| Preface: Evidence-Based Medicine in Orthopedic Surgery |
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| Principles of EvidenceBased Medicine |
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131 | (8) |
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Evidence-based medicine integrates clinical expertise, patients' values and preferences, and the best available evidence from the medical literature. |
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Evidence-based orthopedics is a model to assist surgeons to improve the process of asking questions, obtaining relevant information efficiently, and making informed decisions with patients. |
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With an increasing appreciation for higher levels of evidence, orthopedic surgeons should move away from lower forms of evidence. |
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The adoption of randomized trials and high-quality prospective studies to guide patient care requires 2 prerequisites: (1) greater appreciation for the conduct of randomized trials in orthopedics and (2) improved education and training in evidence-based methodologies in surgery. |
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| Evidence-Based Orthopedic Surgery: Is it Possible? |
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139 | (6) |
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The promise of evidence-based medicine is to integrate the highest levels of clinical data with patient outcomes. |
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After framing the question and identifying appropriate studies, evaluating their relevance to clinical practice is highly dependent on the instruments and measures selected to demonstrate outcomes. |
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Currently, there are hundreds of outcomes measures available in the orthopedic literature evaluating these treatments, and it is not uncommon for different measures to produce conflicting results. |
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Consequently, the ability to evaluate an outcomes measure is critical in determining the value of a specific treatment intervention. |
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Similarly, selecting the appropriate outcomes measure for research or clinical purposes is an important decision that may have far reaching implications on reimbursement, surgeon reputation, and patient treatment success. |
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Evidence-based orthopedic surgery is indeed possible, but demands a detailed understanding of why appropriate outcomes selection is important, the difference between clinician-based and patient-reported outcomes (PROs), and potential future directions in orthopedics outcomes research. |
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| Challenges of Randomized Controlled Surgical Trials |
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145 | (12) |
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The concept of evidence-based medicine has gained broad support in the medical community, because clinical decisions based on information from rigorous scientific study are most likely to provide optimal care. |
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Researchers attempt to answer clinical questions using either observational studies or randomized controlled trials (RCTs). |
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Observational studies currently dominate the surgical literature but provide a level of evidence inferior to RCTs. |
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RCTs are ethically grounded in clinical equipoise and may further reduce the potential for bias or other confounding factors by blinding. |
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This article discusses the barriers to implementation of surgical RCTs. |
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| Optimal Treatment of Femoral Neck Fractures According to Patient's Physiologic Age: An Evidence-Based Review |
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157 | (10) |
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For decades, the basic tenets of managing displaced femoral neck fractures have not changed, but the optimal treatment choice continues to be highly debated. |
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The contemporary controversies associated with the treatment principles of displaced femoral neck fractures are distinct between young and old patients and are considered individually in this article about the current evidence. |
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Although fixation constructs all seem to have similar complication rates, there is increasing evidence suggesting that total hip replacement improves patient functional outcomes for healthy, independent, elderly patients compared with hemiarthroplasty and should be considered as the treatment of choice for these patients. |
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| Fusion Versus Disk Replacement for Degenerative Conditions of the Lumbar and Cervical Spine: Quid EstTestimonium? |
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167 | (16) |
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This article compares the outcomes following spinal fusion and disk replacement for degenerative conditions of the lumbar and cervical spine. |
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The short-term outcomes of lumbar and cervical total disk replacement are equivalent to that following spinal fusion. |
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Long-term follow-up studies of total disk replacement are necessary to confirm its potential benefit in reducing or preventing adjacent level degeneration. |
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Also discussed is the philosophy of the surgical management of degenerative conditions of the lumbar and cervical spine. |
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| Contemporary Management of Symptomatic Lumbar Spinal Stenosis |
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183 | (10) |
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Lumbar spinal stenosis is a common cause of impaired quality of life and diminished functional capacity in the elderly. |
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Due to the advance of noninvasive imaging modalities, spinal stenosis is becoming more frequently identified, and has become the most frequent cause for spinal surgery in patients older than 65 years. |
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Despite the ubiquitous nature of this condition, considerable controversy exists regarding the preferred treatment. |
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Level I evidence that compares the effectiveness of surgical and nonsurgical treatment is lacking. |
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The Spine Patient Outcomes Research Trial, a study that evaluates the common surgical treatments for the lumbar spine, has addressed this deficiency and is discussed in this article. |
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| Cervical Spondylotic Myelopathy: A Review of the Evidence |
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193 | (10) |
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Cervical spondylotic myelopathy (CSM) is the most common progressive spinal cord disorder in patients more than 55 years old. |
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This disease is also the most common cause of acquired spasticity in later life and may lead to progressive spasticity and neurologic decline. |
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This article explores some of the controversies about CSM and reviews pertinent articles, specifically prospective and randomized clinical trials when possible, to obtain the cleanest and least biased data. |
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The 4 current controversial topics that surround CSM are: (1) natural history of mild CSM; (2) surgical approach: anterior versus posterior; (3) laminoplasty or larninectomy; and (4) cervical arthroplasty for CSM. |
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| Dynamic Constructs for Spinal Fusion: An Evidence-Based Review |
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203 | (14) |
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Dynamic stabilization of the spine has applications in cervical and lumbar degenerative disease and in thoracolumbar trauma. |
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There is little evidence to support the use of dynamic cervical plates rather than rigid anterior cervical fixation. |
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Evidence to support the use of dynamic constructs for fusion in the lumbar spine is also limited. |
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Fusion rates, implant loosening, and failure are significant concerns that limit the adoption of current devices. |
