Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Dec 2009
Review Meta AnalysisProphylaxis of heterotopic ossification of the hip: systematic review and meta-analysis.
Heterotopic ossification (HO) is a potentially severe, if infrequent, complication in hip surgery, and uncertainty exists regarding whether to use NSAIDs or radiation in its prevention. Thus, we systematically reviewed the literature in MedLine, EMBASE, CINAHL, and the Cochrane Controlled Trial Register and, after ruling out publication bias and data heterogeneity, performed a meta-analysis of randomized, controlled trials to assess effectiveness and complications of NSAIDs and radiation in the prevention of HO. We identified nine studies reporting on effectiveness and complications including a total of 1295 patients. ⋯ There was no association with gender, age, length of followup, or year of publication. The risk ratio for associated complications was 0.79 (95% confidence interval, 0.45-1.41), and, again, was independent of the aforementioned factors. We found no evidence for a statistically significant or clinically important difference between NSAIDs or radiation in preventing HO.
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Clin. Orthop. Relat. Res. · Dec 2009
Multicenter StudyThe synergistic effect of autograft and BMP-7 in the treatment of atrophic nonunions.
Combining autologous bone graft and recombinant human bone morphogenetic protein-7 (BMP-7) to treat long-bone fracture aseptic atrophic nonunions theoretically could promote bone healing at higher rates than each of these grafting agents separately. We retrospectively reviewed prospectively collected data on patient general characteristics, clinical outcomes, and complications over 3 years to determine the healing rates and the incidence of complications and adverse events of this "graft expansion rationale." There were 45 patients (32 male) with a median age of 43 years (range, 19-76 years). Minimum followup was 12 months (mean, 24.5 months; range, 12-65 months). There were seven humeral, 19 femoral, and 19 tibial nonunions. The median number of prior operations was two (range, 1-7). All fractures united. Clinical and radiographic union occurred within a median of 5 months (range, 3-14 months) and 6 months (range, 4-16 months), respectively. Thirty-nine (87%) patients returned to their preinjury occupation at a mean of 4.2 months (range, 3-6 months). The median visual analog scale pain score was 0.9 (range, 0-2.8; maximum 10), and the median functional score was 86 (range, 67-95; maximum 100) at the final followup. BMP-7 as a bone-stimulating agent combined with conventional autograft resulted in a nonunion healing rate of 100% in these 45 patients. ⋯ Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Dec 2009
The use of confidence intervals in reporting orthopaedic research findings.
Conflict between clinical importance and statistical significance is an important problem in medical research. Although clinical importance is best described by asking for the effect size or how much, statistical significance can only suggest whether there is any difference. One way to combine statistical significance and effect sizes is to report confidence intervals. ⋯ The use of confidence intervals was independent of impact factor, year of publication, and significance of outcomes. The probability of statistically significant results to predict at least a 10% between-group difference was only 69% (95% confidence interval, 55%-83%), suggesting that a high proportion of statistically significant results do not reflect large treatment effects. Confidence intervals could help avoid such erroneous interpretation by showing the effect size explicitly.
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Clin. Orthop. Relat. Res. · Nov 2009
Comparative StudyPredictors of prognosis for elderly patients with poststroke hemiplegia experiencing hip fractures.
Hip fracture is an important cause of mortality and disability in elderly patients, particularly in those with poststroke hemiplegia, but little information is available regarding differences of general characteristics between patients with and without hemiplegia who experience hip fractures, factors predicting recovery of prefracture ambulatory status, and mortality of patients with poststroke hemiplegia with hip fractures. We retrospectively reviewed 1379 consecutive prospectively followed patients with hip fractures treated from January 2000 to May 2006. Of the 1379 patients, 101 (7.3%) had poststroke hemiplegia. All patients were followed a minimum of 1 year if they survived more than a year or until death if they died within a year after surgery (mean, 19.5 months; range, 4-49 months). According to the American Society of Anesthesiologists (ASA) rating, the patients with hemiplegia were sicker than patients without hemiplegia, more likely to have three or more comorbidities, lower cognitive ability, weaker prefracture ambulatory status, more days of hospitalization, and higher mortality rate. Gender, ASA rating, number of comorbidities, and prefracture ambulatory status predicted mortality of hip fractures in elderly patients with poststroke hemiplegia, and the ASA rating, number of comorbidities, and cognitive ability predicted recovery of prefracture ambulatory status for these patients. ⋯ Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Nov 2009
Multicenter Study Comparative StudyIs locking nailing of humeral head fractures superior to locking plate fixation?
The optimal surgical treatment of displaced proximal humeral fractures is controversial. New implants providing angular stability have been introduced to maintain the intraoperative reduction. In a multi-institutional study, we prospectively enrolled and followed 152 patients with unilateral displaced and unstable proximal humeral fractures treated either with an antegrade angular and sliding stable proximal interlocking nail or an angular stable plate. Fractures were classified according to the Neer four-segment classification. Clinical, functional, and radiographic followups were performed 3, 6, and 12 months after surgery. Absolute and relative (to the contralateral shoulder) Constant-Murley scores were used to assess postoperative shoulder function. Using age, gender, and fracture type, we identified 76 pairs (152 patients) for a matched-pairs analysis. Relative Constant-Murley scores 12 months after treatment with an angular and sliding stable nail and after plate fixation were 81% and 77%, respectively. We observed no differences between the two groups. Stabilization of displaced proximal humeral fractures with either an angular stable intramedullary or an extramedullary implant seems suitable with both surgical treatment options. ⋯ Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.