research Centre Amsterdam, Department of Orthopaedics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands
| | - Leendert Blankevoort
- Orthopaedic Research Centre Amsterdam, Department of Orthopaedics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands
| | - Geert J Streekstra
- Department of Biomedical Engineering and Physics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands
| | - Matthias U Schafroth
- Orthopaedic Research Centre Amsterdam, Department of Orthopaedics of the Amsterdam University Medical Centre, University of Amsterdam, The Netherlands
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Mallee WH, Wijsbek AE, Schafroth MU, Wolkenfelt J, Baas DC, Vervest TMJS. Wound complications after total hip arthroplasty: a prospective, randomised controlled trial comparing staples with sutures. Hip Int 2020:1120700020939075. [PMID: 32634064 DOI: 10.1177/1120700020939075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Does the use of staples or sutures for wound closure have a lower surgical site infection rate in patients receiving primary total hip arthroplasty (THA)? DESIGN Prospective, randomised controlled multicentre trial. METHODS 535 patients undergoing THA were included and randomised into 2 groups: 268 wounds were closed with staples, and 267 with sutures. Primary outcome was surgical site infection (SSI). Secondary outcomes were prosthetic joint infection (PJI), other wound complications (dehiscence, necrosis and prolonged drainage) and duration of admittance. Follow-up occurred at 2, 6, and 12 weeks, and at 1 year. RESULTS There were no significant demographic differences between the 2 groups. SSI occurred more frequently when wounds were closed with staples (4% compared to 1% with sutures; OR 2.8; CI, 0.885-0.952; p = 0.057). SSI was treated with oral antibiotics. The staples group showed significantly more wound complications (17% compared to 5%; OR 3.943, CI 2.073-7.498; p = 0.000). Wound discharge was significantly prolonged in the staples group (n = 40, compared to n = 12 in the sutures group; OR 3.728; CI, 1.909-7.281; p = 0.000). There was no significant difference in PJI (p = 0.364). CONCLUSIONS In this large RCT comparing staples with sutures after THA, the use of staples is associated with a nearly 3 times greater risk of SSI (OR 2.8; p = 0.057). Staples significantly prolong wound discharge. The use of sutures for wound closure after THA is advised. Trial registration: Staples Or Sutures trial (S.O.S. trial) http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3946 , NTR3946.
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Affiliation(s)
- Wouter H Mallee
- Department of Orthopaedic surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Anne E Wijsbek
- Department of Orthopaedic surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - Matthias U Schafroth
- Department of Orthopaedic surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Dominique C Baas
- Department of Orthopaedic surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - Ton M J S Vervest
- Department of Orthopaedic surgery, Tergooi Hospital, Hilversum, The Netherlands
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de Boer BNP, Doornberg JN, Mallee WH, Buijze GA. Surgical treatment of non- and minimally-displaced acute scaphoid fractures favours over-conservative treatment but only in the short term: an updated meta-analysis. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Claessen FMAP, Meijer DT, van den Bekerom MPJ, Gevers Deynoot BDJ, Mallee WH, Doornberg JN, van Dijk CN. Reliability of classification for post-traumatic ankle osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2016; 24:1332-7. [PMID: 26611896 PMCID: PMC4823329 DOI: 10.1007/s00167-015-3871-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 11/10/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE The purpose of this study was to identify the most reliable classification system for clinical outcome studies to categorize post-traumatic-fracture-osteoarthritis. METHODS A total of 118 orthopaedic surgeons and residents-gathered in the Ankle Platform Study Collaborative Science of Variation Group-evaluated 128 anteroposterior and lateral radiographs of patients after a bi- or trimalleolar ankle fracture on a Web-based platform in order to rate post-traumatic osteoarthritis according to the classification systems coined by (1) van Dijk, (2) Kellgren, and (3) Takakura. Reliability was evaluated with the use of the Siegel and Castellan's multirater kappa measure. Differences between classification systems were compared using the two-sample Z-test. RESULTS Interobserver agreement of surgeons who participated in the survey was fair for the van Dijk osteoarthritis scale (k = 0.24), and poor for the Takakura (k = 0.19) and the Kellgren systems (k = 0.18) according to the categorical rating of Landis and Koch. This difference in one categorical rating was found to be significant (p < 0.001, CI 0.046-0.053) with the high numbers of observers and cases available. CONCLUSIONS This study documents fair interobserver agreement for the van Dijk osteoarthritis scale, and poor interobserver agreement for the Takakura and Kellgren osteoarthritis classification systems. Because of the low interobserver agreement for the van Dijk, Kellgren, and Takakura classification systems, those systems cannot be used for clinical decision-making. LEVEL OF EVIDENCE Development of diagnostic criteria on basis of consecutive patients, Level II.
