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, andjudicious use of current best evidence in making decisions aboutthe 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 > 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/

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?