The quality of reporting and outcome measures in randomized clinical trials related to upper-extremity disorders

Assessment of 30 Years of Randomized Controlled Trials in The American Journal of Sports Medicine: 1990-2020

Background

Randomized controlled trials (RCTs) stand atop the evidence-based hierarchy of study designs for their ability to arrive at results with the lowest risk of bias. Even for RCTs, however, critical appraisal is essential before applying results to clinical practice.

Purpose

To analyze the quality of reporting of RCTs published in The American Journal of Sports Medicine (AJSM) from 1990 to 2020 and to identify trends over time and areas of improvement for future trials.

Study Design

Systematic review; Level of evidence, 1.

Methods

We queried the AJSM database for RCTs published between January 1990 and December 2020. Data pertaining to study characteristics were recorded. Quality assessments were conducted using the Detsky quality-of-reporting index and the modified Cochrane risk-of-bias (mROB) tool. Univariate and multivariable models were generated to establish factors with associations to study quality. The Fragility Index was calculated for eligible studies.

Results

A total of 277 RCTs were identified with a median sample size of 70 patients. A total of 19 RCTs were published between 1990 and 2000 (t₁); 82 RCTs between 2001 and 2010 (t₂); and 176 RCTs between 2011 and 2020 (t₃). From t₁ to t₃, significant increases were observed in the overall mean-transformed Detsky score (from 68.2% ± 9.8% to 87.4% ± 10.2%, respectively; P < .001) and mROB score (from 4.7 ± 1.6 to 6.9 ± 1.6, respectively; P < .001). Multivariable regression analysis revealed that trials with follow-up periods of <5 years clearly stated primary outcomes, and a focus on the elbow, shoulder, or knee were associated with higher mean-transformed Detsky and mROB scores. The median Fragility Index was 2 (interquartile range, 0-5) for trials with statistically significant. Studies with small sample sizes (<100 patients) were more likely to have low Fragility Index scores and less likely to have a statistically significant finding in any outcome.

Conclusion

The quantity and quality of published RCTs published in AJSM increased over the past 3 decades. However, single-center trials with small sample sizes were prone to fragile results.

Diagnostic criteria and outcome measures in randomized clinical trials on carpal tunnel syndrome: a systematic review

BACKGROUND

The diagnostic criteria for carpal tunnel syndrome (CTS) lack uniformity. Moreover, because CTS is a syndrome, there is no consensus as to which signs, symptoms, clinical and complementary tests are more reproducible and accurate for use in clinical research. This heterogeneity is reflected in clinical practice. Thus, establishing effective and comparable care protocols is difficult.

OBJECTIVE

To identify the diagnostic criteria and outcome measures used in randomized clinical trials (RCTs) on CTS.

DESING AND SETTING

Systematic review of randomized clinical trials carried out at the Federal University of São Paulo, São Paulo, Brazil.

METHODS

We searched the Cochrane Library, PubMed, and Embase databases for RCTs with surgical intervention for CTS published between 2006 and 2019. Two investigators independently extracted relevant data on diagnosis and outcomes used in these studies.

RESULTS

We identified 582 studies and 35 were systematically reviewed. The symptoms, paresthesia in the median nerve territory, nocturnal paresthesia, and special tests were the most widely used clinical diagnostic criteria. The most frequently assessed outcomes were symptoms of paresthesia in the median nerve territory and nocturnal paresthesia.

CONCLUSION

The diagnostic criteria and outcome measures used in RCTs about CTS are heterogeneous, rendering comparison of studies difficult. Most studies use unstructured clinical criteria associated with ENMG for diagnosis. The Boston Questionnaire is the most frequently used main instrument to measure outcomes.

REGISTRATION

PROSPERO (CRD42020150965- https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=150965).

Network meta-analysis: What is its purpose in Orthopaedic literature?

Systematic reviews, of level-I primary literature, are the gold standard for the formation of Clinical Practice Guidelines in Orthopaedic Surgery. When systematic reviews have multiple groups of data, meta-analyses can be conducted to analyse the direct comparison of the data points (pairwise meta-analysis). Over recent years, statisticians have created a new statistical model called network meta-analyses that can be applied to systematic reviews. network meta-analyses allow for comparison of different treatment outcomes that may or may not have been directly assessed through level-I primary studies. network meta-analyses are appearing more and more in Orthopaedic Surgery literature; therefore, in this article, we discuss what a Network Meta-analysis is and its application in Orthopaedics.

A Meta-Analysis of the Outcomes of Ligament Reconstruction Compared to No Reconstruction with or without Tendon Interposition Following Trapeziectomy for Thumb Carpometacarpal Joint Osteoarthritis

Background: The outcomes of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) compared to the trapeziectomy (T) alone or in combination with tendon interposition (TIA) in the treatment of osteoarthritis (OA) of the carpometacarpal joint (CMCJ) of the thumb are still debated. The aim of this study is to conduct a meta-analysis to determine whether the outcomes of LRTI were better compared to T or TIA. Methods: A meta-analysis of randomised trials that included the outcomes of patients with thumb CMCJ OA that underwent LRTI, T or TIA with at least 1 year follow-up. The outcomes included number of patients with pain 1 year after surgery (NPP), Visual Analog Scale for Pain (VAS Pain), key pinch strength, patient reported outcome measurements (PROMs) and number of adverse effect (AEs). The effect was assessed using mean difference for quantitative variables (VAS pain and key pinch), standardised mean difference for PROMs and relative risk for binary variables (NPP and AEs). Results: Seven studies met the inclusion criteria (857 participants: 438 LRTI vs 419 T/TIA). We did not find significant differences between LRTI and T/TIA in NPP, VAS pain, key pinch at 1 year and 5 years or more, PROMs, and AEs at 1 year and at 5 years or more after surgery. Conclusions: The outcomes of LRTI are not superior to T or TIA in the treatment of OA of the thumb CMCJ. Level of Evidence: Level I (Therapeutic).

What Are the Patient-reported Outcomes of Trapeziectomy and Tendon Suspension at Long-term Follow-up?

BACKGROUND

There are multiple options for the treatment of thumb carpometacarpal joint osteoarthritis (CMC1 OA), with evidence for pain relief and improved function. Although simple trapeziectomy has the lowest complication risk, tendon suspension of the first metacarpal and interposition is still the most commonly used surgical procedure in patients with CMC1 OA. Although there are several reports of good short-term results after trapeziectomy and tendon suspension-interposition arthroplasty, few studies have evaluated long-term outcomes. This study is one of the largest and longest follow-up evaluations of a cohort of patients with CMC1 OA who were treated with trapeziectomy and suspension-interposition arthroplasty, capturing 96% of the original cohort for evaluation.

QUESTIONS/PURPOSES

(1) After trapeziectomy and tendon suspension surgery, what are the long-term, patient-reported outcomes and clinical measurements (strength and ROM); and in unilateral procedures, how do these parameters compare with those of the contralateral hand that was not operated on? (2) What is the mean subsidence (unloaded trapezial space), and does pinch strength correlate with the amount of subsidence?

