Graphical data presentation

Figures and charts are the most influential vehicles for distributing scientific information, for affecting decisions as to the acceptance or rejection of a manuscript, and for attracting the attention of the scientific community to study results. Graphical excellence is mainly defined, first, by the highest possible data density (that is, the amount of information provided per graph area); second, by a low ink-to-data ratio (the avoidance of unnecessary shading, three-dimensionality, gridlines and what is often called 'chartjunk'); and third, by clear and unequivocal labelling of axes. The researcher's essential graphical toolbox should contain histograms, bar charts (always with measures of error), box-and-whiskers plots, scatter plots and forest plots.

Surgeons' beliefs and perceptions about removal of orthopaedic implants

Background

The routine removal of orthopaedic fixation devices after fracture healing remains an issue of debate. There are no evidence-based guidelines on this matter, and little is known on surgeons' practice and perceived effectiveness of implant removal in different clinical settings.

Methods

A 41-item questionnaire was distributed to 730 attendees of the AO Principles and Masters Courses of Operative Fracture Treatment in Davos, Switzerland, to assess their attitudes towards removal of different types of implants, and perceived benefits and risks with this common procedure.

Results

The response rate was 655/730 (89.7%), representing 54.6% of all 1199 course attendees. Surgeons from 65 countries (571 males and 84 females, mean age 39 ± SD 9 years) took part in the survey. Fifty-eight percent of the participants did not agree that routine implant removal is necessary, and 49% and 58% did not agree that indwelling implants pose an excess risk for fractures or general adverse effects. Forty-eight percent felt that removal is riskier than leaving the implant in situ. Implant removal in symptomatic patients was rated to be moderately effective (mean rating on a 10-point-scale, 5.8, 95% confidence interval 5.7–6.0). Eighty-five percent of all participants agreed that implant removal poses a burden to hospital resources. Surgeons were undetermined whether implant removal is adequately reimbursed by payers of health care services (44% "I-don't-know"-answers).

Conclusion

Many surgeons refuse a routine implant removal policy, and do not believe in clinically significant adverse effects of retained metal implants. Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes.

Reconstruction of large defects of the long bones with free vascularized bone grafts: functional results after minimum 5-year follow-up

This study evaluated the clinical and radiographic results of 44 patients (26 men and 18 women) who underwent reconstruction of large defects of the long bones with free vascularized bone grafts. Mean patient age was 29+/-15 years and mean follow-up was 8.6+/-2.1 years. Mean Enneking index was 78.6% (95% confidence interval, 73.8-83.4). No differences were noted for different types of graft, etiologies, or anatomic locations. Regression analysis revealed no association between defect size and functional results. Sixteen patients developed 29 complications. All but 1 patient showed full incorporation of the graft. These results confirm the value of vascularized grafts for bridging large bone defects.

Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation

OBJECTIVE

Missed tears of the scapholunate ligament (SLL) and scapholunate dissociation (SLD) after wrist injuries pose a high risk of post-traumatic osteoarthritis of the carpus. Plain X-rays and dynamic radiographic studies are frequently used for initial diagnostic work-up. Given the limited evidence of their accuracy, we retrospectively compared the radiographic findings of patients with suspected traumatic SLD with wrist arthroscopy as the accepted reference standard.

DESIGN AND METHODS

During a 6-year period, plain radiographs and DSA cineradiography scans were obtained from 198 patients who had sustained a hyperextension injury to their hand. Of those, 102 (72 men, 30 women, mean age of 42+/-12 years) subsequently underwent diagnostic arthroscopy. Digital images were reevaluated by experienced radiologists unaware of the arthroscopic findings for the presence or absence of SLD. We calculated the sensitivity (SN) and specificity (SP) with 95% confidence intervals (CI), and computed areas under the receiver operating characteristic curves (AUC/ROC).

RESULTS

Arthroscopy revealed 42 SLL ruptures, 13, 10, and 19 of which were classified as grade I (partial), II (complete with dynamic instability), or III (complete with static instability) respectively. Plain radiographs correctly identified 24 injuries (SN 57.1%, 95% CI 41.0-72.3%), and produced 1 false-positive result (SP 98.3%, 95% CI 91.1-100.0%). The scapholunate distance and the SL angle contributed independently to the diagnostic variance, with an AUC/ROC of 85.7% (95% CI 76.8-92.2%). Cineradiography had a sensitivity of 36 out of 42 (85.7%, 95% CI 71.5-94.6%), and a specificity of 57 out of 60 (95.0%, 95% CI 86.1-99.0%).

