Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 473 | Issue 7 | Jul, 2015

Network Meta-analysis: Users’ Guide for Surgeons: Part I – Credibility

Clary J. Foote MD, Harman Chaudhry MD, Mohit Bhandari MD, PhD, Lehana Thabane PhD, Toshi A. Furukawa MD, PhD, Brad Petrisor MD, Gordon Guyatt MD, MSc Conventional meta-analyses quantify the relative effectiveness of two interventions based on direct (that is, head-to-head) evidence typically derived from randomized controlled trials (RCTs). For many medical conditions, however, multiple treatment options exist and not all have been compared directly. This issue limits the utility of traditional synthetic techniques such as meta-analyses, since these approaches can only pool and compare evidence across interventions that have been compared directly by source studies. Network meta-analyses (NMA) use direct and indirect comparisons to quantify the relative effectiveness of three or more treatment options. Interpreting the methodologic quality and results of NMAs may be challenging, as they use complex methods that may be unfamiliar to surgeons; yet for these surgeons to use these studies in their practices, they need to be able to determine whether they can trust the results of NMAs. The first judgment of trust requires an assessment of the credibility of the NMA methodology; the second judgment of trust requires a determination of certainty in effect sizes and directions. In this Users’ Guide for Surgeons, Part I, we show the application of evaluation criteria for determining the credibility of a NMA through an example pertinent to clinical orthopaedics. In the subsequent article (Part II), we help readers evaluate the level of certainty NMAs can provide in terms of treatment effect sizes and directions.

Network Meta-analysis: Users’ Guide for Surgeons: Part II – Certainty

Harman Chaudhry MD, Clary J. Foote MD, Gordon Guyatt MD, MSc, Lehana Thabane PhD, Toshi A. Furukawa MD, PhD, Brad Petrisor MD, Mohit Bhandari MD, PhD In the previous article (Network Meta-analysis: Users’ Guide for Surgeons—Part I, Credibility), we presented an approach to evaluating the credibility or methodologic rigor of network meta-analyses (NMA), an innovative approach to simultaneously addressing the relative effectiveness of three or more treatment options for a given medical condition or disease state. In the second part of the Users’ Guide for Surgeons, we discuss and demonstrate the application of criteria for determining the certainty in effect sizes and directions associated with a given treatment option through an example pertinent to clinical orthopaedics.

Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

Clary J. Foote MD, Gordon H. Guyatt MD, MSc, FRCPC, K. Nithin Vignesh BHSc, Raman Mundi MD, Harman Chaudhry MD, Diane Heels-Ansdell MSc, Lehana Thabane PhD, Paul Tornetta MD, Mohit Bhandari MD, PhD, FRCSC

Open tibial shaft fractures are one of the most devastating orthopaedic injuries. Surgical treatment options include reamed or unreamed nailing, plating, Ender nails, Ilizarov fixation, and external fixation. Using a network meta-analysis allows comparison and facilitates pooling of a diverse population of randomized trials across these approaches in ways that a traditional meta-analysis does not.

Addition of Vancomycin to Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint Arthroplasty

P. Maxwell Courtney MD, Christopher M. Melnic MD, Zachary Zimmer MD, Jason Anari MD, Gwo-Chin Lee MD

With increasing prevalence of methicillin-resistant(MRSA) in patients undergoing hip and knee arthroplasty, some have advocated a dual-antibiotic regimen including vancomycin as prophylaxis against surgical site infections. However, routine administration of vancomycin may result in impaired renal functions in susceptible patients.

The Alpha-defensin Test for Periprosthetic Joint Infection Responds to a Wide Spectrum of Organisms

Carl Deirmengian MD, Keith Kardos PhD, Patrick Kilmartin MS, Simmi Gulati MS, Patrick Citrano BS, Robert E. Booth MD

The alpha-defensin test has been previously demonstrated to be highly accurate in the diagnosis of prosthetic joint infection (PJI), nearly matching the Musculoskeletal Infection Society definition for PJI. However, the relationship between alpha-defensin levels and differing infecting organism has not yet been investigated.

Are Nucleated Cell Counts Useful in the Diagnosis of Infection in Periprosthetic Fracture?

Stephen Preston MD, Lyndsay Somerville PhD, Brent Lanting MD, James Howard MD

Evaluating for the possibility of prosthetic joint infection in the setting of periprosthetic fracture is important because it determines the course of treatment. However, fracture-related inflammation can make investigations used in the diagnosis of infection less reliable.

Premature Therapeutic Antimicrobial Treatments Can Compromise the Diagnosis of Late Periprosthetic Joint Infection

Alisina Shahi MD, Carl Deirmengian MD, Carlos Higuera MD, Antonia Chen MD, MBA, Camilo Restrepo MD, Benjamin Zmistowski MD, Javad Parvizi MD

In the absence of positive cultures and draining sinuses, the diagnosis of periprosthetic joint infection (PJI) relies on laboratory values. It is unknown if administration of antibiotics within 2 weeks before diagnostic evaluations can affect these tests in patients with PJI.