METHODS

From 1998 to 2005, 130 patients underwent trapeziectomy and abductor pollicis longus (APL) suspension-interposition arthroplasty for CMC1 OA at one orthopaedic department. During this period, 15 patients were treated with CMC1 arthrodesis and four were treated with implant arthroplasty, for a total of 149 patients. The surgeons used APL suspensionplasty for most patients, based on age and expected postoperative function; they also employed this procedure to avoid hardware or implant failure issues. The 100 living patients were asked to participate in this retrospective study, 96% (96) of whom were enrolled. The mean age at surgery was 58 ± 7 years. The patients completed a two-item thumb pain scale (modified from the SF-36 body pain scale), a hand pain VAS (average level of pain experienced over the week preceding measurement), and the 11-item QuickDASH. Patient-reported outcomes data were obtained from all 96 patients, and 83% (80) of patients underwent bilateral hand radiography and a physical examination at a mean follow-up of 17 ± 2.4 years. We calculated outcome data for each patient, and in 39 patients with unilateral surgery and intact contralateral CMC1 joint, we compared the operated side with the contralateral side. We compared our outcome data with that from the Swedish National Quality Registry for Hand Surgery (HAKIR), noting comparable outcomes for pain and QuickDASH scores.

RESULTS

At long-term follow-up after trapeziectomy and APL suspension surgery, the mean thumb pain score was 19 ± 26, hand pain VAS score 23 ± 25, and QuickDASH score 26 ± 21. In the patients with unilateral surgery and intact contralateral CMC1 joint, the thumb pain score for the operated side was lower than the contralateral side, specifically 19 ± 25 compared with 29 ± 30 (mean difference -9.8 [95% CI -19.5 to -0.2]; p = 0.045); hand pain VAS score was 24 ± 23 versus 30 ± 25 (mean difference -6.1 [95% CI -15.2 to 3.1]; p = 0.19), and the QuickDASH score was 27 ± 19. Grip strength showed no differences between the operated and contralateral sides (mean 16.7 ± 7.3 kg versus 16.6 ± 6.9 kg, mean difference 0.1 [95% CI -1.6 to 1.8]; p = 0.90), while pinch was different (4.4 ± 1.4 versus 5.0 ± 1.5 kg, mean difference -0.6 [95% CI -0.9 to -0.3]; p = 0.001). The mean trapezial space was 4.4 ± 2.2 mm, and there was no association between the trapezial space and pinch strength (0.07 kg [95% CI -0.04 to 0.18] per mm of space; p = 0.17).

CONCLUSION

The finding of comparable pain and function between operated and unoperated sides at long-term follow-up suggests that trapeziectomy and tendon suspension-interposition arthroplasty provides predictable outcomes, and surgeons can use these data to counsel patients that surgery can potentially return them to comparable use. However, as patients often have asymptomatic radiographic OA on the contralateral side, future studies are needed to examine the impact of asymptomatic disease on function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Levels of evidence backing the AAOS clinical practice guidelines

Purpose:

The American Academy of Orthopaedic Surgeons produces clinical practice guidelines for the treatment of orthopedic injuries. We examined the strength of the evidence underlying these recommendations in order to answer the following questions: (1) Have AAOS work groups improved guideline creation practices to locate evidence to generate strong recommendations? (2) Is there variability in the available evidence based on anatomic site or stage of care? (3) Has the level of evidence supporting improved over time?

Methods:

Twenty-two current guidelines of the Academy were examined which yielded 408 individual recommendations. These recommendations were assigned one of five strength of evidence ratings (strong, moderate, limited, inconclusive, consensus) by the guideline panel, based on the availability and quality of the supporting evidence. From these guidelines, we extracted all of the recommendations and their corresponding evidence ratings. We then classified the recommendations by stage of care, year, and anatomical site.

Results:

The distribution of the levels of evidence was as follows: 77 (18.9%) were based on consensus; 53 (13.0%) were inconclusive; 93 (22.8%) were based on limited evidence; 112 (27.5%) were based on moderate evidence; and 73 were based on (17.9%) strong evidence. Strong strength of evidence was found in 45.2% of the recommendations for preventive/screening/diagnostic care, 41.1% of nonsurgical treatment, 45.1% of surgical treatment, 51.1% of rehabilitation/postoperative treatment, and 45.5% of the recommendations that had mixed stages of care. Inconclusive strength of evidence was found to be prevalent from 2009–2013, but was eliminated starting in 2014.

Conclusions:

Only 73 (17.9%) recommendations generated by the Academy in its 22 clinical practice guidelines are based on a “strong” strength of evidence. More robust research is needed in orthopedics to bolster confidence in the recommendations in future guideline updates.

Randomized controlled trials in non-pharmacological rehabilitation research: a scoping review of the reporting of sample size calculation, randomization procedure, and statistical analyses

INTRODUCTION

The randomized controlled trials (RCTs) are often considered as the gold standard for clinical trials and researchers argue that the quality of RCT reports should be of the highest standards due to their clinical significance. To review the quality of reporting of the sample size calculation methods, and randomization procedures, and assess whether the statistical analyses correlate as reported in the trials' Evidence acquisition and Evidence synthesis sections in non-pharmacological, physiological rehabilitation RCT interventions.

EVIDENCE ACQUISITION

A systematic electronic search was conducted in Cochrane Central from 1 January 2019 to 16 December 2019. Titles and abstracts were analyzed for inclusion independently by two authors, and disagreements were resolved by a third reader. Studies were included if they met the following criteria: 1) assessed and reported a type of non-pharmacological rehabilitation RCT (e.g. physiotherapy); 2) randomized intervention to patients with a disease comparing to healthy or patients without intervention as the comparison group; 3) published in an indexed journal; and 4) original research, available full text, human study, published in 2019, and written in English. The following information was extracted from the included articles: journal impact factor (JIF), sample size calculation methods (SS), randomization procedure (RND), and statistical analyses (STAT) reported. Analyzing the full text, whether SS and RND were reported or not and whether the STAT correlated with the Methods and Results sections. The prevalence of each statistical method was derived from the Methods section of the report and compared if it was reported in the Results section. The continuous variable of JIF was tested for normality and used for independent t-test for equality of means between categories. In addition, using Downs and Black checklist the methodological quality of the articles was assessed and categorized to be poor, fair, good, and excellent based on the checklist's score. Finally, the association between the assessed quality (categorical variable) of the articles and the reporting variables (categorical variables) was analyzed utilizing the Pearson χ².

EVIDENCE SYNTHESIS

One hundred and nighty-four articles were retrieved from the systematic search out of which 99 (51%) were included for data extraction and further analyses. About one in five (20.2%) and two in five (37.4%) did not properly and adequately report the SS and RND while one in five (19.2%) there was at least one mismatch in STAT. The JIF was not significantly associated to the quality of reporting of SS (t=1.974, P=0.051), RND (t=0.309, P=0.758), and STAT (t=-0.275, P=0.784). This finding could indicate that the quality of the journal did not assure the quality of the reporting these methods. However, there was a significant association between the assessed quality of the article measured with the Down's and Black checklist and the reporting of SS (χ²=29.149, DF=2, P<0.0001), RND (χ²=55.079, df=2, P<0.0001) and STAT (χ²=25.778, df=2, P<0.0001).