CONCLUSION

Pathological results on plain radiographs and cineradiography reliably indicate the presence of SLD after wrist trauma. Although non-conclusive, a negative dynamic study markedly reduces the pre-test probability of disease. Both methods remain key elements of primary diagnostic strategies for suspected traumatic SLD, and may facilitate the selection of additional tests.

[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65]

In a prospective study 104 patients >or=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

[Outcomes research: definitions, methods and challenges in trauma and orthopaedic surgery]

BACKGROUND

Besides basic, illness- and patient-oriented research, outcomes research is regarded as the fourth pillar of modern health care systems. Outcomes research investigates both the desirable and adverse effects of medical and surgical interventions under day-to-day conditions.

METHOD

Because of rigorous entry criteria and selection of eligible subjects, the efficacy of a certain treatment derived from clinical experiments (i.e. classic randomized trials) may not necessarily be transferred to common patient populations or clinical settings. Apart from efficacy, a valuable (thus reimbursable) diagnostic or therapeutic procedure must prove its effectiveness in clinical practice as well. Demanding study designs are necessary to model effectiveness and to separate the observed intervention-related effects from bias and confounding.

RESULTS

Registries and pragmatic randomized trials may represent the most appropriate modalities to establish outcomes research in trauma and orthopaedic surgery. Good examples for interventions still needing proof of effectiveness are kyphoplasty and vertebroplasty, navigated surgery, damage control, interlocking implants and bone growth factors. Revealing over- and undersupply, generating negative lists (i.e. interventions of questionable or almost nil effectiveness) and integrating patients as co-therapists requires networking between hospitals and private practitioners.

CONCLUSION

Also, since outcomes research is a societal need, its development and funding must be ensured by all providers and payers of health care services.

Topotecan weekly versus routine 5-day schedule in patients with platinum-resistant ovarian cancer (TOWER): A randomized, two-stage phase-II study of the North-Eastern German Society of Gynaecological Oncology (NOGGO)

5526

Background: Optimizing the therapeutic index (that is, maintaining drug effectiveness while reducing toxicity) is a major goal in chemotherapy for platinum-resistant ovarian cancer. Early phase-I/II studies suggest that weekly topotecan (T) might be effective and apparently better tolerated than the established 5-day regimen. As yet, no randomized comparison of both regimes was attempted. To prove the hypothesis of an improved therapeutic index with weekly T, we conducted a randomized, multicenter, two-stage phase-II trial, and herein present the data of the planned interim analysis. Methods: Pts with platinresistent ovarian and fallopian tube cancers or primary peritoneal carcinoma, measurable or assessable disease (GCIG-CA-125 response criteria), were eligible. Pts were randomized to receive either weekly T (d1,8,15/q28d, 4 mg/m2) or T from d1–5/q21d at a dose of 1.25 mg/m2. According to Gehan’s two-stage-design, both arms were handled as independent studies. Overall response rate (CR + PR) was defined as primary study endpoint, secondary endpoints of the interim analysis were toxicity and safety. Results: 28 pts in the weekly and 21 pts in the conventional group, enrolled at 38 centers form the basis of this report. 230 cycles of chemotherapy were evaluated for toxicity analyses. Median age was 61 years (range, 36 - 82 years). Demographic baseline characteristics, including tumor stage and grade were well balanced between treatment arms. There were 2/28 and 5/21 responses in weekly and the conventional arm, respectively (Risk Ratio [RR] 0.30, 95% confidence interval [CI] 0.06 - 1.40, p=0.122). The risk of early treatment termination due to tumor progression (RR 1.39, 95%CI 0.75 - 2.56), haematological (RR 0.20, 95% CI 0.01 - 3.97) or non- hematological toxicities (RR 1.96, 95% CI 0.18 - 20.83) did not differ significantly between groups. The only three events of neutropenic fever occurred in the conventional arm (RR 1.70, 95% CI 0.99 - 1.16). Conclusions: Weekly T is well tolerated and potentially active. The second stage of this study will require additional 46 patients each arm. Complete enrolment is expected to be accomplished in May 2007.

No significant financial relationships to disclose.