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Affiliation(s)
- Femke M. A. P. Claessen
- Orthopaedic Hand and Upper Extremity Service, Yawkey Centre, Massachusetts General Hospital, Harvard Medical School and University of Amsterdam Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Diederik T. Meijer
- Orthotrauma Research Centre Amsterdam, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | | | - Wouter H. Mallee
- Orthotrauma Research Centre Amsterdam, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Job N. Doornberg
- Orthotrauma Research Centre Amsterdam, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - C. Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
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Mallee WH, Mellema JJ, Guitton TG, Goslings JC, Ring D, Doornberg JN. 6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures. Arch Orthop Trauma Surg 2016; 136:771-8. [PMID: 27026536 PMCID: PMC4870290 DOI: 10.1007/s00402-016-2438-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Six week follow-up radiographs are a common reference standard for the diagnosis of suspected scaphoid fractures. The main purpose of this study was to evaluate the interobserver reliability and diagnostic performance characteristics of 6-weeks radiographs for the detection of scaphoid fractures. In addition, two online techniques for evaluating radiographs were compared. MATERIALS AND METHODS A total of 81 orthopedic surgeons affiliated with the Science of Variation Group assessed initial and 6-week scaphoid-specific radiographs of a consecutive series of 34 patients with suspected scaphoid fractures. They were randomized in two groups for evaluation, one used a standard website showing JPEG files and one a more sophisticated image viewer (DICOM). The goal was to identify the presence or absence of a (consolidated) scaphoid fracture. Interobserver reliability was calculated using the multirater kappa measure. Diagnostic performance characteristics were calculated according to standard formulas with CT and MRI upon presentation in the emergency department as reference standards. RESULTS The interobserver agreement of 6-week radiographs for the diagnosis of scaphoid fractures was slight for both JPEG and DICOM (k = 0.15 and k = 0.14, respectively). The sensitivity (range 42-79 %) and negative predictive value (range 79-94 %) were significantly higher using a DICOM viewer compared to JPEG images. There were no differences in specificity (range 53-59 %), accuracy (range 53-58 %), and positive predictive value (range 14-26 %) between the groups. CONCLUSIONS Due to low agreement between observers for the recognition of scaphoid fractures and poor diagnostic performance, 6-week radiographs are not adequate for evaluating suspected scaphoid fractures. The online evaluation of radiographs using a DICOM viewer seem to improve diagnostic performance characteristics compared to static JPEG images and future reliability and diagnostic studies should account for variation due to the method of delivering medical images. LEVEL OF EVIDENCE Diagnostic level II.
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Affiliation(s)
- Wouter H. Mallee
- 0000000404654431grid.5650.6Department of Orthopedic Surgery, Academic Medical Center Amsterdam, AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jos J. Mellema
- 0000 0004 0386 9924grid.32224.35Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA USA
| | - Thierry G. Guitton
- 0000 0000 9558 4598grid.4494.dDepartment of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - J. Carel Goslings
- 0000000404654431grid.5650.6Department of Trauma Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, Austin, USA
| | - Job N. Doornberg
- 0000000404654431grid.5650.6Department of Orthopedic Surgery, Academic Medical Center Amsterdam, AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Meijer DT, Doornberg JN, Sierevelt IN, Mallee WH, van Dijk CN, Kerkhoffs GM, Stufkens SA, Engvall A, Arroyo E, Golovakha M, Pereira E, Josep Torrent ET, Haverkamp D, Bojanic I, Sousa M, Aragon OC, Russo A, Cortes C, Pánics G, Vide J, Spanos L, Carvalho MS, Maggi P, Thomas Z, Tanaka H, Dinato M, Fay J, Kimtys V, Correia Moreira AJ, Hatziemmanuil D, Low TC, van der Plaat LW, Mora AD, van Rensen I, del Vecchio J, Ramos J, Azevedo J, Bustamante C, Oliveira A, Zaw H, Kurup H, Yli-Kyyny T, Baca E, Haapasalo H, Bakhtamyan G, Zbikowski P, Kalb J, Hemmingsson P, Pinheiro M, Davenport J, Guidi PL, Simoes da Silva AP, Martinho G, Spennacchio P, Postnov Y, Dreiangel N, Junior NG, Frangez I, Bissell I, Khan Y, Toom A, Bergen CV, Liszka H, Moreno N, Patczai B, van den Bogaert M, Marquis C, Hussein AK, Andersen M, Botezatu L, Santos FF, Nery C, Becirbegovc S, Stoffel CL, Ferrao P, Rakovac I, Darabos N, Sicchiero P, Tengiz K, Keiserman L, Yeap EJ, Rocha de Souza AL, Abdulsalam S, Ramos A, Martinelli N, Verfaillie S, Silva C, Stufkens S, Chouliaras V, da Costa D, Freihaut R, Bulstra G, Burg A, Rudge B, Abdelwahab A, Sirio A, Watson T, Gaspar AR, Sharp I, Hossain M, van Deurzen D, van den Bekerom M, Wiegerinck JJ, van Eekeren I, de Muinck Keizer RJ. Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury 2015; 46:2024-9. [PMID: 26253385 DOI: 10.1016/j.injury.2015.07.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/14/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Accurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs. METHODS Quantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm(2)) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus? RESULTS The average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant (p<0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I=0.76, Haraguchi type II=0.40, Haraguchi type III=0.25). CONCLUSIONS Diagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).
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Affiliation(s)
- D T Meijer
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands.
| | - J N Doornberg
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - I N Sierevelt
- Clinical Epidemiologist, Slotervaartziekenhuis, Amsterdam, Netherlands
| | - W H Mallee
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - C N van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - G M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - S A Stufkens
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands
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Weel H, Mallee WH, van Dijk CN, Blankevoort L, Goedegebuure S, Goslings JC, Kennedy JG, Kerkhoffs GMMJ. The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial. BMC Musculoskelet Disord 2015; 16:211. [PMID: 26290323 PMCID: PMC4546041 DOI: 10.1186/s12891-015-0649-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 07/27/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION Netherlands Trial Register (reg.nr NTR4377 ).
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Affiliation(s)
- Hanneke Weel
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - Wouter H Mallee
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - Leendert Blankevoort
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
| | - Simon Goedegebuure
- The Sport Physician Group, Saint Lucas Andreas Hospital department of Sports Medicine, Jan Tooropstraat 164, 1061, AE, Amsterdam, The Netherlands.
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academical Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - John G Kennedy
- Orthopaedic Surgery, Hospital for Special Surgery, 523 East 72nd Street, 5th Floor Rm 514, New York, NY, 10021, USA.
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, G4-264, 1105, AZ, Amsterdam, The Netherlands.
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Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, Doornberg JN. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev 2015; 2015:CD010023. [PMID: 26045406 PMCID: PMC6464799 DOI: 10.1002/14651858.cd010023.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In clinically suspected scaphoid fractures, early diagnosis reduces the risk of non-union and minimises loss in productivity resulting from unnecessary cast immobilisation. Since initial radiographs do not exclude the possibility of a fracture, additional imaging is needed. Computed tomography (CT), magnetic resonance imaging (MRI) and bone scintigraphy (BS) are widely used to establish a definitive diagnosis, but there is uncertainty about the most appropriate method. OBJECTIVES The primary aim of this study is to identify the most suitable diagnostic imaging strategy for identifying clinically suspected fractures of the scaphoid bone in patients with normal radiographs. Therefore we looked at the diagnostic performance characteristics of the most used imaging modalities for this purpose: computed tomography, magnetic resonance imaging and bone scintigraphy. SEARCH METHODS In July 2012, we searched the Cochrane Register of Diagnostic Test Accuracy Studies, MEDLINE, EMBASE, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials, the NHS Economic Evaluation Database. In September 2012, we searched MEDION, ARIF, Current Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform, conference proceedings and reference lists of all articles. SELECTION CRITERIA We included all prospective or retrospective studies involving a consecutive series of patients of all ages that evaluated the accuracy of BS, CT or MRI, or any combination of these, for diagnosing suspected scaphoid fractures. We considered the use of one or two index tests or six-week follow-up radiographs as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts and assessed full-text reports of potentially eligible studies. The same authors extracted data from full-text reports and assessed methodological quality using the QUADAS checklist. For each index test, estimates of sensitivity and specificity from each study were plotted in ROC space; and forest plots were constructed for visual examination of variation in test accuracy. We performed meta-analyses using the HSROC model to