CONCLUSIONS

Recent reporting quality of non-pharmacological rehabilitation RCTs was investigated. We found that the quality of the article but not the quality of the journal in which it is published in may be associated to the quality of reporting in sample size methods, randomization processes, and statistical analyses reporting. The quality of study reporting may be enhanced utilizing a guideline that addresses the required information in sample size calculation, randomization of individuals, and proper statistical analyses used and reported.

Detecting the extent of control over selection bias relating to oral health and otorhinolaryngology: cross-sectional study

BACKGROUND

The authors of randomized controlled trials will usually claim that they have met the randomization process criterion. However, sequence generation schemes differ and some schemes that are claimed to be randomized are not genuinely randomized. Even less well understood, and often more difficult to ascertain, is whether the allocation was really concealed.

OBJECTIVE

To detect the extent of control over selection bias, in a comparison between two Cochrane groups: oral health and otorhinolaryngology; and to describe the methods used to control for this bias.

DESIGN AND SETTING

Cross-sectional study conducted in a public university in São Paulo, Brazil.

METHODS

The risk of selection bias in 1,714 records indexed in Medline database up to 2018 was assessed, independent of language and access. Two dimensions implicated in the allocation were considered: generation of the allocation sequence; and allocation concealment.

RESULTS

We included 420 randomized controlled trials and all of them were evaluated to detect selection bias. In the sample studied, only 28 properly controlled the selection bias. Lack of control over selection bias was present in 80% of the studies evaluated in both groups.

CONCLUSION

The two groups were similar regarding control over selection bias. They are also similar to the methods used. The dimension of allocation concealment appears to be a limiting factor with regard to production of randomized controlled trials with low risk of selection bias. The quality of reporting in studies on oral health and otorhinolaryngology is suboptimal and needs to be improved, in line with other fields of healthcare.

The methodological requirements for clinical examination and patient-reported outcomes, and how to test them

This article presents the methodological requirements for clinical examination and patient-reported outcomes measurements. The assessment of any measurement for clinical research in hand surgery is difficult. A method of measuring a criterion could be 100% reliable but 100% invalid. Bias may be present in our assessment if we do not take into account the methodological requirements related to reliability, validity, and responsiveness of our measures. Reliability refers to intra-observer agreement, inter-observer agreement, or agreement between two methods of assessment, and, for patient-reported measures, internal consistency and test-retest reliability. Validity is the capability of a clinical method to measure what it proposes to measure. Assessing validity involves comparing a measure with one or more other measures, and, if possible, with a reference standard criterion. Responsiveness is the ability to detect important clinical change. The Consensus-based Standards for the Selection of Health Measurement Instruments provides the standards required for design and recommended statistical analyses of patient-reported outcome measures.

Effects of a proposal to alter the statistical significance threshold on previously published orthopaedic trauma randomized controlled trials

INTRODUCTION

A recent proposal suggests changing the threshold for statistical significance from a P value of .05 to .005 to minimize bias and increase reproducibility of future studies. P values less than .05 but greater than .005 would be reclassified as "suggestive", whereas P values less than .005 would be considered significant. The present study explores how lowering the P value threshold would affect the interpretation of previously published orthopaedic trauma randomized controlled trials (RCTs) and whether outcomes from these trials would maintain statistical significance under the proposed P value threshold.

METHODS

All RCTs published between January 01, 2016 and January 31, 2018 in the Journal of Orthopaedic Trauma, Injury, and Archives of Orthopaedic and Trauma Surgery were screened by at least 2 authors. Data from included trials were extracted in blinded and duplicate fashion. All P values for primary endpoints were included from each study.

RESULTS

We identified 124 primary endpoints from 48 trials: 39.5% (49/124) of endpoints had a P value less than .05 and 60.5% (75/124) had a P value greater than .05. Overall, 51.0% (25/49) of statistically significant primary endpoints were less than .005, while 49.0% (24/49) would be reclassified as suggestive.

CONCLUSION

Based on our results, adopting a lower threshold of significance would heavily alter the significance of orthopaedic trauma RCTs and should be further evaluated and cautiously considered when viewing the effect such a proposal on orthopaedic practice.

Quality of Randomized Controlled Trials for Surgical Treatment of Carpal Tunnel Syndrome: A Systematic Review

BACKGROUND

Randomized controlled trials are considered the gold standard in evidence-based medicine. The authors conducted a systematic review to evaluate the quantity, quality, and trends of randomized controlled trials that assess surgical treatment of carpal tunnel syndrome.

METHODS

The authors identified randomized controlled trials comparing two or more surgical interventions for carpal tunnel syndrome in PubMed, Cochrane, Scopus, Google Scholar, and Clinicaltrials.gov. Two independent reviewers evaluated articles for inclusion, extracted data, and assessed randomized controlled trial quality using the Jadad score.

RESULTS

Of 2253 identified studies, 58 met full inclusion criteria. They were published between 1985 and 2015, with a significant increase over time (p = 0.003). They were most frequently published in Journal of Hand Surgery (European Volume) [n = 15 (25.9 percent)]. Most randomized controlled trials were single-center studies [n = 54 (93.1 percent)] conducted in the United Kingdom [n = 13 (22.4 percent)] or the United States [n = 10 (17.2 percent)], with a mean study size of 80.1 ± 55.5 patients. Funding source was unknown in 62.1 percent (n = 36). Three-quarters [n = 44 (75.9 percent)] of randomized controlled trials did not define the primary outcome measure(s). Less than 30 percent (n = 17) of randomized controlled trials conducted a power analysis. Only four studies with patients reported lost to follow-up provided an explanation for each patient. Six randomized controlled trials (10.3 percent) conducted intention-to-treat analysis. The mean Jadad score was 2.14 ± 1.26, with no significant improvement over time (p = 0.245).

CONCLUSIONS

Despite the significant increase in the number of randomized controlled trials published studying surgical treatment of carpal tunnel syndrome over time, a mean Jadad score of 2.14 with no change over time indicates a need for improvement in quality. Proper study design is key to avoiding introduction of bias and ensuring the validity of conclusions drawn.

Quality of surgical randomized controlled trials in hand surgery: a systematic review

We assessed the quantity, quality and trends of randomized controlled trials comparing hand surgical interventions. Study characteristics were collected for 125 randomized controlled trials comparing hand surgical interventions. The Jadad scale (0-5), which assesses methodological quality of trials, was calculated. Logistic regressions were conducted to determine associations with the Jadad score. The studies were published between 1981 and 2015, with an increase over time, most often in Journal of Hand Surgery (European). Mean study size was 68 patients. Mean Jadad score was 2.1, without improvement over time. Thirty percent conducted a power analysis and 8% an intention-to-treat analysis. Studies conducted in the United Kingdom and with smaller sample sizes, power analysis and intention-to-treat analysis were associated with a higher Jadad score. The quantity of trials has increased over time while methodological quality has remained low, indicating a need to improve quality of trials in hand surgery literature.

The Robustness of Trials That Guide Evidence-Based Orthopaedic Surgery

BACKGROUND

The fragility index (FI) may prove to be a powerful metric of trial robustness. The FI is the minimum number of patient events that would need to become nonevents in order to nullify a significant result. The fragility quotient (FQ) is the FI divided by the total sample size. This study evaluates the robustness of the 20% of orthopaedic clinical trials that were cited as having strong evidence in the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines and that could be analyzed with these indices.