Screening for Blunt Cerebrovascular Injuries: The Essential Role of Computed Tomography Angiography

The implementation of aggressive diagnostics refuted the thesis that blunt cerebrovascular injuries (BCVI) are rare events. Given the estimates from recent studies, the prevalence may be as high as 1 per 100 among blunt multiple trauma patients. The morbidity and mortality of unrecognized and untreated BCVI is exceptionally high and warrants distinct efforts to detect these injuries during the primary trauma survey. The primary goal is to detect BCVI before neurological symptoms occur, and to introduce anticoagulation or antiplatelet therapy as appropriate. Index injuries such as cervical spine fractures increase the prior probability of disease, but are not helpful in ruling BCVI out. Computed tomography angiography (CTA) may represent the screening tool of choice, although there is still limited evidence about its accuracy. Pooled data from six studies (1368 patients) published between 2002 and 2006 suggest a sensitivity of 79% and a specificity of 97% in the trauma setting. In the two largest investigations, no false negative results were observed. Further research is needed to determine the efficacy of CTA for disclosing BCVI, and to evaluate the potential benefits to patients.

Oldie but goldie: Bristow-Latarjet procedure for anterior shoulder instability

PURPOSE

To analyse the functional and radiological outcomes of the Bristow-Latarjet procedure in patients with recurrent anterior glenohumeral instability.

METHODS

Records of 29 patients were reviewed retrospectively. Date of first dislocation, injury mechanism, and number of recurring dislocations before and after surgery were recorded. The overall function and stability of the shoulder was evaluated.

RESULTS

24 (83%) of the glenohumeral instabilities were caused by trauma. The mean number of recurring dislocations was 8 (95% confidence interval [CI], 0-18); one patient had had 40 recurrences. No dislocation ensued postoperatively. The overall functional outcome was good, with a mean Rowe score of 90 points (95% CI, 78-100). Scores of 17 (59%) of the patients were excellent, 7 (24%) were good, 3 (10%) were fair, and 2 (7%) were poor.

CONCLUSION

The Bristow-Latarjet procedure is a good surgical treatment for recurrent anterior-inferior instability of the glenohumeral joint.

Weekly paclitaxel and carboplatin (PC-W) for patients with primary advanced ovarian cancer: results of a multicenter phase-II study of the NOGGO

OBJECTIVES

To study the toxicity and efficacy of weekly paclitaxel and carboplatin (PC-W) in women with primary ovarian cancer

METHODS

This investigation extended a phase-I dose finding study and was approved by the institutional review boards of all participating institutions. Between 1999 and 2003, women with radically resected ovarian cancer of FIGO stages II B to IV were enrolled at 17 German centres. Patients received weekly paclitaxel at a dose of 100 mg/m2, followed by carboplatin AUC 2. After a first treatment block consisting of six cycles of chemotherapy, patients had a treatment-free interval of 14 days, followed by a second block of six cycles. Treatment was completed by a 28-days break and a final block of six cycles.

RESULTS

Altogether, 129 women with a mean age of 59 +/- standard deviation 11 years entered the study. Most patients (82.9%) had serous papillary carcinoma of FIGO stage III (72.9%) and IV (20.9%). Participants received 1,851 cycles of chemotherapy; averaging 14.3 +/- 4.3 cycles each patient. PC-W produced low rates of peripheral neuropathy (grade 3: 2.3%, 95% confidence interval [CI] 0.5-6.6%), with rapid recovery after 3 months. However, 72 patients had grade III/IV anaemia (55.8%, 95% CI 46.8-64.5%). There were 36 events of grade III/IV leukopenia (27.9%, 95% CI 20.4-36.5%). One patient sustained neutropenic fever. CA-125- and objective response was noted in 73.9% (95% CI 64.7-81.8%) and 55.6% (95% CI 41.4-69.1%) of patients. Median progression free and overall survival was 21 and 43 months, respectively.

CONCLUSIONS

PC-W is feasible; a randomized study is warranted to compare this new regimen with conventional 3-weekly treatment.

Randomized clinical trial comparing bipolar coagulating and standard great saphenous stripping for symptomatic varicose veins

Background

Typical side-effects of saphenous stripping for symptomatic varicose veins include painful thigh haematomas, which a new bipolar coagulating electric vein stripper (EVS) may reduce.

Methods

In a randomized, single-blind trial at three vascular centres, 99 patients were assigned to EVS and 101 to conventional stripping. The primary outcome was postoperative pain at rest and following physical exercise (climbing stairs). Haematomas were quantified by ultrasonography. Further endpoints were duration of postoperative compression, sick leave and quality of life (measured by the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ) and Short Form 36 (SF-36®)).

Results

Mean resting visual analogue scale for pain 24 h after surgery was 1·6 in the EVS group and 3·3 in the conventional stripping group (mean difference 1·7, 95 per cent confidence interval (c.i.) 1·4 to 1·9, P < 0·001). Mean ratings following exercise were 3·3 and 5·5 (mean difference 2·3, 95 per cent c.i. 2·0 to 2·6, P < 0·001) respectively. No patient in the EVS group had a measurable thigh haematoma, compared with 74 patients after conventional stripping (P < 0·001). The EVS significantly decreased the length of compression therapy and sick leave, and produced superior CIVIQ and SF-36 ratings.

