Sohail Bajammal

Background: Decision aids help physicians convey information to patients and enable patients to be involved in the decision-making process. There is a lack of use of decision aids in the orthopedic literature. The purpose of this study was to develop a decision board to elicit preferences for treatment of displaced femoral neck fractures in patients over 60 years old.

Abstract Several clinical, imaging, and therapeutic factors affecting recovery following spinal cord injury (SCI) have been described. A systematic review of the topic is still lacking. Our primary aim was to systematically review clinical factors that may predict neurological and functional recovery following blunt traumatic SCI in adults. Such work would help guide clinical care and direct future research.

Abstract Surgical interventions have inherent benefits and associated risks. Before implementing a new therapy, we should ascertain the benefits and risks of the therapy, and assure ourselves that the resources consumed in the intervention will not be exorbitant. Materials and Methods: We suggest a three-step approach to the critical appraisal of a clinical research study that addresses a question of therapy. Readers should ask themselves the following three questions: Are the study results valid?

Abstract Surgical interventions have inherent benefits and associated risks. Before implementing a new therapy, we should ascertain the benefits and risks of the therapy, and assure ourselves that the resources consumed in the intervention will not be exorbitant. Materials and Methods: We suggest a three-step approach to the critical appraisal of a clinical research study that addresses a question of therapy.

Background: Cardiovascular diseases are one of the leading causes of death in India. There is high prevalence of cardiovascular risk factors in urban Tamil Nadu. There are limited data on the prevalence of behavioral risk factors and overweight in rural Tamil Nadu. Aim: We estimated prevalence of behavioral risk factors, overweight and central obesity in a rural population in Tamil Nadu, India. Setting and Design: We conducted a cross-sectional survey in 11 villages in Kancheepuram/Thiruvallur districts, Tamil Nadu.

High-quality randomized controlled trials (RCTs) are the highest level of evidence in assessing the effectiveness of a treatment. It is random allocation that places RCTs in the highest level of evidence. The purpose of randomization is to create groups of patients that are comparable for known and unknown factors at the start of the trial so that any differences at the completion of the trial can be attributed to the treatment under investigation. The purpose of this article is to discuss the processes that would help create balanced groups and maintain between-group comparability throughout the study period.

Several clinical, imaging, and therapeutic factors affecting recovery following spinal cord injury (SCI) have been described. A systematic review of the topic is still lacking. Our primary aim was to systematically review clinical factors that may predict neurological and functional recovery following blunt traumatic SCI in adults. Such work would help guiding clinical care and direct future research. Both Medline and Embase (to April 2008) were searched using index terms for various forms of SCI, paraplegia or quadri/tertraplegia, and functional and neurological recovery. Search was limited to published articles that were in English and included human subjects. Article selection included class I and II evidence, blunt traumatic SCI, injury level above L1/2, baseline assessment within 72 hours of injury, use of American Spinal Injury Association (ASIA) scoring system for clinical assessment, and functional and neurological outcome. A total of 1526 and 1912 citations located from Medline and Embase respectively. Two surgeons reviewed titles, abstracts, and full text articles for each database. 10 articles were identified, only 1 of them was level-1 evidence. Age and gender were identified as 2 patient related predictors. While motor and functional recovery decreased with advancing age for complete SCI, there was no correlation considering incomplete ones. Therefore, treatment should not be restructured based on age in incomplete SCI. Among Injury related predictors, severity of SCI was the most significant. Complete injuries correlated with increased mortality and worse neurological and functional outcomes. Other predictors included SCI level, energy transmitted by the injury, and baseline electrophysiological testing.

Background: The optimal treatment for displaced femoral neck fractures in elderly patients is controversial. Compared with hemiarthroplasty (HA), internal fixation (IF) is associated with less operative trauma, bleeding, and possibly lower mortality at the expense of a higher reoperation rate and possibly increased cost.



Methods: We estimated the costs from a third party payer perspective after 1 year of 2 strategies (HA and IF) for the treatment of femoral neck fractures in patients over the age of 60 years. Using a decision board, we elicited patient preferences for the 2 operative approaches and calculated the net benefit using the willingness-to-pay technique.



Results: The 1-year projected cost of 1 IF was $18,100, and that of 1 HA was $15,843 (incremental cost of $2257 for each IF). Of 108 participants, 61 (56.5%) chose IF as the preferred treatment option and were willing to pay an average of $3.33 per month to have this option available if needed. In Ontario, the total incremental cost of performing IF in patients that choose it was $64,714,103, and the total societal benefit was $289,263,600, yielding a net benefit of $224,549,497.