Antimicrobial Release From Prefabricated Spacers Is Variable and the Dose Is Low

Oren Goltzer MD, Alex McLaren MD, Derek Overstreet PhD, Christopher Galli BS, Ryan McLemore PhD

High-dose antimicrobial-loaded bone cement (ALBC) is recommended to treat orthopaedic infections. Elution characteristics from prefabricated ALBC spacers and how they compare with hand-mixed ALBC are not well described.

Liposomal Formulation Decreases Toxicity of Amphotericin B In Vitro and In Vivo

Justin Roberts MD, Josh Bingham MD, Alex C. McLaren MD, Ryan McLemore PhD

Liposomal amphotericin B is locally delivered to treat fungal orthopaedic infections but little is known about local tissue toxicity, if any, that might be associated with local delivery.

Novel Antibiotic-loaded Point-of-care Implant Coating Inhibits Biofilm

Jessica Amber Jennings PhD, Daniel P. Carpenter BS, Karen S. Troxel PhD, Karen E. Beenken PhD, Mark S. Smeltzer PhD, Harry S. Courtney PhD, Warren O. Haggard PhD

Orthopaedic biomaterials are susceptible to biofilm formation. A novel lipid-based material has been developed that may be loaded with antibiotics and applied as an implant coating at point of care. However, this material has not been evaluated for antibiotic elution, biofilm inhibition, or in vivo efficacy.

Twenty Percent of Patients May Remain Colonized With Methicillin-resistant Staphylococcus aureus Despite a Decolonization Protocol in Patients Undergoing Elective Total Joint Arthroplasty

Michael D. Baratz MD, Ruth Hallmark BSN, Susan M. Odum PhD, Bryan D. Springer MD

is the most commonly isolated organism in periprosthetic joint infection (PJI). Resistant strains such as methicillin-resistant(MRSA) are on the rise, and many programs have instituted decolonization protocols. There are limited data on the success ofnasal decolonization programs and their impact on PJI.

The Gown-glove Interface Is a Source of Contamination: A Comparative Study

James F. Fraser MD, MPH, Simon W. Young FRACS, Kimberly A. Valentine RN, Nicholas E. Probst PA-C, Mark J. Spangehl MD

The original Charnley-type negative-pressure body exhaust suit reduced infection rates in randomized trials of total joint arthroplasty (TJA) decades ago. However, modern positive-pressure surgical helmet systems have not shown similar benefit, and several recent studies have raised the question of whether these gowning systems result in increased wound contamination and infections. The gown-glove interface may be one source of particle contamination.

A History of Treated Periprosthetic Joint Infection Increases the Risk of Subsequent Different Site Infection

Hany Bedair MD, Nitin Goyal MD, Mathew J. Dietz MD, Kenneth Urish MD, PhD, Viktor Hansen MD, Jorge Manrique MD, William Hamilton MD, Greg Deirmengian MD

After the successful treatment of periprosthetic joint infection (PJI), patients may present with degenerative joint disease in another joint with symptoms severe enough to warrant arthroplasty. However, it is not known whether patients with a history of treated PJI at one site will have an increased risk of PJI in the second arthroplasty site.

Revision of Metal-on-metal Hip Prostheses Results in Marked Reduction of Blood Cobalt and Chromium Ion Concentrations

Olli Lainiala BM, Aleksi Reito MD, Petra Elo MD, PhD, Jorma Pajamäki MD, PhD, Timo Puolakka MD, PhD, Antti Eskelinen MD, PhD

High revision rates attributable to adverse reactions to metal debris have been reported for total hip arthroplasties (THAs) with metal-on-metal implants and hip resurfacings. The effect of revision on blood metal ion levels is described only in small series, the clinical results of revisions have been contradictory, and concerns regarding component loosening have been presented.

Arthroscopic Transplantation of Synovial Stem Cells Improves Clinical Outcomes in Knees With Cartilage Defects

Ichiro Sekiya MD, PhD, Takeshi Muneta MD, PhD, Masafumi Horie MD, PhD, Hideyuki Koga MD, PhD

Transplantation of mesenchymal stem cells (MSCs) is one possible strategy to achieve articular cartilage repair. We previously reported that synovial MSCs were highly proliferative and able to undergo chondrogenesis. We also found that placing a suspension of synovial MSCs on a cartilage defect for 10 minutes promoted cartilage repair in rabbit and pig models. However, the in vivo efficacy of this approach has not been tested clinically.

Bicruciate-retaining Total Knee Replacement Provides Satisfactory Function and Implant Survivorship at 23 Years

James W. Pritchett MD

One of the goals of a TKA is to approximate the function of a normal knee. Preserving the natural ligaments might provide a method of restoring close to normal function. Sacrifice of the ACL is common and practical during a TKA. However, this ligament is functional in more than 60% of patients undergoing a TKA and kinematic studies support the concept of bicruciate-retaining (that is, ACL-preserving) TKA; however, relatively few studies have evaluated patients treated with bicruciate-retaining TKA implants.

