Evidence Based Orthopaedic Surgery

1
Evidence Based Orthopaedic Surgery

• Dr Paul Della Torre
• Orthopaedic Registrar
• Concord/Canterbury Hospitals

2
History of EBM

• 1747 James Lind
• Ships Surgeon, British Navy
• First ever systematic clinical trial, basic
  principles
• 6 interventions for scurvy prevention
• Citrus of proven benefit
• Implemented in voyages of James Cook, and British
  Navy 1795.
• Questions established systems
• Locate, evaluate, incorporate best available
  research into clinical practice

3
Evidence Based Medicine

• Defined as the conscientious, explicit, and
  judicious use of current best evidence in making
  decisions about the care of individual patients.
  Sackett et al, BMJ 1996.
• Evidence based practice involves integrating
  clinical expertise with
• Best available evidence
• Patient factors/preferences
• Priorities
• Resources etc.

4
Process of EBM

• Formulate clinical question
• Locate evidence
• Critical appraisal
• Incorporate into clinical practice
• Evaluate effect of change on performance
• Review practice, modify as required

5
Levels of Evidence

• Oxford Centre for Evidence Based Medicine (CEBM)
• www.cebm.net
• Study question types
• Therapy / Prevention, Aetiology / Harm
• Prognosis
• Diagnosis
• Differential diagnosis / symptom prevalence study
• Economic and decision analyses
• I II III IV V

Quality
Bias
6
Study Type

• Therapy
• RCT gt Cohort gt Case control gt Case series
• Diagnosis
• Cross-sectional analytic study
• Aetiology/Harm
• Cohort gt Case control gt Case series
• Prognosis
• Cohort study gt Case control gt Case series
• Prevention
• RCT gt Cohort gt Case control gt Case series
• NB SYSTEMATIC REVIEWS (including Meta Analysis)
  Highest level evidence for each study type/

7
Definitions

• Systematic Review
• Overview of scientific literature on a specific
  problem
• Thorough, defined literature search
• Appraisal of individual studies identified
• Summary of studies
• Meta Analysis
• Statistical technique
• Combination of data from similar studies
• Quantitative summary
• Weighted average of individual study effects.

8
Where to look?

• Cochrane Collaboration
• Founded 1993, named after Archie Cochrane
• Not for profit
• Independent
• Updated
• Produce
• Cochrane Database of Systematic Reviews
  (Quarterly)
• Cochrane Library
• www.cochrane.org

9
How to Find

• www.ciap.health.nsw.gov.au
• Librarian
• IT Support
• CIAP Representative

10
Cochrane Library
11
Cochrane Systematic Reviews

• Abstract
• Background
• Search strategy
• Selection criteria
• Data collection, analysis
• Main results
• Authors' conclusions
• Plain language summary
• PDF download
• Summary
• Main review

12
Level 1 Evidence Recommendations
13
A balanced approach

• Exercise for improving balance in older people
• 34 studies, 2883 participants
• Interventions involving gait balance
  co-ordination and functional exercises muscle
  strengthening and multiple exercise types have
  greatest impact on balance.
• Limited evidence that effects were long-lasting.
• Overall, a lack of standardised outcome measures
  limiting conclusions re. efficacy.

14
Defy gravity?

• Interventions for preventing falls in older
  people living in the community
• 30 of people over 65 years of age living in the
  community fall each year
• 111 trials, 55,303 participants
• Reduced rate of falls and risk of falling
• Multiple-component group exercise
• Individually prescribed multiple-component
  home-based exercise
• Tai Chi
• Reduced rate of falls
• Assessment and multifactorial intervention
• Gradual withdrawal of psychotropic medication
• First eye cataract surgery
• Pacemakers in carotid sinus hypersensitivity
• Reduced risk of falls
• Home safety interventions in patients with severe
  visual impairment
• Prescribing modification programme for primary
  care physicians

15
Does being hippy help?

• Hip protectors for preventing hip fractures in
  older people
• 15 studies, over 15,000 elderly rest or nursing
  home residents or older adults living at home.
• No or marginal reduction in hip fracture, pelvic
  or other fractures incidence
• No major adverse effects reported
• Compliance, particularly in the long term is poor
  due to discomfort and practicality

16
To cement or not to cement?

• Arthroplasties (with and without bone cement) for
  proximal femoral fractures in adults
• 19 trials, 2115 patients
• No significant difference for unipolar vs bipolar
  hemiarthroplasty.
• Tendancy for cemented hemiarthroplasty to reduce
  postop pain and improved mobility at 1yr postop.
• No significant difference in surgical
  complications between cemented and uncemented
• Significantly longer operative times, but better
  functional outcome scores for THR.

17
To drain or not to drain?

• Closed suction surgical wound drainage after
  orthopaedic surgery
• 36 studies, 5464 participants with 5697 surgical
  wounds
• Hip/knee replacement, shoulder surgery, hip
  fracture surgery, spinal surgery, ACL
  reconstruction, open meniscectomy and fracture
  fixation surgery
• No difference in wound infection, haematoma,
  dehiscence or re-operation rate
• Blood transfusion required more frequently with
  drains
• Reinforcement of wound dressings and bruising
  more common without drains
• Insufficient evidence from randomised trials to
  support the routine use of closed suction
  drainage in orthopaedic surgery.

18
To stop the clot

• Heparin, LMW heparin and physical methods for
  preventing DVT and PE following surgery for hip
  fractures
• 31 trials, 2958 female and elderly patients
• Unfrac and LMW heparins protect against lower
  limb DVT
• Foot and calf pumping devices appear to prevent
  DVT, may protect against PE, and reduce
  mortality, but compliance a problem
• Trial quality an issue
• Aspirin needs to be included

19
Running on bone

• Exercise for osteoarthritis of the knee
• 32 studies, 3616 participants
• Outcome of improved physical function
• Dependant on provision of a supervised exercise
  program
• Land-based therapeutic exercise has short term
  benefit in reduction of knee pain and improved
  physical function in knee OA
• Magnitude of the treatment effect comparable to
  estimates reported for NSAID drugs

20
The ankle dilemma

• Immobilisation and functional treatment for acute
  lateral ankle ligament injuries in adults
• 21 trials, 2184 participants
• Functional treatments compared with
  immobilisation
• No differences between varying types of
  immobilisation, immobilisation and physiotherapy
  or no treatment
• Functional treatment was found to improve
• Number returning to sport in the long term
• Time taken to return to sport
• Return to work at short term follow-up
• Time taken to return to work was shorter
• Likelyhood of persistent swelling at short term
  follow-up
• Numbers suffering from objective instability as
  tested by stress X-ray
• Patient satisfaction
• Many low quality trials, most of differences not
  significant when excluded

21
What to pop

• Paracetamol for osteoarthritis
• 15 studies, 5986 participants
• Compare efficacy and safety of paracetamol versus
  placebo versus NSAIDs for treating OA
• NSAIDs are superior to paracetamol for improving
  knee and hip pain due to OA.
• In OA with moderate-to-severe levels of pain,
  NSAIDs are more effective than paracetamol.

22
Questions?