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Despite the methodological differences between studies, the common finding is that there is a paucity of high-level evidence to support a large volume of surgical procedures. This disconnect between evidence and practice may be explained by several factors, including clinician bias. The lack of generalisability of randomised controlled trial findings to individual patients is often proposed as a reason for the surgeon's reticence to accept RCT evidence [30]. However well-conducted the trial, the rigidity of RCT design means that the findings can only suggest what was more effective for a specific group of patients with a particular condition, but not whether this evidence is applicable to a particular case or to an indiv i dual patient [30].

An RCT is also considered by surgeons to be too simplistic to adequately assess the complex nature of surgical interventions [32]. The various components of a surgical intervention in the pre-operative, intra-operative and post-operative stages all significantly influence the final outcome - the complexity of which cannot be adequately accounted for by an RCT [31]. That the quality of the RCT evidence that is available is generally poor may also serve to explain the lack of acceptance. The 83 included RCTs had variable levels of bias. The risk of bias summary for each surgical procedure consistently showed poor scores in the performance and outcome detection categories of bias due to difficulties with blinding the surgical intervention.

Furthermore, a quarter of studies reported poorly on their randomisation strategy while only a handful performed sample size calculations for power. The only category that was consistently adequate across the included RCTs was follow-up. Of the two included domains, RCTs performed most poorly in blinding of outcome assessment. Just 17 studies specifically attempted to address this potential source of detection bias in their methodology and was the largest avoidable contributor to the overall high risk of bias across the included studies.

When RCTs were analysed against sample size, less than half the total volume of procedures were supported by RCTs with a sample size greater than the median of Though inadequate sample size does not directly influence study bias, underpowered studies are more likely to have a greater rates of type II errors in which studies fail to detect statistically significant treatment effects. An investigation by Lochner et al into the rates of type II errors of randomised trials involving orthopaedic fracture care showed higher than accepted levels of type II errors and, low mean level of study power [33].

The high proportion of underpowered orthopaedic RCTs may be one of the reasons for the low support rate seen in our study. We acknowledge the limitations of our study. Not subdividing the RCT evidence by indication for the specific procedures in our analysis for example, the removal of implants for pain as opposed to other indications, or cruciate ligament reconstruction for an isolated tear as opposed to a multi-ligamentous injury is a potential limitation of this study as the RCT evidence support for a procedure may be restricted to specific indications.

Given the primary aim of the study was to assess potential differences between available RCT evidence and current clinical practice, an analysis subdividing each of the included procedure groups for indication would have contributed little value to the primary outcome.

As our criteria allowed inclusion of supportive RCTs for any indication, however, it is likely that there was a potential overestimation of RCT support for any procedure group.

Dr. Claire Shannon - Orthopaedic Pediatric Surgeon

Our study investigated RCT-level evidence exclusively as this study design provides the least biased evidence for the efficacy and safety of an intervention though its ability to deal with confounding [4]. This does not imply that every operative procedure requires RCT-level evidence to support its efficacy over a non-operative alternative.

Large, well-designed prospective cohort studies can adequately minimise bias comparable to that of RCTs [28] and therefore have acceptable levels of validity in cases where an RCT may not be feasible [34] , [35]. While improvements have occurred in the quantity and to a lesser extent, the quality of surgical research over the past several decades, this study confirms that, consistent with other surgical specialities, the majority of orthopaedic surgical interventions are not based on RCT evidence.

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The findings of this study are reflections of the current disconnect between trial evidence and orthopaedic surgical practice and its comparison to other specialities. These findings support the need for better quality RCTs to evaluate the indications for orthopaedic procedures and stakeholder discussions about the lack of support for many procedures currently being performed. Syntax of search strategies for each operative procedure category.

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Abstract We investigated the proportion of orthopaedic procedures supported by evidence from randomised controlled trials comparing operative procedures to a non-operative alternative. Funding: The authors have no support or funding to report. Methods Identification and Selection of Orthopaedic Procedures We reviewed the RCT evidence for commonly performed orthopaedic procedures in three major metropolitan teaching hospitals in southwest Sydney, Australia. Data Extraction and Categorisation Included RCTs were independently assessed in their entirety by two reviewers, and the sample size and population, the specific interventions being compared, primary outcome, primary outcome findings, secondary outcomes, findings of secondary outcomes and the authors' conclusions were identified.

For RCTs where a primary outcome was stated, and the findings demonstrated a statistically significant result in favour of the non-operative treatment or where no significant difference was shown for the stated primary outcome, the study was categorised as being 'not supportive of operative treatment'. For RCTs where a primary outcome was not stated but several outcomes were measured, and where the measured outcomes did not consistently demonstrate statistically significant results in favour of operative treatment, the study was categorised as 'not supportive of operative treatment'".

Discrepancies were resolved by discussion and arbitrated by a third author if necessary. Data Analysis Results were analysed and presented as: The proportion of the total volume of procedures that were assessed by RCTs; The proportion of the total volume of procedures that were: supported by at least one RCT supported by at least one low risk of bias RCT supported by at least one RCT with sample size greater than or equal to the median sample size of included RCTs Primary analyses were conducted using total procedure volume, as this was a more accurate reflection of surgical volume.

Results A total volume of 9, orthopaedic procedures were performed across the three hospitals in the years , and comprising 91 operative procedure categories. Download: PPT. Figure 1.

Selected References in Elective Orthopaedics. : JBJS

Flow diagram of searches executed, abstracts screened, full-texts screened and RCTs included. Table 1. Table 2. Figure 2. Figure 3. Risk of Bias Summary 12 of the 83 included RCTs were assessed as having low risk of bias across the two domains: allocation concealment and blinding of outcome assessment. Figure 4. Risk of bias assessment summary for 83 included RCTs using the Cochrane Collaboration's risk of bias tool. Discussion We reviewed the available RCT evidence in relation to commonly performed orthopaedic procedures in the years , and to establish what proportion of these procedures was supported by RCT evidence.

Supporting Information. Appendix S1. List of procedures performed ordered according to frequency. Appendix S2. Appendix S3. List of included and excluded RCTs after full-text assessment. Appendix S4. Characteristics of included RCTs. Appendix S5. Rene Louis. Sports Injuries in Children and Adolescents. Joan C. Neuromuscular Diseases. Michael Swash. Pediatric Orthopedic Deformities. Frederic Shapiro.


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Weiter einkaufen Checkout Weiter einkaufen. It seems that you're in Germany. We have a dedicated site for Germany. This work provides a selection of references from the Trauma and Orthopedic literature, which will be of interest to the surgeon preparing for the Intercollegiate Specialty Board examination, and similar end-of training examinations in other countries. It will also be of interest to examiners and trainers who are preparing their trainee colleagues for the examination, as well as providing a literature basis for their own practice. Selected References in Trauma and Orthopaedics presents the classical papers underlying current practice as well as recent publications which have brought about innovation.


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  8. The references are presented with a brief summary which allows the reader to access a literature review, with the use of online resources.