produce summary estimates of sensitivity and specificity. MAIN RESULTS We included 11 studies that looked at diagnostic accuracy of one or two index tests: four studies (277 suspected fractures) looked at CT, five studies (221 suspected fractures) looked at MRI and six studies (543 suspected fractures) looked at BS. Four of the studies made direct comparisons: two studies compared CT and MRI, one study compared CT and BS, and one study compared MRI and BS. Overall, the studies were of moderate to good quality, but relevant clinical information during evaluation of CT, MRI or BS was mostly unclear or unavailable.As few studies made direct comparisons between tests with the same participants, our results are based on data from indirect comparisons, which means that these results are more susceptible to bias due to confounding. Nonetheless, the direct comparisons showed similar patterns of differences in sensitivity and specificity as for the pooled indirect comparisons.Summary sensitivity and specificity of CT were 0.72 (95% confidence interval (CI) 0.36 to 0.92) and 0.99 (95% CI 0.71 to 1.00); for MRI, these were 0.88 (95% CI 0.64 to 0.97) and 1.00 (95% CI 0.38 to 1.00); for BS, these were 0.99 (95% CI 0.69 to 1.00) and 0.86 (95% CI 0.73 to 0.94). Indirect comparisons suggest that diagnostic accuracy of BS was significantly higher than CT and MRI; and CT and MRI have comparable diagnostic accuracy. The low prevalence of a true fracture among suspected fractures (median = 20%) means the lower specificity for BS is problematic. For example, in a cohort of 1000 patients, 112 will be over-treated when BS is used for diagnosis. If CT is used, only 8 will receive unnecessary treatment. In terms of missed fractures, BS will miss 2 fractures and CT will miss 56 fractures. AUTHORS' CONCLUSIONS Although quality of the included studies is moderate to good, findings are based on only 11 studies and the confidence intervals for the summary estimates are wide for all three tests. Well-designed direct comparison studies including CT, MRI and BS could give valuable additional information.Bone scintigraphy is statistically the best diagnostic modality to establish a definitive diagnosis in clinically suspected fractures when radiographs appear normal. However, physicians must keep in mind that BS is more invasive than the other modalities, with safety issues due to level of radiation exposure, as well as diagnostic delay of at least 72 hours. The number of overtreated patients is substantially lower with CT and MRI.Prior to performing comparative studies, there is a need to raise the initially detected prevalence of true fractures in order to reduce the effect of the relatively low specificity in daily practice. This can be achieved by improving clinical evaluation and initial radiographical assessment.
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Affiliation(s)
- Wouter H Mallee
- Academic Medical CenterDepartment of Orthopaedic SurgerySecretariaat G4‐NoordMeibergdreef 9AmsterdamNetherlands1057 GB
| | - Junfeng Wang
- Academic Medical CenterDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Rudolf W Poolman
- Onze Lieve Vrouwe GasthuisDepartment of Orthopaedic SurgeryOosterpark 9AmsterdamNetherlands1091 AC
| | - Peter Kloen
- Academic Medical CenterDepartment of Orthopaedic SurgerySecretariaat G4‐NoordMeibergdreef 9AmsterdamNetherlands1057 GB
| | - Mario Maas
- Academic Medical CenterDepartment of RadiologyUniversity of AmsterdamMeibergdreefAmsterdamNetherlands
| | - Henrica CW de Vet
- VU University Medical CenterDepartment of Epidemiology and Biostatistics, EMGO Institute for Health and Care ResearchPO Box 7057AmsterdamNetherlands1007 MB
| | - Job N Doornberg
- Academic Medical CenterDepartment of Orthopaedic SurgerySecretariaat G4‐NoordMeibergdreef 9AmsterdamNetherlands1057 GB
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11
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Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am 2014; 39:1683-1691.e2. [PMID: 25091335 DOI: 10.1016/j.jhsa.2014.06.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 05/29/2014] [Accepted: 06/01/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide an overview of available clinical evaluation tests for scaphoid fractures and to compare their diagnostic accuracies. METHODS PWe performed a systematic review of all studies assessing diagnostic characteristics of clinical evaluation in scaphoid fractures by searching MEDLINE, EMBASE, Cochrane, and CINAHL databases. Only studies on clinical testing prior to radiographic evaluation and with acceptable reference standard for occult fractures were included. Thirteen relevant articles were analyzed that described a total of 25 tests. Diagnostic characteristics of the tests were used to construct contingency tables. If possible, data were pooled and summary receiver operating characteristic curves were fitted. RESULTS Anatomic snuff-box tenderness (ASB, 8 studies, 1,164 patients) and longitudinal thumb compression (LTC, 8 studies, 961 patients) had sufficient data for statistical analyses. Sensitivity for ASB ranged from 0.87 to 1.00; for LTC, 0.48 to 1.00. Specificity of ASB ranged from 0.03 to 0.98; for LTC, 0.22 to 0.97. Owing to considerable heterogeneity, pooled estimate points were not calculated. Other high-sensitivity tests were scaphoid tubercle tenderness, with sensitivity and specificity ranging from 0.82 to 1.00 and 0.17 to 0.57, respectively, and painful ulnar deviation, ranging from 0.67 to 1.00 and 0.17 to 0.60, respectively. Three studies showed that combining tests increased the specificity and post-test fracture probability while maintaining high sensitivity. Quality assessment showed high or unclear risk of bias and applicability concerns in reference standard and patient selection. Twelve study designs were prospective, and 1 was retrospective. CONCLUSIONS Anatomical snuff box tenderness was the most sensitive clinical test. The low specificity of the clinical tests may result in a considerable number of overtreated patients. Combining tests improved the post-test fracture probability. This can be used to limit unnecessary immobilization, number of hospital visits, and use of imaging. The data presented herein may help to develop clinical prediction rules that could increase specificity without reducing sensitivity. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Wouter H Mallee
- Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
| | - Erik P Henny
- Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands
| | - Sjoerd P Kamminga
- Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands
| | - Wynanda A van Enst
- Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands
| | - Peter Kloen
- Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands
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12
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Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CWC. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med 2014; 49:370-6. [PMID: 25138980 DOI: 10.1136/bjsports-2013-093246] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. METHODS Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate. RESULTS 18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low. CONCLUSIONS Strong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research. STUDY REGISTRATION NUMBER PROSPERO database of systematic reviews: CRD42013004201.
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Affiliation(s)
- Wouter H Mallee
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Weel
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Chung-Wei Christine Lin
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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13
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Mallee WH, Doornberg JN, Ring D, Maas M, Muhl M, van Dijk CN, Goslings JC. Computed tomography for suspected scaphoid fractures: comparison of reformations in the plane of the wrist versus the long axis of the scaphoid. Hand (N Y) 2014; 9:117-21. [PMID: 24570648 PMCID: PMC3928374 DOI: 10.1007/s11552-013-9556-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Definitive diagnosis of occult scaphoid fractures remains difficult. We tested the null hypothesis that, for diagnosis of true fractures among suspected scaphoid fractures, computed tomography (CT) reformations along the long axis of the scaphoid have the same accuracy as reformations made relative to the anatomical planes of the wrist. METHODS In a prospective trial, 34 patients with a suspected scaphoid fracture underwent CT scanning within 10 days after trauma. CT reformations along the long axis of the scaphoid (CT-scaphoid) and along planes relative to the wrist (CT-wrist) were made. We used radiographs obtained 6 weeks after injury as the reference standard for a true fracture. A blinded panel including two surgeons and one radiologist came to a consensus diagnosis for each reformation plane. RESULTS The reference standard showed six fractures of the scaphoid (prevalence, 18 %). Using CT-wrist, a scaphoid fracture was diagnosed in five patients (15 %), with three false positive, four false negative and two true positive diagnoses. Using CT-scaphoid, a scaphoid fracture was diagnosed in five patients (15 %), with one false positive, two false negative and four true positive results. Sensitivity, specificity and accuracy were 33, 89 and 79 % for CT-wrist and 67, 96 and 91 % for CT-scaphoid, respectively. This resulted in positive predictive values of 36 % for CT-wrist and 76 % for CT-scaphoid. Negative predictive values were 87 % for CT-wrist and 94 % for CT-scaphoid. No significant differences were found with the number of patients available. CONCLUSIONS For diagnosis of true fractures among suspected scaphoid fractures, the diagnostic performance characteristics of CT scans reformatted along the long axis of the scaphoid were better than CT scans in the planes of the wrist, but the differences were not significant.
