Knowledge management tools and mechanisms for evidence-informed decision-making in the WHO European Region: a scoping review

BACKGROUND

Knowledge management (KM) emerged as a strategy to promote evidence-informed decision-making. This scoping review aims to map existing KM tools and mechanisms used to promote evidence-informed health decision-making in the WHO European Region and identify knowledge gaps.

METHODS

Following the Joanna Briggs Institute (JBI) guidance for conducting scoping reviews, we searched Medline, PubMed, EMBASE, the Cochrane library, and Open Grey. We conducted a descriptive analysis of the general characteristics of the included papers and conducted narrative analysis of the included studies and categorized studies according to KM type and phase.

RESULTS

Out of 9541 citations identified, we included 141 studies. The KM tools mostly assessed are evidence networks, surveillance tools, observatories, data platforms and registries, with most examining KM tools in high-income countries of the WHO European region. Findings suggest that KM tools can identify health problems, inform health planning and resource allocation, increase the use of evidence by policymakers and stimulate policy discussion.

CONCLUSION

Policymakers and funding agencies are called to support capacity-building activities, and future studies to strengthen KM in the WHO European region particularly in Eastern Europe and Central Asia. An updated over-arching strategy to coordinate KM activities in the WHO European region will be useful in these efforts.

Three-Year Rates of Reoperation and Revision Following Mobile Versus Fixed-Bearing Total Ankle Arthroplasty: A Cohort of 302 Patients with 2 Implants of Similar Design

BACKGROUND

Currently, the implants utilized in total ankle arthroplasty (TAA) are divided between mobile-bearing 3-component and fixed-bearing 2-component designs. The literature evaluating the influence of this mobility difference on implant survival is sparse. The purpose of the present study was therefore to compare the short-term survival of 2 implants of similar design from the same manufacturer, surgically implanted by the same surgeons, in fixed-bearing or mobile-bearing versions.

METHODS

All patients were enrolled who underwent TAA with either the mobile-bearing Salto (Tornier and Integra) or the fixed-bearing Salto Talaris (Integra) in 3 centers by 2 surgeons between January 2004 and March 2018. All patients who underwent TAA from January 2004 to April 2013 received the Salto implant, and all patients who underwent TAA after November 2012 received the Salto Talaris implant. The primary outcome was time, within 3 years, to first all-cause reoperation, revision of any metal component, and revision of any component, including the polyethylene insert. Secondary outcomes included the frequency, cause, and type of reoperation.

RESULTS

A total of 302 consecutive patients were included, of whom 171 received the mobile-bearing and 131 received the fixed-bearing implant. The adjusted hazard ratio for all-cause reoperation was 1.42 (95% confidence interval [CI], 0.67 to 3.00; p = 0.36); for component revision, 3.31 (95% CI, 0.93 to 11.79; p = 0.06); and for metal component revision, 2.78 (95% CI, 0.58 to 13.33; p = 0.20). A total of 31 reoperations were performed in the mobile-bearing group compared with 14 in the fixed-bearing group (p = 0.07). More extensive reoperation procedures were performed in the mobile-bearing group.

CONCLUSIONS

With the largest comparison of 2 implants of similar design from the same manufacturer, the present study supports the use of a fixed-bearing design in terms of short-term failure. We found a 3-times higher rate of revision among mobile-bearing implants compared with fixed-bearing implants at 3 years after TAA. Reoperations, including first and subsequent procedures, tended to be less common and the causes and types of reoperations less extensive among fixed-bearing implants.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hawkins' type-II talar fracture with subtalar dislocation: A very unusual combination

We report the unusual case of a 16-year-old young man who sustained a rare association of a Hawkins' type-II talar neck fracture with a complete medial subtalar dislocation (Hawkins type-IIB) that occurred as an isolated injury after indirect trauma during a soccer game. Following closed reduction of the subtalar dislocation, standard radiographs and computed tomography (CT) demonstrated a comminuted fracture of the talus involving the base of the talar neck. Open reduction was performed and the fracture was stabilized by ORIF. At 1-year follow-up, functional and radiographic outcomes were graded as excellent, with no radiographic evidence of talar osteonecrosis.

Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren-Lawrence scale is reliable and correlates with clinical symptoms

OBJECTIVE

To assess reliability and construct validity of the Kellgren-Lawrence (K&L) scale in posttraumatic ankle osteoarthritis (OA); additionally evaluate the validity of including tibiotalar tilting in the scale.

METHOD

One-hundred and fifty ankle radiographs (75 patients, unilateral malleolar fractures) evaluated at average of 18 years after surgery. American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot (HF) score and pain (visual analog scale) were recorded. Grading of OA according to K&L criteria and identification of OA features was performed on standardized radiographs by four physicians. Minimal joint space width, sclerosis, and talar tilt angle were quantified by digital measurements. A modified K&L scale including talar tilting is presented. Validity of original and modified scale was evaluated and expressed as ability to (1) Identify those with clinical symptoms of ankle OA; and (2) Distinguish between different degrees of fracture severity.

RESULTS

Inter- and intra-observer reliability of OA assessment according to K&L were good (ICC 0.61 and 0.75). Original and modified K&L grades significantly increased with decreasing AOFAS ankle-HF scores and greater pain. A talar-tilt angle > 2° compared with ≤ 2° in grade 3 was associated with significantly higher pain levels (VAS pain 4.2 vs 1.4, respectively; mean difference 2.8, 95% CI 0.5-5.1). More severe fracture patterns at time of surgery were more often in patients with the highest K&L grades.

CONCLUSIONS

The K&L scale is a valid and reliable radiographic grading system for assessment of ankle OA. Inclusion of the talar tilt angle might allow for better differentiation with respect to clinical outcomes.

[Incidence of major lower limb amputation in Geneva: twenty-one years of observation]

Between 1990 and 2010 the incidence of major lowerlimb amputations (by definition any level of amputation above the foot) in the canton of Geneva was 10.02 per 100,000 inhabitants/ year. The analysis of various population groups revealed that the presence of diabetes increased the relative risk of amputation by a factor of 20, and age 65 years or older by a factor of 9. During this 21 years period we observed a gradual decline in the incidence of amputation and an increased age at the time of amputation, despite the increasing prevalence of diabetes and an aging population. This was a reflection on the efforts of primary and secon- dary prevention, initiated in the 1980s in which Geneva was a pioneer.

[Benefit of computer assisted surgery in foot and ankle surgery]

In foot and ankle surgery accurate fracture reduction and implant placement may be challenging. Fracture malreduction or implant malposition may remain undetected with use of conventional fluoroscopy and are often only recognized on postoperative computed tomography (CT) scans. The development of a three-dimensional (3D) mobile imaging system has provided intraoperative control of fracture reduction and implant position. Three-dimensional computer assisted surgery (3D-CAS) has demonstrated improved accuracy in spine and pelvic surgery. Recently, the application of 3D-CAS in the field of foot and ankle surgery has shown very promising preliminary results. It appears that the intraoperative use of 3D imaging will become a standard of care.

Validation techniques for quantitative brain tumors measurements

Quantitative measurements of tumor volume becomes more realistic with the use of imaging- particularly specially when the tumor have non-ellipsoidal morphology, which remains subtle, irregular and difficult to assess by visual metric and clinical examination. The quantitative measurements depend strongly on the accuracy of the segmentation technique. The validity of brain tumor segmentation methods is an important issue in medical imaging because it has a direct impact on many applications such as surgical planning and quantitative measurements of tumor volume. Our goal was to examine two popular segmentation techniques seeded region growing and active contour "snakes" to be compared against experts' manual segmentations as the gold standard. We illustrated these methods on brain tumor volume cases using MR imaging modality.

[Diagnosis and treatment of the ruptured Achilles tendon]

The treatment of the recently ruptured Achilles tendon can be conservative or surgical. The conservative treatment may be carried out using either a static cast immobilisation or using a dynamic brace and an early functional rehabilitation. The surgical technique can be either open or mini-invasive. Neglected and ancient ruptures may need to be treated surgically by a tendinoplasty. There is an ongoing discussion about how to manage the recently ruptured Achilles tendon, especially since recent descriptions of conservative-functional treatment procedures and mini-invasive surgical techniques. We present the choice of the different treatment options and the clinical reasoning to identify the best adapted treatment for the individual patient. The ideal treatment option depends on the functional demand and the medical condition of the patient.