Subchondral Calcium Phosphate is Ineffective for Bone Marrow Edema Lesions in Adults With Advanced Osteoarthritis

Dipal Chatterjee MD, Alan McGee MD, Eric Strauss MD, Thomas Youm MD, Laith Jazrawi MD

Injury to subchondral bone is associated with knee pain and osteoarthritis (OA). A percutaneous calcium phosphate injection is a novel approach in which subchondral bone marrow edema lesions are percutaneously injected with calcium phosphate. In theory, calcium phosphate provides structural support while it is gradually replaced by bone. However, little clinical evidence supports the efficacy of percutaneous calcium phosphate injections.

Are Allogeneic Blood Transfusions Associated With Decreased Survival After Surgery for Long-bone Metastatic Fractures?

Stein J. Janssen MD, Yvonne Braun MD, John E. Ready MD, Kevin A. Raskin MD, Marco L. Ferrone MD, Francis J. Hornicek MD, MS, PhD, Joseph H. Schwab MD, MS

Previous studies have shown that perioperative blood transfusion increases cancer recurrence and decreases patient survival after resection of primary malignancies. The question arises whether this association also exists in patients with already disseminated disease undergoing surgery for metastatic long-bone fractures.

What is the Proportion of Patients With Multiple Hereditary Exostoses Who Undergo Malignant Degeneration?

Cory M. Czajka MD, Matthew R. DiCaprio MD

Multiple hereditary exostoses is an autosomal-dominant skeletal disorder that has a wide-ranging reported risk of malignant degeneration to chondrosarcoma.

Time Seeing a Hand Surgeon Is Not Associated With Patient Satisfaction

Teun Teunis MD, Emily R. Thornton BSc, Prakash Jayakumar MD, David Ring MD, PhD

Previous studies, predominantly in the primary care setting, identified time spent with the physician as an important predictor of satisfaction. It is unknown if the same holds true in hand surgery.

Is the Control of Applied Digital Forces During Natural Five-digit Grasping Affected by Carpal Tunnel Syndrome?

Po-Tsun Chen MS, I-Ming Jou MD, PhD, Chien-Ju Lin PhD, Hsiao-Feng Chieh PhD, Li-Chieh Kuo PhD, Fong-Chin Su PhD

The impaired sensory function of the hand induced by carpal tunnel syndrome (CTS) is known to disturb dexterous manipulations. However, force control during daily grasping configuration among the five digits has not been a prominent focus of study. Because grasping is so important to normal function and use of a hand, it is important to understand how sensory changes in CTS affect the digit force of natural grasp.

Bone Regeneration Is Promoted by Orally Administered Bovine Lactoferrin in a Rabbit Tibial Distraction Osteogenesis Model

Wenyang Li PhD, Songsong Zhu PhD, Jing Hu PhD

Lactoferrin, an iron-binding glycoprotein which belongs to the transferrin family, has been shown to promote bone growth. However, reports regarding effects of lactoferrin on bone regeneration during distraction osteogenesis are limited. Our study was designed to investigate the effect of bovine lactoferrin treatment on bone formation of the distracted callus.

Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment

Sasha Carsen MD, MBA, Sam Si-Hyeong Park MD, David A. Simon MD, Robert J. Feibel MD

The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device.

Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery

Mariano E. Menendez MD, David Ring MD, PhD, Brian T. Bateman MD, MSc

Many patients having discretionary orthopaedic surgery take opioids daily, either with a prescription or illicitly, however little is known regarding the prevalence and effect of high-risk opioid use (eg, abuse, dependence) in the perioperative orthopaedic setting.

Orthopaedic Trainees Retain Knowledge After a Partner Abuse Course: An Education Study

Kim Madden MSc, Sheila Sprague PhD, Brad A. Petrisor MD, MSc, FRCSC, Forough Farrokhyar PhD, Michelle A. Ghert MD, FRCSC, Marium Kirmani BSc (Cand), Mohit Bhandari MD, PhD, FRCSC

Intimate partner violence (IPV) is a serious global issue that results in a large number of injuries and deaths among women. Educating clinicians about IPV can help providers identify, prevent, and treat victims, and, ultimately, improve care for victims of abuse. We sought to determine the effect of a half-day educational course on IPV for orthopaedic surgical trainees on knowledge and attitudes.

The 50 Most-cited Articles in Orthopaedic Surgery From Mainland China

Zhiwei Jia MD, Fan Ding MD, Yaohong Wu MD, Qing He MD, Dike Ruan MD, PhD

Citation analysis has been widely used to evaluate the impact of articles in medical and surgical specialties. Although China is the most populous country in the world, and although more than 50,000 orthopaedic surgeons practice there, to our knowledge no formal citation analysis of Chinese orthopaedic articles has been performed.

An Unusual Cause of Lumbar Radiculopathy

Jesse Even MD, Gregory Gasbarro MD, Liron Pantanowitz MD, James Kang MD, Kurt Weiss MD

Erratum to: Mortality and Revision Surgery Are Increased in Patients With Parkinson’s Disease and Fractures of the Femoral Neck

Mark S. Karadsheh MD, Edward K. Rodriguez MD, PhD, Mitchel B. Harris MD, David Zurakowski PhD, Robert Lucas BA, Michael J. Weaver MD
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