Conclusion

The EVS was safe and effective in avoiding painful haematomas following varicose vein surgery.

Navigated total knee replacement. A meta-analysis

BACKGROUND

Proponents of navigated knee arthroplasty stress its potential to increase the precision of component placement. We conducted a systematic review and meta-analysis to substantiate the validity and relevance of this contention.

METHODS

We searched major medical and publishers' databases for randomized trials and any other studies comparing navigated with conventional knee arthroplasty. Major periodicals were searched manually. We made no restrictions for types of studies or language. Methodological features were rated independently by two reviewers. After testing for publication bias and heterogeneity was done, the data were aggregated by random-effects modeling. We estimated the weighted mean differences of mechanical limb axes and functional scales and the risk ratios of deviations from the straight axis with 95% confidence intervals.

RESULTS

We included thirty-three studies (eleven randomized trials) of varying methodological quality involving 3423 patients with a mean age (and standard deviation) of 67.3 +/- 4.1 years (62.6% were women, and 83.7% had primary osteoarthritis). The mean preoperative deviation from the mechanical axis was 2.3 degrees +/- 5.1 degrees. There was no evidence of publication bias, but there was strong statistical heterogeneity. The alignment of the mechanical axes did not differ between the navigated and conventional surgery group (weighted mean difference, 0.2 degrees; 95% confidence interval, -0.2 degrees to 0.5 degrees). Patients managed with navigated surgery had a lower risk of malalignment at critical thresholds of >3 degrees (risk ratio, 0.79; 95% confidence interval, 0.71 to 0.87) and >2 degrees (risk ratio, 0.76; 95% confidence interval, 0.71 to 0.82). No conclusive inferences could be drawn on functional outcomes or complication rates. Navigation lengthened the mean duration of surgery by 23%.

CONCLUSIONS

Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. Its clinical benefits are unclear and remain to be defined on a larger scale.

[Surgical management of abdominal injury]

PURPOSE

Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.

METHODS

Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.

RESULTS

Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.

DISCUSSION

Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

[The clinical use of the ISO-C(3D) imaging system in calcaneus fracture surgery]

We compared in a prospective study including 82 patients treated with ORIF of an intraarticular calcaneus fracture the quality of fluoroscopy, intraoperatively Iso-C(3D) and postoperative CT-scans. Therefore the posterior facet of the calcaneus (PFOC) was divided into three sectors. Joint steps and fracture gaps were detected by two independent investigators and statistically analysed. Another focus was to evaluate if the findings due to intraoperatively Iso-C(3D) assessment performed by the surgeon were correct and subsequently influenced the surgical procedure. There were no statistically differences between the Iso-C(3D)- and CT findings concerning joint steps or fracture gaps in PFOC sectors I-III. With fluoroscopy an assessment of the PFOC sectors I and II was not possible. In six cases (7.3%), intraoperative reduction was redone after performing an Iso-C(3D) scan. In ten cases, 12 malpositioned screws were replaced (12.2%/14.6%). These results suggest that intraoperative 3D Iso-C(3D) imaging provides a high diagnostic reliability. By careful assessment of the images the surgeons receive information which could lead to a change of the operative strategy.

A randomized multicenter phase III trial of topotecan monotherapy versus topotecan + etoposide versus topotecan + gemcitabine for second-line treatment of recurrent ovarian cancer