METHODS

From the AAOS recommendations with strong evidence, we extracted the randomized controlled trials that were cited as having supporting evidence that could be analyzed with the FI. Each trial's FI was calculated using the fragility calculator (http://www.fragilityindex.com). With use of the Cochrane Risk of Bias Tool 2.0, we evaluated the likelihood of bias. We also performed a post hoc power analysis of eligible studies.

RESULTS

The median FI for the 72 trials was 2 events, and the median FQ was 0.022. Of the 72 trials, only 3 (4.2%) were at a low risk of bias, and 35 (48.6%) were at a high risk of bias. Thirty-eight (53%) of the trials were underpowered. We identified a strong correlation between a trial's FI or FQ and the trial's power.

CONCLUSIONS

Our study found that trials that provided strong evidence for orthopaedic surgery guidelines were largely fragile, underpowered, and at risk of bias.

An Evaluation of Reporting Guidelines and Clinical Trial Registry Requirements Among Orthopaedic Surgery Journals

BACKGROUND

The responsibility for ensuring that studies are adequately reported is primarily that of those conducting the study; however, journal policies may influence how thoroughly authors choose to report their research. The use of reporting guidelines and prospective trial registration are promising avenues for ensuring that published studies adhere to the highest methodological standards. The purpose of this study is to evaluate orthopaedic surgery journal policies regarding reporting guidelines and trial registration, and to evaluate the effects that these policies have on adherence to reporting.

METHODS

We conducted a cross-sectional survey of journal policies and "Instructions for Authors" to determine the journals' policies and guidance regarding use of reporting guidelines and study registration. We also examined whether trials published in journals referencing CONSORT (Consolidated Standards of Reporting Trials) had higher rates of compliance with publishing a CONSORT flow diagram and whether journals with trial registration policies were more likely to contain registered trials than journals without these requirements.

RESULTS

Of the 21 orthopaedic surgery journals, 6 (29%) did not mention a single guideline, and clinical trial registration was required by 11 (52%) orthopaedic surgery journals and recommended by 2 (10%). Of the 21 general medical journals, 3 (14%) did not mention a single guideline, and trial registration was required by 13 (62%) general medical journals and recommended by 5 (24%) others. Furthermore, journals that referenced CONSORT were more likely to publish trials with a CONSORT flow diagram. Journals with trial registration policies were more likely to publish registered trials.

CONCLUSIONS

Reporting guidelines and trial registration are suboptimally required or recommended by orthopaedic surgery journals. These 2 mechanisms may improve methodology and quality, and should be considered for adoption by journal editors in orthopaedic surgery.

CLINICAL RELEVANCE

Because orthopaedic surgeons rely on high-quality research to direct patient care, measures must be taken to ensure that published research is of the highest quality. The use of reporting guidelines and prospective clinical trial registration may improve the quality of orthopaedic research, thereby improving patient care.

Cómo escribir un artículo original en Cirugía de la Mano

Considerar la calidad de la «escritura científica» a la hora de difundir nuevas ideas, resultados de tratamientos o nuevos descubrimientos, es un paso fundamental en la publicación científica. Pocos cirujanos de mano han recibido formación específica en este campo durante su residencia o entrenamiento. El propósito del presente artículo es presentar los principios fundamentales de la escritura científica a la hora de desarrollar un artículo original en investigación, fundamentalmente en la clínica, en el campo de la Cirugía de la Mano.

WITHDRAWN: Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement). We did not find any studies that compared surgery with sham surgery or surgery with non-surgical interventions.Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery or to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

The quality of randomised controlled trials involving surgery from the hand to the elbow

Aims

Our purpose was to determine the quality of current randomised controlled trials (RCTs) in hand surgery using standardised metrics.

Materials and Methods

Based on five-year mean impact factors, we selected the six journals that routinely publish studies of upper extremity surgery. Using a journal-specific search query, 62 RCTs met our inclusion criteria. Then three blinded reviewers used the Jadad and revised Coleman Methodology Score (RCMS) to assess the quality of the manuscripts.

Results

Based on the Jadad scale, 28 studies were of high quality and 34 were of low quality. Methodological deficiencies in poorly scoring trials included the absence of rate of enrolment, no power analysis, no description of withdrawal or dropout, and a failure to use validated outcomes assessments with an independent investigator.

Conclusion

A large number of RCTs in hand, wrist, and elbow surgery were of suboptimal quality when judged against the RCMS and Jadad scales. Even with a high level of evidence, study design and execution of RCTs should be critically assessed. Methodological deficiencies may introduce bias and lead to statistically underpowered studies. Cite this article: Bone Joint J 2017;99-B:94–9.

Update on the Methodological Quality of Research Published in The American Journal of Sports Medicine: Comparing 2011-2013 to 10 and 20 Years Prior

BACKGROUND

In recent years, the number of articles in The American Journal of Sports Medicine (AJSM) has risen dramatically, with an increasing emphasis on evidence-based medicine in orthopaedics and sports medicine.

HYPOTHESIS

Despite the increase in the number of articles published in AJSM over the past decade, the methodological quality of articles in 2011-2013 has improved relative to those in 2001-2003 and 1991-1993.

STUDY DESIGN

Meta-analysis.

METHODS

All articles published in AJSM during 2011-2013 were reviewed and classified by study design. For each article, the use of pertinent methodologies, such as prospective data collection, randomization, control groups, and blinding, was recorded. The frequency of each article type and the use of evidence-based techniques were compared relative to 1991-1993 and 2001-2003 by use of Pearson χ(2) testing.

RESULTS

The number of research articles published in AJSM more than doubled from 402 in 1991-1993 and 423 in 2001-2003 to 953 in 2011-2013. Case reports decreased from 15.2% to 10.6% to 2.1% of articles published over the study period (P < .001). Cadaveric/human studies and meta-analysis/literature review studies increased from 5.7% to 7.1% to 12.4% (P < .001) and from 0.2% to 0.9% to 2.3% (P = .01), respectively. Randomized, prospective clinical trials increased from 2.7% to 5.9% to 7.4% (P = .007). Fewer studies used retrospective compared with prospective data collection (P < .001). More studies tested an explicit hypothesis (P < .001) and used controls (P < .001), randomization (P < .001), and blinding of those assessing outcomes (P < .001). Multi-investigator trials increased (P < .001), as did the proportion of articles citing a funding source (P < .001).

CONCLUSION

Despite a dramatic increase in the number of published articles, the research published in AJSM shifted toward more prospective, randomized, controlled, and blinded designs during 2011-2013 compared with 2001-2003 and 1991-1993, demonstrating a continued improvement in methodological quality.

