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 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
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
• Evidence based practice involves
integrating clinical expertise with:
Best available evidence
Patient factors/preferences
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
Differential diagnosis / symptom prevalence study
Economic and decision analyses
Study Type
• Therapy
 RCT > Cohort > Case control > Case series
• Diagnosis
 Cross-sectional analytic study
• Aetiology/Harm
 Cohort > Case control > Case series
• Prognosis
 Cohort study > Case control > Case series
• Prevention
 RCT > Cohort > Case control > Case series
• NB: SYSTEMATIC REVIEWS (including Meta
Analysis) – Highest level evidence for each
study type/
• 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.
Where to look?
• Cochrane Collaboration
Founded 1993, named after Archie Cochrane
Not for profit
• 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
Search strategy
Selection criteria
Data collection, analysis
Main results
Authors' conclusions
• Plain language summary
• PDF download
 Summary
 Main review
Level 1 Evidence
A balanced approach
• Exercise for improving balance in older
 34 studies, 2883 participants
 Interventions involving gait; balance; co-ordination
and functional exercises; muscle strengthening; and
multiple exercise types have greatest impact on
 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:
o Multiple-component group exercise
o Individually prescribed multiple-component home-based exercise
o 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:
o Home safety interventions in patients with severe visual impairment
o 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
 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 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.
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
 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
 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
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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