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This article provides a synopsis of the literature on human subjects. |
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There is a need for high-quality evidence for interventions for spinal pathology. |
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An evidence-based approach to the management of spinal disorders will require ongoing assessment of clinical outcomes and comparison of effectiveness between alternatives. |
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| Contemporary Management of Symptomatic Lumbar Disc Herniations |
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217 | (8) |
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Lumbar disc herniations are common clinical entities that may cause lumbar-related symptoms. |
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The spectrum of treatment options is geared toward a patient's clinical presentation and ranges from nothing to surgical intervention. |
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Many lumbar disc herniations cause no significant symptoms. |
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In studies of asymptomatic individuals who have never experienced lumbar-related symptoms, 30% have been reported to have major abnormality on magnetic resonance imaging. |
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The mainstay of treatment of patients with symptomatic disc herniations is accepted to be nonoperative (as long as there are no acute or progressive neurologic deficits); this includes medications, physical therapy, and potentially lumbar injection. |
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For patients with symptomatic disc herniations who fail to respond appropriately to conservative measures, surgical intervention may be considered. |
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For this population, lumbar discectomy is considered to be a good option. |
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| Clavicle Fractures in 2010: Sling /Swathe or Open Reduction and Internal Fixation? |
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225 | (8) |
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Clavicle fractures are common, and they comprise close to 3% of all fractures seen in fracture clinics. |
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Midshaft fractures account for approximately 80% of all clavicle fractures and are the focus of this article. |
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In carefully selected cases primary plate fixation of displaced midshaft clavicle fractures improves outcome, results in earlier return to function, and reduces the nonunion and symptomatic malunion rate significantly compared with nonoperative treatment. |
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| Lower Extremity Assessment Project (LEAP) - The Best Available Evidence on Limb-Threatening Lower Extremity Trauma |
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233 | (8) |
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Lower Extremity Assessment Project (LEAP) study set out to answer many of the questions surrounding the decision of whether to amputate or salvage limbs in the setting of severe lower extremity trauma. |
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A National Institutes of Health-funded, multicenter, prospective observational study, the LEAP study represented a milestone in orthopedic trauma research, and perhaps in orthopedics. |
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The LEAP study attempted to define the characteristics of the individuals who sustained these injuries, the characteristics of their environment, the variables of the physical aspects of their injury, the secondary medical and mental conditions that arose from their injury and treatment, their ultimate functional status, and their general health. |
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In the realm of evidence-based medicine, the LEAP studies provided a wealth of data, but still failed to completely determine treatment at the onset of severe lower extremity trauma. |
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| A Critical Appraisal of the SPRINT Trial |
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241 | (8) |
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The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. |
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The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. |
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This article is a review and critique of the methodology used in the SPRINT trial. |
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Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. |
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Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery. |
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| Graft Selection for Anterior Cruciate Ligament Reconstruction: A Level I Systematic Review Comparing Failure Rates and Functional Outcomes |
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249 | (14) |
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Tear of the anterior cruciate ligament (ACL) is the most common ligamentous injury of the knee. |
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Reconstructing this ligament is often required to restore functional stability of the knee. |
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Many graft options are available for ACL reconstruction, including different autograft and allograft tissues. |
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Autografts include bone-patellar tendon-bone composites (PT), combined semitendinosus and gracilis hamstring tendons (HT), and quadriceps tendon. |
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Allograft options include the same types of tendons harvested from donors, in addition to Achilles and tibialis tendons. |
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Tissue-engineered anterior cruciate grafts are not yet available for clinical use, but may become a feasible alternative in the future. |
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The purpose of this systematic review is to assess whether one of the popular grafts (PT and HT) is preferable for reconstructing the ACL. |
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For this objective, the authors selected only true level I studies that compared these graft choices in functional clinical outcomes, failure rates, and other objective parameters following reconstruction of the ACL. |
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In addition, this review discusses mechanical considerations related to different allograft tissues. |
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| Hip Resurfacing Arthroplasty: A Review of the Evidence for Surgical Technique, Outcome, and Complications |
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263 | (10) |
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Hip resurfacing arthroplasty has reemerged as a valid reconstruction option for the osteoarthritic hip. |
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Patient selection is critical for excellent surgical outcomes, especially when compared with total hip arthroplasty. |
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However, concerns regarding surgical technique and postsurgical complications persist. |
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The authors review the evidence for surgical technique, outcomes, and complications related to modern metal-on-metal hip resurfacing arthroplasty. |
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| DVT Prophylaxis inTotal Joint Reconstruction |
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273 | (8) |
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Deep venous thrombosis (DVT) is the end result of a complex interaction of events including the activation of the clotting cascade in conjunction with platelet aggregation. |
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Patients undergoing major lower extremity orthopedic surgery, especially total joint arthroplasty (TJA), are at high risk for developing a postoperative DVT or a subsequent pulmonary embolus. |
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Venous thromboembolic (VTE) prophylaxis, most commonly pharmacologic prophylaxis, has become the standard of care for patients undergoing elective TJA. |
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However, the controversy between the efficacy of VTE prophylaxis and the increased risk for bleeding in the postoperative period continues to exist. |
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This review addresses the controversy underlying VTE prophylaxis by outlining 2 guidelines and demonstrating the pros and cons of different DVT prophylaxis regimens based on the available evidence-based literature. |
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| Index |
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