5030

Background: Topotecan combined with etoposide (GINECO 1998) and gemcitabine (NOGGO 2001) proved effective for second-line treatment of recurrent ovarian cancer. It is, however, unclear whether combined treatment improves survival and tumor control compared to topotecan alone. Methods: Women with recurrent ovarian cancer after primary surgery and platinum therapy were enrolled in an open-label randomized phase-III trial at 93 German institutions. Stratifying for treatment-free intervals (TFI) of less or more than 12 months, subjects were centrally allocated to topotecan 1.25 mg/m2/d (TM), topotecan 1.0 mg/m2/d plus oral etoposide 50 mg/d (TE) on day 6–12, or topotecan 0.5 mg/m2/d plus gemcitabine (TG) 800 mg/m2/d1 and 600 mg/m2/d8 every three weeks. Local institutional review boards approved this study, and all patients provided written informed consent. With 145 subjects each arm, this study yielded 90% power to detect a Hazard Ratio (HR) of 0.60 in overall survival (OS) at a two-sided alpha of 0.01. We employed Cox regression for primary endpoint analysis, and addressed progression-free survival (PFS) and toxicity descriptively. Results: Between September 1999 and November 2004, 3036 courses were administered to 505 patients (mean age 60.4 [SD 11.3] years), 208 of whom had a TFI <12 months. Women assigned to TM, TE, and TG received a median of 6.7 (range, 0–10), 6.2 (0–9), and 5.4 (1–42) cycles. Median OS after TM, TE, and TG was 17.8, 17.8, and 15.3 months. Setting TM as the reference, HRs for OS with TE and TG were 1.13 (95% confidence interval [CI] 0.87–1.47) and 1.07 (95% CI 0.80–1.43, p = 0.590). HRs for PFS with TE and TG versus TM were calculated at 0.84 (95% CI 0.66–1.07) each. Subgroup analysis suggested enhanced PFS among subjects with TFI ≥12 months who received TE (HR 0.62, 95% CI 0.42–0.91) or TG (HR 0.68, 95% CI 0.46–1.01) rather than TM. TE produced higher CTC grade 3/4 hematotoxicity than TM or TG, with cumulative incidences of 24.4% (95% CI 20.2–29.0%), 16.0% (95% CI 11.9–20.9%), and 14.7% (10.6–19.5%). Conclusions: This large RCT does not provide evidence that combined treatment performs generally better than topotecan monotherapy in recurrent ovarian cancer.

No significant financial relationships to disclose.

Biweekly pegylated liposomal doxorubicin in patients with relapsed ovarian cancer: results of a multicenter phase-II trial

BACKGROUND

The obvious benefit of pegylated liposomal doxorubicin (PLD) for tumour control in recurrent ovarian cancer is frequently offset by severe palmar-plantar erythrodysesthesia (PPE). There is evidence that dose reduction from 50 to 40 mg/m(2) reduces the incidence of PPE without compromising cytotoxic activity. We set out to investigate whether biweekly application further improves the therapeutic index of PLD.

PATIENTS AND METHODS

Patients with recurrent ovarian cancer after surgery and adjuvant chemotherapy with platinum and taxane compounds were eligible to participate in this multi-institutional phase II study. PLD was administered at a dose of 20 mg/m(2) every two weeks. Eligible patients had ECOG performance status of < or =2, and sufficient organ function. We employed an optimized two-stage design to test the hypothesis that biweekly application of PLD reduces the frequency of grade III and IV PPE from 25% to 10%. Response and survival were addressed descriptively.

RESULTS

Between October 2001 and February 2004, 64 patients with median age of 59 (range 38-81) years were recruited onto this trial. We evaluated 553 (median 7, range 1-25) courses of PLD treatment. Most patients were in their third or fourth line of chemotherapy. PPE was noted in 30 patients (47.6%), but only three participants progressed to grade 3 severity (4.7%, 95% confidence interval 1.0-13.1%). Partial response, stable disease, and tumour progression were observed in 5, 13, and 24 patients, respectively. Median overall and progression-free survival were 18.2 (range, 1.4-34.0) and 4.3 (range 0.5-22.3) months.

CONCLUSIONS

Biweekly PLD may reduce the incidence of PPE while retaining efficacy in relapsed ovarian cancer. Our data support the need for a randomized trial to strengthen these assumptions.

Second-line treatment of limb-threatening diabetic foot infections with intravenous fosfomycin

Diabetic foot infections (DFI) expanding to bones and joints are associated with a poor prognosis of limb salvage. The bactericidal epoxide fosfomycin accumulates in inflamed soft and bone tissue, and may represent a potential treatment option for targeting severe DFI. Fifty-two patients (35 men, 17 women, mean age 62.9 +/- SD 9.2 years) with limb-threatening DFI (that is, Wagner grade 3 and higher) were enrolled in a multi-center compassionate use program of fosfomycin. Twenty-two patients (42.4%) had unsuccessfully been pretreated with other antimicrobials. Besides standard treatment (topical wound care and surgical debridement), eligible subjects received a combination of 8 to 24 g fosfomycin daily, and a conventional antibiotic agent, usually a beta-lactam compound. Treatment duration averaged 14.4 +/- 8.3 days. Limb-sparing surgery was possible in 48 patients (92.3%, 95% confidence interval 81.5-97.9%). Only four participants faced mild drug-related side effects (nausea, rash). Logistic regression analysis showed a trend towards better results with prolonged treatment, whereas a dose increase above 12 g daily did not affect outcomes. In DFI being resistant to conventional antibiotic agents, intravenous fosfomycin offers an effective treatment choice that may increase the likelihood of limb preservation. The present data warrant a larger comparative trial to stabilize effect estimates.