[Open fractures of the tibia in the adult: surgical treatment and complications]

Open tibial shaft fractures represent high-energy trauma and are associated with a substantial risk of complications. Management is an emergency, and the first steps in treatment include antibiotic prophylaxis, tetanus booster, surgical debridement, irrigation of the wound and stabilization of the fracture. The Gustilo and Anderson classification helps to guide definitive treatment. Intramedullary nailing is the surgical technique of choice. An indirect approach utilizing external fixation is recommended for Gustilo IIIB and IIIC fractures. The most prevalent complications are compartment syndrome (10%), infection (2%-40% without antibiotics according to Gustilo grading, most notably in the presence of vascular lesions), aseptic nonunion (23%), venous thromboembolism (60% without prevention) and anterior knee pain (>50%).

The effect of collateral ligament release on ankle dorsiflexion: an anatomical study

BACKGROUND

Ankle stiffness is a common complication after ankle fracture, reconstructive surgery or total ankle replacement, and the usual limitation is in dorsiflexion. There are few articles in the literature concerning this frequent problem, and furthermore they are not recent and tend to be controversial. The purpose of this anatomical study was to evaluate and quantify the effect of ankle collateral ligament release on dorsiflexion, specifically the amount of increase in ankle dorsiflexion following section of the two ligaments most often implicated in ankle stiffness: the deep posterior tibiotalar ligament (dPTTaL, or posterior deep deltoid) and the posterior talofibular ligament (PTaFL).

METHODS

We dissected 18 adult fresh cadaveric ankle joints, and with an electronic goniometer combined with an electronic dynamometer measured their mobility in dorsiflexion before and after transection of each ligament separately, and the two ligaments combined.

RESULTS

The results showed a significant difference between the two groups of ankles with section of the dPTTaL resulting in a greater increase in ankle dorsiflexion than section of the PTaFL (mean 7.45° vs. 3.5°, respectively; p<0.001). Combined section of both ligaments improved the gain in ankle dorsiflexion more than isolated section of each ligament, but was not statistically significant (p=0.88).

CONCLUSION

If after gastrocnemius recession or Achilles tendon lengthening persistent restriction remains in ankle dorsiflexion, the results of our study demonstrate that the next step should be release of the dPTTaL.

[Diabetic foot infection: a multidisciplinary approach]

Diabetic foot infection is a frequent, multifactorial and multifacettal disease. Its management requires an interdisciplinary collaboration. Multiple medical and surgical specialties are enrolled for its prevention and treatment, for good reasons. Concomitant management by various specialists shows a significant reduction in amputation rates. We review the issues of this interdisciplinary collaboration.

Biofeedback for foot offloading in diabetic patients with peripheral neuropathy

AIMS

The reduction of high plantar pressure in diabetic patients with peripheral neuropathy is mandatory for prevention of foot ulcers and amputations. We used a new biofeedback-based method to reduce the plantar pressure at an at-risk area of foot in diabetic patients with peripheral neuropathy.

METHODS

Thirteen diabetic patients (age 60.8 +/- 12.3 years, body mass index 29.0 +/- 5.0 kg/m(2)) with peripheral neuropathy of the lower limbs were studied. Patients with memory impairment were excluded. The portable in-shoe foot pressure measurement system (PEDAR) was used for foot offloading training by biofeedback. The learning procedure consisted in sequences of walking (10 steps), each followed by a subjective estimation of performance and objective feedback. The goal was to achieve three consecutive walking cycles of 10 steps, with a minimum of seven steps inside the range of 40-80% of the baseline peak plantar pressure. The peak plantar pressure was assessed during the learning period and at retention tests.

RESULTS

A significant difference in peak plantar pressure was recorded between the beginning and the end of the learning period (when the target for plantar pressure was achieved) (262 +/- 70 vs. 191 +/- 53 kPa; P = 0.002). The statistically significant difference between the beginning of learning and all retention tests persisted, even at the 10-day follow-up.

CONCLUSIONS

Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term.

Successful treatment of Candida parapsilosis (fluconazole-resistant) osteomyelitis with caspofungin in a HIV patient

Treating Candida arthritis is challenging. We report a case of Candida parapsilosis arthritis successfully treated with caspofungin. We illustrate the likelihood of severe infections due fluconazole resistant C. parapsilosis after extensive fluconazole use and discuss the role of newer antifungal agents in the treatment of arthritis due to Candida spp.

Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.

The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.

We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.

Capacité de marche en milieu extra-hospitalier des amputés appareillés

PURPOSE OF THE STUDY

A large body of literature has been devoted to gait analysis in amputees. Most studies have been conducted in the laboratory setting where numerous variables are analyzed: gait efficiency, energy cost, walking velocity. At the present time however, data are lacking on the real-life use of walking prostheses. Little is known about how long patients wear their prosthesis or how difficult it is for them to walk during different periods of the day. Currently, such information depends on the quality of the interview and the patient-physician relationship. A precise assessment of walking activity in amputees and use of prostheses would be a valuable source of information for therapists and would provide complimentary information to that collected from laboratory gait analysis. The purpose of this study was to study walking activity in home-dwelling prosthesis-bearing lower-limb amputees and to determine variables affecting walking performance. To our knowledge, this is the first published study on this topic.

MATERIAL AND METHODS

The series included home-dwelling prosthesis-wearing lower-limb amputees (Syme amputation or more proximal) who were able to get up and go without assistance. A StepWatch3 recorder was implanted on the prosthesis for 15 consecutive days. Variables recorded were number of steps, total walking time, and walking velocity. Variables which might affect walking in prosthesis-wearing amputees were also recorded: body mass index, use of a walking aid, level and reason for amputation, age at amputation and at recording, time between amputation and recording.

RESULTS

From June 2004 to May 2005, 43 patients wore the StepWatch3 for the scheduled 15 days during their daily activities. Mean age at amputation was 42 years (range 13-78 years) and at recording 52 years (range 25-85 years). Considered separately, gait parameters showed that all of the patients wore their prosthesis daily and that the best walking performance was significantly observed among below-knee amputees who did not use a walking aid and who underwent amputation for a non-vascular cause. Multivariate analysis revealed that above-knee amputees lost 93 minutes of walking time per day (21% loss), and that amputees who used a walking aid lost 58 minutes per day (13% loss). Daily walking time declined 2.5 minutes per year of age. Body mass index was not correlated with total daily walking time but had a direct significant effect on walking velocity.

[Mini-invasive suture of Achilles tendon ruptures: a concept whose time has come]

Rupture of the Achilles tendon is a frequent injury particularly among sports enthusiasts, and there has been an increased incidence over these past years which parallels the rise in popularity of sporting activities. Traditionally, an open operative repair of the tendon has been proposed. Over the past ten years we have utilized a mini-invasive technique with the help of instrumentation we have developed, with the objective to minimize the surgical trauma and improve the quality of suture fixation. These past ten years of observation have allowed us to objectively assess its clinical and functional benefit. This operative approach is in the process of replacing the traditional open procedure for the management of acute Achilles tendon ruptures in the majority of centers which manage these injuries.

[Ankle arthroplasty. Rationale for interfaculty collaboration]

Arthroplasty has become increasingly popular as a solution for end-stage ankle arthrosis. Good results, with a 90% survival rate at ten years, have been reported with use of recent prostheses. However, the role of ankle arthroplasty needs to be more clearly defined. Due to its particular nature and specific biomechanical aspects, the ankle joint presents a real challenge for arthroplasty. Patient selection and surgical technique need to be optimized to improve long-term results. Careful clinical and biomechanical studies need to be conducted to objectively determine the long term benefit in terms of quality of life. To better address these points the authors of this manuscript have coordinated their expertise in a collaborative approach, so as to optimize surgical indications, prosthesis implantation, postoperative rehabilitation and research.

[Hallux valgus: which treatment]

Hallux valgus deformity is characterized by lateral deviation of the proximal phalanx on the metatarsal head. Variable severity of the deviation causes prominence of the medial eminence, giving rise to a painful bunion deformity. Many patients will find permanent or temporary relief with non surgical measures. For those who failed conservative treatment, surgery may cure their symptoms. However unsatisfactory outcomes following hallux valgus surgery is not rare. Therefore a clear understanding of the pathology and of the patient's expectations must anticipate any treatment strategy in order to optimise patient's outcome. Cosmetic considerations should never be an indication for surgery.

