Views on orthopaedics motivated by recent editorial – Part 1

A recent editorial in the Bone & Joint Journal was about weight-bearing in orthopaedic traumatology. Written by Alex Trompeter, the title was intriguing: A call to arms: it’s time to bear weight!

This editorial was best I have read in a while. Besides weight-bearing, Trompeter addressed many other general topics. In following posts I will shortly recap his saying and give my insight.

Orthopaedic fracture surgery has, for a very long time, suffered a paucity of high-quality, robust evidence supporting our interventions. Much of what we do in treating our patients is based on either what we were taught by our trainers, or what our industry partners have led us to believe. Over the last decade we have seen a drive to change this and numerous areas of research are challenging this received dogma. We are now seeing the pendulum swing in terms of treatments we select, as our understanding of the science of fracture fixation improves.

Trompeter A (2020)

Just great. I actually tweeted about this some time ago.

Trompeter is saying exactly the same I meant in my twitter. We keep thinking that orthopaedics is very EBM. Well it is not. Great majority of our evidence is based on level 4 studies, like retrospective case series. Just think about nonoperative treatment in sports surgery. How many studies have been published studying nonoperative treatment in meniscal tears, hamstring injuries or ACL ruptures?

Earliest definition of EBM was included in a 1992 JAMA paper written by the “founding fathers” of EBM from the McMaster University. In that paper the former and the new pradigm are described. First two descriptions of the former paradigm are follows:

1.Unsystematic observations from clinical experience are a valid way of building and maintaining one’s knowledge about patient prognosis, the value of diagnostic tests, and the efficacy of treatment.
2.The study and understanding of basic mechanisms of disease and pathophysiologic principles are a sufficient guide for clinical practice.

Sackett al. JAMA 1992

“Unsystematic observations” sounds very similar to uncontrolled patient series which the most common study setting especially in sports surgery. Usually these studies state that investigated surgical technique or procedure result to good outcome and that efficacy is proven.

A recent study publised in KSSTA journal investigated the effect of osteotomy, ACL reconstrution and chondral resurfacing in patients with varus knees with osteoarthritis and ACL insufficiency. There was no control group. An osteotomy is done to change the knee alignment, ACL reconstrution is done to restore presumed ACL insufficiency and chondral resurfacing is done due to cartilage repair. When surgical procedure is based on these principles and there is no control group, all sounds just like “pathophysiologic principles are a sufficient guide for clinical practice.”

So, this does not sound very EBM but more like the former paradigm. But sadly this is the story of modern orthopaedics, traumatology and especially sports surgery. We justify numerous surgeries based on “sound” biomechanical theory and low level of evidence. But I believe a change is coming. Numerous high quality studies have been published investigating the effects of nonoperative treatment and even placebo surgery in orthopaedics. This has especially improved our understading of degenerative joint diseases and their natural course. We also need to raise awareness of the methodological caveats associated to studies with no control group. These include fundamental issues such as causal inference and regressio-to-mean. It won´t be a rapid change but I believe it is coming.

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