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Affiliation(s)
- Wouter H. Mallee
- Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Secretariaat Orthopaedie, G4-Noord, Meibergdreef 9, 1100 Amsterdam, The Netherlands
| | - Job N. Doornberg
- Department of Orthopaedic Surgery, University of Amsterdam Orthopaedic Residency Program, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - David Ring
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - Mario Maas
- Department of Radiology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Maaike Muhl
- Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - C. Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - J. Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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Mallee WH, Veltman ES, Doornberg JN, Blankevoort L, van Dijk CN, Goslings JC. [Variations in management of suspected scaphoid fractures]. Ned Tijdschr Geneeskd 2012; 156:A4514. [PMID: 22805789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE This study evaluated the daily clinical practice for management of patients with suspected scaphoid fractures in hospitals in the Netherlands and compared it with recommendations from the current literature. DESIGN Questionnaire-based investigation. METHOD Doctors working in emergency departments in hospitals in the Netherlands were asked to complete an 8-question survey including questions on diagnostic strategies, treatment type and the time between different steps in the management policy. RESULTS Doctors from 90 of the 100 hospitals approached completed the questionnaire. A total of 71 of these 90 hospitals had an established protocol. In the other 19 it depended on the preference of the treating doctor. In 75 hospitals a follow-up outpatient clinic appointment was made for within 10 days. In 70 hospitals X-rays were repeated before additional imaging investigation. CT was the most frequently used additional investigation in 35 hospitals, followed by bone scintigraphy (12) and MRI (2). No additional investigation was carried out in 11 hospitals and when X-rays showed no abnormalities treatment was implemented on the basis of clinical evaluation. In 72 hospitals the wrist was immobilised with a lower-arm plaster cast including the thumb. Lower-arm plaster cast not including the thumb was used in 1 hospital. CONCLUSION There is a great deal of variation in diagnosis and treatment of patients with a suspected scaphoid fracture within hospitals in the Netherlands. Furthermore, management policy in most hospitals is not in keeping with the most recent recommendations. Evidence-based guidelines are required in order to limit over-diagnosis and unnecessary immobilisation.
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Affiliation(s)
- Wouter H Mallee
- Academisch Medisch Centrum, Afd. Orthopedie, Amsterdam, the Netherlands.
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Buijze GA, Mallee WH, Beeres FJP, Hanson TE, Johnson WO, Ring D. Diagnostic performance tests for suspected scaphoid fractures differ with conventional and latent class analysis. Clin Orthop Relat Res 2011; 469:3400-7. [PMID: 21960154 PMCID: PMC3210285 DOI: 10.1007/s11999-011-2074-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 08/26/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Evaluation of the diagnostic performance characteristics of radiographic tests for diagnosing a true fracture among suspected scaphoid fractures is hindered by the lack of a consensus reference standard. Latent class analysis is a statistical method that takes advantage of unobserved, or latent, classes in the data that can be used to determine diagnostic performance characteristics when there is no consensus reference (gold) standard. PURPOSES We therefore compared the diagnostic performance characteristics of MRI, CT, bone scintigraphy, and physical examination to identify true fractures among suspected scaphoid fractures. PATIENTS AND METHODS We used data from two studies, one that prospectively studied 34 patients who had MRI and CT of the wrist, and a second that studied 78 patients who had MRI, bone scintigraphy, and structured physical examination. We compared the diagnostic performance characteristics calculated by latent class analysis with those calculated using formulas based on a reference standard. RESULTS In the first cohort, the calculated sensitivity and specificity with latent class analysis were different than those with traditional reference standard-based calculations for the CT in the scaphoid planes (sensitivity, 0.78 versus 0.67; specificity, 1.0 versus 0.96) and the MRI (sensitivity, 0.80 versus 0.67; specificity, 0.93 versus 0.89). In the second cohort, the greatest differences were in the sensitivity of MRI (0.84 versus 0.75) and the sensitivities of physical examination maneuvers (range, 0.63-0.73 versus 1.0). CONCLUSIONS The diagnostic performance characteristics calculated using latent class analysis may differ from those calculated according to formulas based on a reference standard. We believe latent class analysis merits further study as an option for assessing diagnostic performance characteristics for orthopaedic conditions when there is no consensus reference standard. LEVEL OF EVIDENCE Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Geert A. Buijze
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
- Orthopaedic Research Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Wouter H. Mallee
- Orthopaedic Research Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Frank J. P. Beeres
- Department of General Surgery, Medical Center Haaglanden, ’s-Gravenhage, The Netherlands
| | - Timothy E. Hanson
- Division of Biostatistics, University of Minnesota, Minneapolis, MN USA
| | | | - David Ring
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
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