Conclusion: The benefits of IF over HA outweigh the incremental costs from the perspective of a third-party payer. IF should be available to patients that choose it.

Background
Medical education in Saudi Arabia is facing multiple challenges, including the rapid increase in the number of medical schools over a short period of time, the influx of foreign medical graduates to work in Saudi Arabia, the award of scholarships to hundreds of students to study medicine in various countries, and the absence of published national guidelines for minimal acceptable competencies of a medical graduate.

Discussion
We are arguing for the need for a Saudi national medical licensing examination that consists of two parts: Part I (Written) which tests the basic science and clinical knowledge and Part II (Objective Structured Clinical Examination) which tests the clinical skills and attitudes. We propose this examination to be mandated as a licensure requirement for practicing medicine in Saudi Arabia.

Conclusion
The driving and hindering forces as well as the strengths and weaknesses of implementing the licensing examination are discussed in details in this debate.

Purpose

Most surgical interventions have inherent benefits and associated risks. Before implementing a new therapy we should ascertain the benefits and risks of the therapy and assure ourselves that the resources consumed in the intervention will not be exorbitant.



Materials and Methods

We suggest a 3-step approach to using an article from the urological literature to guide patient care. We recommend asking whether the study can provide valid results, reviewing the results and considering how the results can be applied to patient care.



Results

Key methodological characteristics that have an impact on the validity of a surgical trial include randomization, allocation concealment, stratification, blinding, completeness of followup and intent to treat analysis. To the extent that the quality is poor inferences from this study are weakened. However, if its quality is acceptable, one must determine the range within which the true treatment effect lies (95% CI). One must then consider whether this result can be generalized to a patient and whether the investigators have provided information about all clinically important outcomes. It is then necessary to compare the relative benefits of the intervention with its risks. If one perceives that the benefits outweigh the risks, the intervention may be of use to the patient.



Conclusions

Given the time constraints of busy urological practices and training programs, applying this analysis to every relevant article would be challenging. However, the basics of this process are essentially what we all do hundreds of times each week when treating patients. Making this process explicit with guidelines to assess the strength of the available evidence will serve to improve patient care. It will also allow us to defend therapeutic interventions based on available evidence and not on anecdote.

Background: Available options to fill fracture voids include autogenous bone, allograft bone, and synthetic bone materials. The objective of this meta-analysis was to determine whether the use of calcium phosphate bone cement improves clinical and radiographic outcomes and reduces fracture complications as compared with conventional treatment (with or without autogenous bone graft) for the treatment of fractures of the appendicular skeleton in adult patients.



Methods: Multiple databases, online registers of randomized controlled trials, and the proceedings of the meetings of major national orthopaedic associations were searched. Published and unpublished randomized controlled trials were included, and data on methodological quality, population, intervention, and outcomes were abstracted in duplicate. Data were pooled across studies, and relative risks for categorical outcomes and weighted mean differences for continuous outcomes, weighted according to study sample size, were calculated. Heterogeneity across studies was determined, and sensitivity analyses were conducted.



Results: We identified eleven published and three unpublished randomized controlled trials. Of the fourteen studies, six involved distal radial fractures, two involved femoral neck fractures, two involved intertrochanteric femoral fractures, two involved tibial plateau fractures, one involved calcaneal fractures, and one involved multiple types of metaphyseal fractures. All of the studies evaluated the use of calcium phosphate cement for the treatment of metaphyseal fractures occurring primarily through trabecular, cancellous bone. Autogenous bone graft was used in the control group in three studies, and no graft material was used in the remaining studies. Patients managed with calcium phosphate had a significantly lower prevalence of loss of fracture reduction in comparison with patients managed with autograft (relative risk reduction, 68%; 95% confidence interval, 29% to 86%) and had less pain at the fracture site in comparison with controls managed with no graft (relative risk reduction, 56%; 95% confidence interval, 14% to 77%). We were unable to compare pain at the bone-graft donor site between the studies because of methodological reasons. Three studies independently demonstrated improved functional outcomes when the use of calcium phosphate was compared with the use of no grafting material.



Conclusions: The use of calcium phosphate bone cement for the treatment of fractures in adult patients is associated with a lower prevalence of pain at the fracture site in comparison with the rate in controls (patients managed with no graft material). Loss of fracture reduction is also decreased in comparison with that in patients managed with autogenous bone graft.