A systematic review on randomized control trials on rennin angiotensin aldosterone system inhibitors role in managing hypertension among hemodialysis patients

Randomized control trials (RCTs) are considered as most rigors way of determining the cause-effect relationship of a treatment and outcome. Activation of rennin angiotensin aldosterone system (RAAS) is an important contributor to hypertension in hemodialysis patients. The prevalence of hypertension in hemodialysis patients varies from 60% to 80% and hypertension management alone with conventional hemodialysis is insufficient. Hence, the current review was aimed to investigate the effect of RAAS inhibitors in managing hypertension among hemodialysis patients in a randomized control trial. Using PUBMED and EMBASE databases, randomized control trial with primary or secondary outcomes related to the effect of RAAS inhibitors on blood pressure among hemodialysis patients were included for analysis. The current review also assessed the quality of reporting of RCT. A total of eight RCT met inclusion criteria for current review. According to modified jaded scale, one (12.5%) study scored four points for quality reporting, whereas two (25%) studies scored one point that was the least score. The mean score for all included studies was 2.25. Six (75%) of the eight RCT included, involved ARB in hypertension management among hemodialysis patients, whereas two (25%) studies involved angiotensin-converting enzyme (ACE) inhibitors. Of the siz RCT involving ARB, two (33.3%) RCT also included ACE inhibitors comparison group. Altogether six (75%) studies report a reduction in blood pressure with the use of RAAS inhibitors compared to control group; however, of the six studies, two (33.3%) reported that the reduction in blood pressure was not significant. Whereas, two (25%) studies reported no reduction in blood pressure compared to the control group. The findings from current review do not indicate a clear pattern for a role of RAAS inhibitors for hypertension control among hemodialysis patients.

Systematic Literature Review on ICF From 2001 to 2013 in the Nordic Countries Focusing on Clinical and Rehabilitation Context

We present a systematic review on International Classification of Functioning, Disability and Health (ICF) used in the Nordic countries from 2001 through 2013, describing and quantifying the development in utilization of ICF, and describe the extent to which the different components of the ICF have been used. A search was conducted in EMBASE, MEDLINE and PsycInfo. Papers from Nordic countries were included if ICF was mentioned in title or abstract. Papers were assigned to one of eight categories covering the wide rehabilitation area; furthermore, area of focus was assigned. Use of ICF components and intervention were coded in papers categorized as "clinical and/or rehabilitation contexts" or "non-clinical contexts". One hundred seventy papers were included, of these 99 papers were from the categories "clinical and/or rehabilitation contexts" or "non-clinical contexts". Forty-two percent of the 170 included papers were published in the period 2011 - 2013. There was an increase in ICF-relevant papers from 2001 to 2013, especially in the categories "clinical and/or rehabilitation contexts" and "non-clinical contexts". The most represented focus areas were neurology, musculoskeletal, and work-related areas. All five or at least four ICF components were mentioned in the results or discussions in most papers, and activity was most frequently mentioned.

The Quality of Randomized Controlled Trials in Pediatric Orthopaedics: Are We Improving?

PURPOSE

The quality of randomized controlled trials (RCTs) in orthopaedics is a topic of considerable importance, as RCTs play a major role in guiding clinical practice. The quality of RCTs published between 1995 and 2005 has previously been documented. The purpose of the current study was to assess and describe the quality of pediatric orthopaedic RCTs published from 2005 to 2012, by identifying study characteristics associated with higher quality and outlining areas for improvement.

METHODS

A standardized literature search was used to identify pediatric orthopaedic RCTs published in 7 well-recognized journals between September 2005 and July 2012 inclusive. The Detsky Quality Assessment Scale and the CONSORT checklist for Non-Pharmacologic Trials were used to assess the quality of the RCTs. Scores for the Detsky and CONSORT were calculated by 2 independent blinded orthopaedic surgeon reviewers with epidemiologic training.

RESULTS

Forty RCTs were included in this analysis. The mean percentage score on the Detsky quality scale was 67%. Sixteen (40%) of the articles satisfied the threshold for a satisfactory level of methodological quality (Detsky >75%). Twenty-five (63%) of these studies were negative studies, concluding no difference between treatment arms. In 52% of the negative studies, an a priori sample size analysis was absent, and 28% were self-described as underpowered. In multiple variable regression analysis, only working with a statistician was significantly associated with higher Detsky percentage scores (P=0.01).

CONCLUSIONS

There is a trend for improving quality in pediatric orthopaedic RCTs. Compared with past reports, the mean Detsky score improved from 53% to 67%, and the proportion meeting an acceptable level of quality improved from 19% to 40%. One of the most concerning findings of this study was the lack of attention to sample size and power analysis, and the potential for underpowered studies. Ongoing efforts are necessary to improve the conduct and reporting of clinical trials in pediatric orthopaedics.

SIGNIFICANCE

Pediatric orthopaedic surgeons, JPO, and POSNA are working toward improving levels of quality in pediatric orthopaedic research. This paper highlights progress that has been made, and addresses some high-yield areas for future improvement.

Core domain and outcome measurement sets for shoulder pain trials are needed: systematic review of physical therapy trials

OBJECTIVES

To explore the outcome domains and measurement instruments reported in published randomized controlled trials of physical therapy interventions for shoulder pain (rotator cuff disease, adhesive capsulitis, or nonspecific shoulder pain).

STUDY DESIGN AND SETTING

We included trials comparing physical therapy to any other intervention for shoulder pain, indexed up to March 2015 in CENTRAL, MEDLINE, EMBASE, or CINAHL Plus. Two authors independently selected trials for inclusion and extracted information on the domains and measurement instruments reported.

RESULTS

We included 171 trials. Most trials measured pain (87%), function (72%), and range of movement (67%), whereas adverse events, global assessment of treatment success, strength, and health-related quality of life were measured in 18-27% of trials, and work disability and referral for surgery were measured in less than 5% of trials. Thirty-five different measurement instruments for pain and 29 for function were noted. Measurement of function increased markedly from 1973 to 2014. In rotator cuff disease trials, there was a more frequent measurement of pain and strength and a less frequent measurement of range of movement compared with adhesive capsulitis trials.

CONCLUSIONS

There was wide diversity in the domains and measurement instruments reported. Our results provide the foundation for the development of a core domain and outcome measurement set for use in future shoulder pain trials.

Evaluation of Quality of Lower Limb Arthroplasty Observational Studies Using the Assessment of Quality in Lower Limb Arthroplasty (AQUILA) Checklist

This study used the assessment of quality in lower limb arthroplasty (AQUILA) checklist to assess the quality of lower limb arthroplasty observational studies. Among 132 studies the mean reporting quality score was 5.4 (SD=1.2) out of 8 possible points. Most studies adequately reported reasons for revisions (98%) and prosthesis brand and fixation (95%) in sufficient detail. Only 3% of studies adequately reported the number of patients unwilling to participate, 15% stated a clear primary research question or hypothesis, 11% reported a worst-case analysis or competing risk analysis for endpoints, and 42% reported more than 5% of patients were lost to follow-up. There is significant room for improvement in the reporting and methodology of lower limb arthroplasty observational studies.

LEVEL OF EVIDENCE

Level III.

Which assessment tools address the categories of the Brief ICF Core Set for Hand Conditions?

Introduction

The purpose of this study was to explore whether assessment tools address aspects that are relevant according to the Brief ICF Core Set for Hand Conditions (BICF-CS).