Are drivers more likely to injure their right or left foot in a frontal car crash: a crash and biomechanical investigation

In this study we hypothesized that for frontal crashes, the driver was more likely to sustain foot injury than the front seated passenger and the right foot was more likely to be injured than the left because the driver's right foot was positioned in dorsiflexion and eversion during the crash and less able to tolerate crash forces. Seventeen CIREN frontal crashes were studied to document the circumstances and resulting foot injuries. NASS data was sampled to determine frequencies of injury to foot side and occupant position. Biomechanically, matched pairs of cadaveric feet were tested in compression with one in dorsiflexion, and the other, dorsiflexion, and eversion. Results showed that drivers were more likely than passengers to sustain a foot or ankle injury and this was almost exclusively due to a higher frequency of right foot injuries in drivers. Braking, with significant toepan intrusion, was associated with an increase in both right and left foot injuries in drivers. Biomechanically, 9 of 15 pairs tested provided useable data. There was a significant decrease in load to failure between specimens forced into dorsiflexion and eversion (mean, 4107 N, sd = 1630 N) compared with dorsiflexion alone (mean, 6468 N, sd = 2435 N, p = 0.001). The majority (16 of 17) of foot injuries in the CIREN cases were to drivers of which 13 injured their right foot and ankle. An implication of this work is that if thresholds based on data from dorsiflexion and compression loading are used to predict foot and ankle injury in frontal crashes they may not represent that population of drivers who are braking at the time of the crash and could suffer injuries at forces lower than current threshold values.

The axial view to measure posterior laxity of the knee. A mathematical analysis

Posterior laxity of the knee can be assessed clinically, but interpretation of the amount of displacement is highly subjective. Mechanical methods are more efficacious for measuring anterior laxity. Radiologic techniques are available for measurement in a lateral projection, but some variables may interfere with their accuracy. We undertook a trigonometric analysis of the axial view to confirm that it can be used to reliably measure posterior displacement. The ideal radiologic conditions consist of 80 degrees of knee flexion in both knees maintained with a knee support and a 26 degrees x-ray beam incidence with respect to the tibia. Although such accuracy is rarely obtained in routine clinical practice, even with a variability of +/- 10 degrees in the x-ray beam incidence the error factor will be less than 10%. Such a degree of error is in the same range (+/- 2 mm) as noted by investigators using the lateral radiograph to measure anteroposterior displacement. We believe that our study validates the use of a single axial radiograph of both knees to assess the state of the posterior cruciate ligament of an injured knee as compared with a normal knee.

Osteosynthesis of metastatic lesions of the proximal femur with a solid femoral nail and interlocking spiral blade inserted without reaming

OBJECTIVES

To evaluate the efficiency of a solid femoral nail and interlocking spiral-blade, inserted without reaming (UFN/ spiral blade, Synthes-Stratec, Oberdorf, Switzerland), for the fixation of pathologic and impending pathologic fractures of the proximal femur, particularly those involving the subtrochanteric area.

DESIGN

Retrospective, consecutive series.

SETTING AND PATIENTS

All patients treated for pathologic and impending pathologic fractures of the trochanteric or subtrochanteric area, stabilized using a UFN/spiral blade, inserted without reaming, from June 1994 to June 1997.

INTERVENTION

Femoral intramedullary nailing was performed without reaming on a radiolucent operating room table. The nail was inserted through a five-centimeter supratrochanteric approach, and the interlocking spiral-blade device was introduced percutaneously.

METHODS

The following parameters were assessed: pathology reports, location of bone lesions, patient survival, pain relief, ambulation, hardware failure on successive radiographs, and intraoperative complications.

RESULTS

Twelve pathologic and impending pathologic fractures were stabilized in ten patients. Two patients required bilateral nailing that was staged with intervals of two and three weeks, respectively. The average postsurgical survival was six and one-half months. No implant failure was noted, and no surgical revision was performed. One intraoperative death occurred during surgery and was documented on autopsy as massive pulmonary fat embolization. Neither patient with bilateral nailing suffered from fat embolism syndrome.

CONCLUSIONS

Femoral nail insertion without reaming using an interlocking spiral blade provides appropriate stabilization of the proximal femur in case of metastatic lesions, even with extensive subtrochanteric involvement. Although the nails were inserted without reaming, this did not avoid the risk of fat embolization syndrome. This study only addressed results in patients with short-term survival.