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Evidence Based Orthopaedic Surgery


... but compliance a problem Trial quality an issue Aspirin needs to be included Running on bone Exercise for osteoarthritis of the knee 32 studies, ... – PowerPoint PPT presentation

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Title: Evidence Based Orthopaedic Surgery

Evidence Based Orthopaedic Surgery
  • Dr Paul Della Torre
  • Orthopaedic Registrar
  • Concord/Canterbury Hospitals

History of EBM
  • 1747 James Lind
  • Ships Surgeon, British Navy
  • First ever systematic clinical trial, basic
  • 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

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.

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

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

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/

  • Systematic Review
  • Overview of scientific literature on a specific
  • 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.

Where to look?
  • Cochrane Collaboration
  • Founded 1993, named after Archie Cochrane
  • Not for profit
  • Independent
  • Updated
  • Produce
  • Cochrane Database of Systematic Reviews
  • Cochrane Library
  • www.cochrane.org

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

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

Level 1 Evidence Recommendations
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.

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

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

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
  • 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.

To drain or not to drain?
  • Closed suction surgical wound drainage after
    orthopaedic surgery
  • 36 studies, 5464 participants with 5697 surgical
  • 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
  • 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.

To stop the clot
  • Heparin, LMW heparin and physical methods for
    preventing DVT and PE following surgery for hip
  • 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

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
  • 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

The ankle dilemma
  • Immobilisation and functional treatment for acute
    lateral ankle ligament injuries in adults
  • 21 trials, 2184 participants
  • Functional treatments compared with
  • 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
  • Numbers suffering from objective instability as
    tested by stress X-ray
  • Patient satisfaction
  • Many low quality trials, most of differences not
    significant when excluded

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.

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