Methods

Assessment tools meant to assess functioning and/or environmental factors in adults with hand conditions were reviewed. MEDLINE and CINAHL databases, previously published reviews, the book Clinical Assessment Recommendations of the ASHT, and websites of assessment tools were used for the content comparison and linking to the 23 categories of the BICF-CS. The updated version of the linking rules was applied by two reviewers.

Results

Forty-six assessment tools, known within the areas of hand therapy and hand surgery, were linked to the 23 categories of the BICF-CS. Regarding Body functions and body structures, the categories that were most frequently addressed were b730 “Muscle power functions,” b280 “Sensation of pain,” b710 “Mobility of joint functions, ” and s730 “Structure of upper extremity. ” Regarding Activities and Participation, d440 “Fine hand use” was addressed mostly and 25 assessment tools (with a total of 146 items) were linked to this category. Regarding Environmental Factors, only one assessment tool was identified that could be linked to two categories. Fifteen points of discussion were encountered in the linking process.

Conclusions

Content comparison of 46 assessment tools revealed that 19 of the 23 categories of the BICF-CS were addressed. The environmental factors were hardly addressed.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005.

OBJECTIVES

To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis.

SEARCH METHODS

We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events.

MAIN RESULTS

We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure.

AUTHORS' CONCLUSIONS

We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Patterns of shoulder pain during a 14-year follow-up: results from a longitudinal population study in Norway

BACKGROUND

Population studies have reported that shoulder pain is the third most frequently reported musculoskeletal pain. Long duration, pain intensity and high level of disability predict persistent complaints. The present study aimed to describe the prevalence of shoulder pain in a general population and follow this over a long period (1990 to 2004). The objective was also to describe the stability of shoulder pain and patterns of co-occurrence with neck and upper back pain.

METHODS

Data were obtained from a self-reported questionnaire in a population in Ullensaker muncipality, north-east of Oslo. The Standard Nordic Questionnaire was sent in 1990, 1994 and 2004 to inhabitants belonging to six birth cohorts from 1918-20 to 1968-70.

RESULTS

The 1-year prevalence of shoulder pain was 46.7% (95% CI, 44.9% to 48.6%) in 1990, 48.7% (95% CI, 46.8% to 50.5%) in 1994, and 55.2% (95% CI, 53.5% to 56.9%) in 2004. Approximately three-quarters of the persons with shoulder pain at one given time also reported shoulder pain at the next follow-up.

CONCLUSIONS

Prevalence of shoulder pain during a 14-year period was high and slightly increasing. Shoulder pain was reported most frequently in co-occurrence with neck pain. Classification models should include neck pain as well as other co-occurring pain sites.

Intervention randomized controlled trials involving wrist and shoulder arthroscopy: a systematic review

Background

Although arthroscopy of upper extremity joints was initially a diagnostic tool, it is increasingly used for therapeutic interventions. Randomized controlled trials (RCTs) are considered the gold standard for assessing treatment efficacy. We aimed to review the literature for intervention RCTs involving wrist and shoulder arthroscopy.

Methods

We performed a systematic review for RCTs in which at least one arm was an intervention performed through wrist arthroscopy or shoulder arthroscopy. PubMed and Cochrane Library databases were searched up to December 2012. Two researchers reviewed each article and recorded the condition treated, randomization method, number of randomized participants, time of randomization, outcomes measures, blinding, and description of dropouts and withdrawals. We used the modified Jadad scale that considers the randomization method, blinding, and dropouts/withdrawals; score 0 (lowest quality) to 5 (highest quality). The scores for the wrist and shoulder RCTs were compared with the Mann–Whitney test.

Results

The first references to both wrist and shoulder arthroscopy appeared in the late 1970s. The search found 4 wrist arthroscopy intervention RCTs (Kienböck’s disease, dorsal wrist ganglia, volar wrist ganglia, and distal radius fracture; first 3 compared arthroscopic with open surgery). The median number of participants was 45. The search found 50 shoulder arthroscopy intervention RCTs (rotator cuff tears 22, instability 14, impingement 9, and other conditions 5). Of these, 31 compared different arthroscopic treatments, 12 compared arthroscopic with open treatment, and 7 compared arthroscopic with nonoperative treatment. The median number of participants was 60. The median modified Jadad score for the wrist RCTs was 0.5 (range 0–1) and for the shoulder RCTs 3.0 (range 0–5) (p = 0.012).

Conclusion

Despite the increasing use of wrist arthroscopy in the treatment of various wrist disorders the efficacy of arthroscopically performed wrist interventions has been studied in only 4 randomized studies compared to 50 randomized studies of significantly higher quality assessing interventions performed through shoulder arthroscopy.

Frequency and use of pain assessment tools implemented in randomized controlled trials in the adult burns population: a systematic review

INTRODUCTION

Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians.

METHODS

Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients.

RESULTS

The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain.

CONCLUSION

The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain.

Hierarchy of evidence relating to hand surgery in Brazilian orthopedic journals

CONTEXT AND OBJECTIVE

There is no systematic assessment of the quality of scientific production in the specialty of hand surgery in our setting. This study aimed to systematically assess the status of evidence generation relating to hand surgery and to evaluate the reproducibility of the classification method based on an evidence pyramid.

DESIGN AND SETTING

Secondary study conducted at Universidade Federal de São Paulo (Unifesp) and Faculdade Estadual de Medicina de Marília (Famema).

METHODS

Two researchers independently conducted an electronic database search for hand surgery studies published between 2000 and 2009 in the two main Brazilian orthopedic journals (Acta Ortopédica Brasileira and Revista Brasileira de Ortopedia). The studies identified were subsequently classified according to methodological design (systematic review of the literature, randomized clinical trial, cohort study, case-control study, case series and other studies) and evidence level (I to V).

RESULTS

A total of 1,150 articles were evaluated, and 83 (7.2%) were included in the final analysis. Studies with evidence level IV (case series) accounted for 41 (49%) of the published papers. Studies with evidence level V (other studies) accounted for 12 (14.5%) of the papers. Only two studies (2.4%) were ranked as level I or II. The inter-rater reproducibility was excellent (k = 0.94).

CONCLUSIONS

Hand surgery articles corresponded to less than one tenth of Brazilian orthopedic production. Studies with evidence level IV were the commonest type. The reproducibility of the classification stratified by evidence level was almost perfect.

Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation

PURPOSE

To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001.

METHOD

The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application.

RESULTS

A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009.

CONCLUSIONS

The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.

A guide to organizing a multicenter clinical trial

Multicenter clinical trials are important research tools. Planning a multicenter clinical trial is a long and arduous task that requires substantial preparation time. In this guide, the authors discuss the steps used to plan a multicenter clinical trial. A preplanning phase, which involves formulating and refining a research question and conducting pilot studies, is detailed, and the planning phase, which involves the acquisition of funding to support the coordination and preparation of a multicenter clinical trial, culminating in the submission of an R01 grant, is described. An essential asset to planning a multicenter clinical trial is the fluidity with which all collaborators work together toward a common vision. The philosophy among collaborators should be consensus and commitment and is emphasized by the development of a consensus assisted study protocol. Most important are the recruitment of centers and co-investigators who are dedicated, collaborative, and selfless in the team effort to achieve goals that cannot be reached by a single-center effort.