Level of Evidence: Therapeutic Level I.

Purpose: To review the imaging results of a novel posterior lumbar interbody fusion (PLIF) construct using local bone graft for supplemental intertransverse arthrodesis, and to determine intraobserver and interobserver reliability in the radiographic assessment of these lumbar fusions.

Results: Six experienced observers each made 2 separately blinded reviews of randomized radiographic images from a consecutive series of 43 adult patients who had had posterolateral lumbar interbody fusions at 62 lumbar motion segments performed with a unique osteoconductive lumbar interbody implant, allowing for 360° lumbar fusion without iliac bone graft harvest. All 63 instrumented motion segments were reviewed independently. Fusions were graded according to previously established radiographic criteria from the literature. Weighted kappa statistics were calculated from the resulting Microsoft Excel database and SPSS software.

Intraobserver reliability was slight to substantial (kappa ranged from 0.13 to 0.76) and interobserver variability was only slight to moderate (kappa 0.19–0.52). Seniority or experience of the observers produced no trend to improved consistency in intraobserver reliability.

Significance: The use of local autograft bone for intertransverse arthrodesis in this PLIF construct is supported, and simple radiographs may be adequate to assess the presence of lumbar fusion.

Discussion: Plain radiograph analysis of lumbar fusion constructs, according to standardized criteria taken from the literature, was found to be moderately consistent. The use of local autograft bone for intertransverse arthrodesis in this PLIF application is supported.

Background: Periprosthetic bone loss following total joint arthroplasty may threaten the survival of the implant. Bisphosphonates are effective in reducing bone loss in conditions associated with accelerated bone turnover. To determine the current understanding of the effect of bisphosphonates on periprosthetic bone mineral density after total joint arthroplasty, we conducted computerized searches for randomized controlled trials evaluating the use of bisphosphonates in patients treated with primary total joint arthroplasty.



Methods: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the web site of the United Kingdom National Research Register, and the archives of the American Academy of Orthopaedic Surgeons annual meetings (1989 through 2003), and we conducted hand searches of the bibliographies of relevant articles. We assessed methodological quality and abstracted relevant data. When necessary, we contacted authors to provide additional information.



Results: Of 386 citations that were initially identified, six (five complete papers and one abstract), which included a total of 290 patients, met our inclusion criteria. Those papers showed that significantly less periprosthetic bone loss had occurred in the bisphosphonate-treated patients than in the control patients at three months (152 patients; weighted mean difference, 3.3%; 95% confidence interval, 1.9% to 4.7%; p < 0.01), six months (248 patients; weighted mean difference, 4.5%; 95% confidence interval, 1.6% to 7.4%; p < 0.001), and twelve months (197 patients; weighted mean difference, 4.2%; 95% confidence interval, 1.5% to 6.9%; p = 0.03). Bisphosphonates appeared to have a larger effect on bone loss following arthroplasties with cement than on bone loss following arthroplasties without cement (difference, 0.1%, 5%, and 5.4% at three, six, and twelve months; significant difference [p < 0.001] at one year only) and a larger effect on bone loss following total knee arthroplasties than on bone loss following total hip arthroplasties (difference, 4.1%, 11.5%, and 7.1% at three, six, and twelve months; significant difference [p < 0.001] at six months only). None of the studies related the effects of bisphosphonates on bone mineral density to clinically relevant outcomes.



Conclusions: A meta-analysis of six randomized controlled trials suggested that bisphosphonates have a beneficial effect with regard to maintaining more periprosthetic bone mineral density than that in controls. However, the limitations of the available studies and the lack of analyses of clinically relevant outcomes (functional outcomes, revision rates, and quality of life) necessitate the planning and conduct of a sufficiently sized, methodologically sound study with clinically relevant end points. Until this has been done, the current evidence regarding the beneficial effects of bisphosphonates on periprosthetic bone after total joint arthroplasty should be interpreted with caution.



Level of Evidence: Therapeutic Level I.

An overview on doing a literature review for a mutli-disciplinary professionals (physicians, engineers, and IT) covering some tips & tricks on organization (using Papers Software for literature files management, MindMapping for Literature Mapping, EndNote for bibliography program). It shows some examples of Citation Maps from Web of Science.

A generic introductory presentation on using evidence-based medicine (EBM) principles to answer clinical questions. Back pain was used as an example to introduce the concept. The presentation does not address the treatment of back pain. The presentation was given in May 2010.