Challenges of randomized controlled surgical trials

The concept of evidence-based medicine has gained broad support in the medical community, because clinical decisions based on information from rigorous scientific study are most likely to provide optimal care. Researchers attempt to answer clinical questions using either observational studies or randomized controlled trials (RCTs). Observational studies currently dominate the surgical literature but provide a level of evidence inferior to RCTs. RCTs are ethically grounded in clinical equipoise and may further reduce the potential for bias or other confounding factors by blinding. This article discusses the barriers to implementation of surgical RCTs.

Reporting randomised clinical trials of analgesics after traumatic or orthopaedic surgery is inadequate: a systematic review

BACKGROUND

Several randomised clinical trials (RCTs) of analgesics in postoperative pain after traumatic or orthopaedic surgery (TOS) have been published, but no studies have assessed the quality of these reports. We aimed to examine the quality of reporting RCTs on analgesics for postoperative pain after TOS.

METHODS

Reports of RCTs assessing analgesics in postoperative pain after TOS were systematically searched from electronic databases. The quality of reports was assessed using the CONSORT checklist (scoring range from 0 to 22). The quality was considered poor when scoring was 12 or lesser. The publication year and the impact factor of journals were recorded.

RESULTS

A total of 92 reports of RCTs were identified and 69 (75%) scored 12 or lesser in CONSORT checklist (range 5-17). The mean (SD) CONSORT score of all reports was 10.6 (2.7). Missing CONSORT items included primary and secondary outcome measures (11%), the specific objectives and hypothesis definition (12%), the sample size calculation (12%), the dates defining the periods of recruitment (12%), the discussion of external validity of findings (14%), the allocation sequence generation (24%), and the interpretation of potential bias or imprecision of results (25%). There was a little improvement in CONSORT scores over time (r = 0.62; p < 0.001) and with impact factor of journals (r = 0.30; p < 0.001).

CONCLUSION

Quality of reporting RCTs on analgesics after TOS is poor. Reporting of those RCTs should be improved according to methodological standard checklists in the next years.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis

BACKGROUND

This is an update of a Cochrane Review first published in 2005. Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another.

OBJECTIVES

To compare the effect of different surgical techniques in reducing pain and improving physical function, patient global assessment, range of motion and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, to investigate whether there was any improvement or deterioration in outcomes between the 12-month review and five year follow up.

SEARCH STRATEGY

We searched:(CENTRAL) (The Cochrane Library 2008, issue 1), MEDLINE (1950 to Dec 2008), CINAHL (1982 to Dec 2008), AMED (1985 to Dec 2008) and EMBASE (1974 to Dec 2008), and performed handsearching of conference proceedings and reference lists from reviews and papers.

SELECTION CRITERIA

Randomised or quasi-randomised trials where the intervention was surgery and pain, physical function, patient global assessment, range of motion or strength was measured as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse effects. We contacted trial authors for missing information.

MAIN RESULTS

We included nine studies involving 477 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing, arthrodesis and joint replacement). Studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement for pain and physical function. The majority of studies included in this review had an unclear risk of bias which raises some doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment or range of motion. Of participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1)) compared to 10% who underwent trapeziectomy. Trapeziectomy with ligament reconstruction and tendon interposition is therefore associated with 12% more adverse effects (RR = 2.21, 95% CI 1.18 to 4.15).

AUTHORS' CONCLUSIONS

Although it appears that no one procedure produces greater benefit in terms of pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy has fewer complications than trapeziectomy with LRTI.

Clinimetric evaluation of measurement tools used in hand therapy to assess activity and participation

STUDY DESIGN

Systematic review.

INTRODUCTION

A number of measurement tools with strong clinimetric properties address activities and participation in hand-injured persons.

PURPOSE OF THE STUDY

To evaluate clinimetric quality of measurement tools assessing activities and participation in patients with hand injuries.

METHODS

The electronic databases Medline, Cochrane library, EMBASE, PEDro, Cumulative Index to Nursing and Allied Health Literature (ClNAHL), and Allied and Complementary Medicine Database (AMED) were searched for appropriate literature. Descriptive data of included tools were given, and their clinimetric quality was scored with specific criteria.

RESULTS

The literature search identified 696 publications, referring to 15 measurement tools that met the inclusion criteria. For most of the included tests, applicability was good, whereas information on clinimetric properties was often lacking, especially for the performance tests. Overall, the Disabilities of the Arm, Shoulder, and Hand (DASH) was the most extensively studied tool with positive ratings for all criteria, closely followed by the Michigan Hand Outcomes Questionnaire (MHQ). Of the performance tests, the Functional Dexterity Test (FDT) received the best ratings.

CONCLUSIONS

Optimal measurement tool selection depends highly on the purpose of measurement and the type of hand injury.

LEVEL OF EVIDENCE

2a-.

A systematic review of trends in the methodological quality of randomized controlled trials in various research fields

OBJECTIVES

We sought to evaluate the trends in the methodological quality of randomized controlled trials in various medical fields.

STUDY DESIGN AND SETTING

Relevant studies were retrieved by the PubMed and the ISI Web of science databases.

RESULTS

Thirty-five out of 457 retrieved studies met the inclusion criteria. Twenty-one out of 35 selected studies reported significant improvement in at least one methodological quality factor. Overall quality scores were increased in 13 out of 26 studies providing relevant data. The most commonly separately examined key quality factors were allocation concealment and blinding in 13 out of 21 studies that reported relevant data. Allocation concealment was the quality characteristic most commonly reported as significantly improving during the reviewed period (in five out of eight studies reporting relevant comparative data).

CONCLUSION

Certain aspects of methodological quality have improved significantly over time, but others remain stagnant. Further efforts to improve study design, conduct, and reporting of randomized controlled trials are warranted.

Randomized controlled trials in plastic surgery: a 20-year review of reporting standards, methodologic quality, and impact

BACKGROUND

Randomized controlled trials in plastic surgery have not been analyzed comprehensively. We analyzed plastic surgical randomized controlled trials with respect to reporting standards, methodologic quality, and impact on the specialty.

METHODS

Randomized controlled trials published from 1986 to 2006 in three major plastic surgery journals were scored for quality and impact using the Consolidated Standards of Reporting Trials checklist, the Jadad criteria, citation numbers, and other parameters. The associations between the quality scores and multiple independent parameters, including trial impact, were explored. The relative impact of randomized controlled trials in plastic surgery was compared with that in other specialties.

RESULTS

A total of 163 randomized controlled trials were evaluated. The average Consolidated Standards of Reporting Trials and Jadad scores were 49 percent and 2.3, respectively. There were deficiencies in the reporting of parameters that influence bias and statistical significance. Randomized controlled trials with high impact or high methodologic quality had higher reporting scores. However, the quality and impact scores did not correlate with the number of participants, subject category, country of origin, or year or journal of publication. Nonsurgical trials had significantly higher quality and impact than surgical trials. Randomized controlled trials in plastic surgery had relatively lower impact as compared with randomized controlled trials in other specialties.

CONCLUSIONS

The reporting and methodologic standards of randomized controlled trials in plastic surgery need improvement. Standards could be improved if well-accepted reporting and methodologic criteria are considered when designing and evaluating randomized controlled trials. Instituting higher standards may improve the impact of randomized controlled trials and make them more influential in plastic surgery.

The international registry on hand and composite tissue transplantation

BACKGROUND

Since May 2002, all groups performing hand transplantations have supplied information to the International Registry on Hand and Composite Tissue Transplantation (IRHCCT). The analysis of all cases with follow-up information up to September 2007 is presented here.

METHODS

From September 1998 to September 2007, 38 hands (18 unilateral and 10 bilateral hand transplantations) and two digits have been reported to IRHCTT, for a total of 30 patients with a follow-up period ranging from 6 months to 9 years. They were 28 males and two females, median age of 34 years. Time since hand loss ranged from 2 months to 34 years and in 50% of cases the level of amputation was at wrist level. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, rapamycin, and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was also employed in several cases.

RESULTS

Patient survival was 100%. Graft survival was 100% at 1 and 2 years. Except for the Chinese patients, current graft survival is 95.6% and cause of graft loss was always no compliance to the treatment. Acute rejection episodes occurred in 85% of the patients within the first year and they were reversible in all compliant patients. Side-effects included opportunistic infections and metabolic complications. All patients developed protective sensibility, 90% of them developed tactile sensibility, and 72% also a discriminative sensibility. Motor recovery enabled patients to perform most daily activities.

CONCLUSIONS

Hand transplantation is feasible with a high success rate and satisfactory functional outcome.

Randomization procedures in orthopaedic trials

Historically, the surgical literature has lacked in reports of randomized clinical trials. This deficit is now being addressed, but the best methods are not always followed. One opportunity for improvement is in the area of randomization. Randomization is of central importance in clinical trials because it reduces bias and represents a basis for ensuring the validity of data analysis using statistical testing. Randomization requires a table of random numbers. Simple randomization is adequate for large trials. Block randomization is a method of balancing equal numbers of patients in each treatment group. Stratification allows balanced distribution of one or more confounding prognostic variables among treatment groups to ensure that groups have similar prognoses (minimizing selection bias). Block randomization and stratification improve validity in trials with fewer patients. Commercially available computer software facilitates randomization.

Basal joint arthritis of the thumb

The carpometacarpal joint of the thumb is the second most common site of arthritis in the hand. Patients in whom conservative treatment fails benefit from surgical intervention, although no consensus exists as to the best method to provide maximum pain relief and functional outcomes. The pathophysiology of carpometacarpal arthritis is loss of the integrity of the palmar oblique ligament, which allows for dorsal subluxation of the metacarpal on the trapezium. Most treatments revolve around resection or replacement of the arthritic carpometacarpal joint and restoration of the palmar oblique ligament. A critical appraisal of the current evidence-based research offers no guidance in treatment in the early stages of carpometacarpal arthritis; however, several evidence-based studies exist for more advanced stages. Although these studies exhibit limitations in regard to validated outcomes, power analysis, and blinded assessment, their conclusions question the clinical benefits of ligament reconstruction and tendon interposition. Further research is needed to delineate the best treatment of early stages of arthritis as well as the clinical significance of metacarpal subluxation and subsidence. Further, a standardized set of outcome tools is needed for the interpretation and comparison of data in regard to clinical outcomes.

Randomised controlled trials in orthopaedic surgery and traumatology: overview of parameters and pitfalls

There is a growing consensus that randomised controlled clinical trial (RCT) provide a secure basis for determining treatment effects. Prospective randomised clinical trials can be a powerful tool in medical science and evidence-based medicine. A well-defined study hypothesis, with a prospectively applied study design, blinded and randomised treatment allocation and assessment, with appropriate control groups can provide strong evidence in support of treatment decisions. However, the recent reviews of the medical literature indicate that the study design itself does not ensure the quality of science or useful and valid scientific data. Thus, regardless of the study design or level of evidence, it remains imperative for the physician and surgeon to critically evaluate a scientific report. Moreover, as randomisation, concealment of treatment allocation and blinding are difficult issues to resolve in orthopaedic surgery, future trials should focus on detailed and correct reporting of outcome measures.

Evidence-based hand surgery: the role of Cochrane reviews

A detailed literature search was performed to investigate whether the increasing importance of evidence-based hand surgery is reflected in the actual status of Cochrane reviews. Fourteen Cochrane reviews were found and evaluated. Of these, five reviews were in the field of distal radial fractures and four concerned carpal tunnel syndrome. Cochrane reviews were also found for antibiotic treatment, rehabilitation after flexor tendon injuries, mallet finger injuries, little finger metacarpal neck fractures and thumb joint arthritis. All 14 reviews were compromised by methodological flaws and significant clinical heterogeneity of the included studies. Within most reviews the underlying evidence was insufficient and only a very limited number of clinical recommendations could be made. In conclusion, the existing Cochrane reviews in the field of hand surgery show both an increasing interest in establishing systematically summarised knowledge and an enormous demand for good-quality randomised controlled trials.

A guide to planning and executing a surgical randomized controlled trial

Evidence-based medicine requires that treatments given to patients demonstrate effectiveness. The randomized controlled trial (RCT) has become the preeminent study design to assess the efficacy of treatments. Randomized controlled trials are frequently used to evaluate pharmaceutical treatments but are less often used in surgery. The lack of surgical RCTs is partly due to ethical and methodological concerns associated with surgical interventions. We provide a guide to planning and conducting a surgical RCT.

Scales to assess the quality of randomized controlled trials: a systematic review

BACKGROUND AND PURPOSE

The methodological quality of randomized controlled trials (RCTs) is commonly evaluated in order to assess the risk of biased estimates of treatment effects. The purpose of this systematic review was to identify scales used to evaluate the methodological quality of RCTs in health care research and summarize the content, construction, development, and psychometric properties of these scales.

METHODS

Extensive electronic database searches, along with a manual search, were performed.

RESULTS

One hundred five relevant studies were identified. They accounted for 21 scales and their modifications. The majority of scales had not been rigorously developed or tested for validity and reliability. The Jadad Scale presented the best validity and reliability evidence; however, its validity for physical therapy trials has not been supported.

DISCUSSION AND CONCLUSION

Many scales are used to evaluate the methodological quality of RCTs, but most of these scales have not been adequately developed and have not been adequately tested for validity and reliability. A valid and reliable scale for the assessment of the methodological quality of physical therapy trials needs to be developed.

Assessing the clinical significance of change scores following carpal tunnel surgery

This article presents a prospective longitudinal study to determine the cut-off values for change scores of DASH, Levine, and Kamath questionnaires to distinguish clinical improvement following carpal tunnel surgery. Fifty-four patients (40 female, 14 male), with positive nerve conduction studies, were prospectively followed up. Three questionnaires (DASH, Levine, and Kamath) were posted to patients at four and two weeks prior to their operation and then six weeks following surgery. A patient global impression of change (PGIC) score was completed for patients to rate the overall change in their symptoms. According to the PGIC, 93% of patients improved. The cut-off values for raw change scores that best define clinically significant improvement following carpal tunnel release were 20.9 for DASH, 0.47 for Levine, and 1.97 for the Kamath questionnaire. This study provides a methodological framework for identifying clinically significant changes following treatment. A questionnaire follow-up of patients is now possible using the data provided.