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ÖGU Newsletter – Wissenschaft 01/2012

ÖGU Österreichische Gesellschaft für Unfallchirurgie
  ÖGU Newsletter – Wissenschaft 01/2012

  Der erstmals erscheinende Research Newsletter der ÖGU soll für das Fachgebiet interessante Publikationen auflisten und Lust auf weiterführende Beschäftigung mit wissenschaftlicher Literatur machen.

Für diesen Newsletter wurden zehn Publikationen aus dem Jahre 2011 ausgewählt, die das weite Spektrum publizierter Literatur aufzeigen sollen.
Die ersten fünf Arbeiten behandeln generell das Thema Forschung im muskuloskelettalen Bereich, die Aussagekraft von Meta-Analysen und die Beurteilung der Qualität der publizierten Arbeiten. Ein systematischer Review sowie die Bedeutung von nationalen Registern werden in den weiteren beiden Arbeiten dargestellt.
Eine prospektive randomisierte Studie und zwei hochrangig publizierte experimentelle Studien aus Österreich runden die Auswahl ab.
Für jede der Publikationen wird der Link zu der Fachzeitschrift angeboten, so dass bei Interesse der Volltext gelesen oder erworben werden kann.

Univ.-Doz. Dr. Stefan Marlovits
ÖGU Wissenschaftsreferent

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  Clinical Trials in Orthopaedics Research. Part I. Cultural and Practical Barriers to Randomized Trials in Orthopaedics
Wright JG, Katz JN, Losina E
J. Bone Joint Surg Am. 2011 Mar 2;93(5):e15 1-7

Randomized clinical trials are the most rigorous clinical research design. However, trials are expensive, time-consuming, and challenging to design and complete. In May 2009, the Clinical Trials in Orthopaedics Research Symposium, sponsored by the American Academy of Orthopaedic Surgeons (AAOS), the Orthopaedic Research and Education Foundation (OREF), and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), brought together multiple disciplines to define a randomized clinical trials research agenda by focusing on important clinical questions in each subspecialty and to debate the major important methodological, cultural, and practical barriers to performing more randomized clinical trials in orthopaedics. We defined barriers as any challenge that makes a randomized clinical trial difficult to design or perform. We plan to report the deliberations of the Clinical Trials in Orthopaedics Research Symposium in three publications. The purpose of this first article is to present the cultural and practical barriers and to highlight the key infrastructure needed to support performing randomized trials in orthopaedics. We largely focused on randomized clinical trials but realized that methodologically sound prospective cohort studies also provide important information1. Our deliberations were clearly not exhaustive, and readers can refer to texts for basic information about randomized clinical trials not addressed during the symposium2. We have included the names of symposium speakers in parentheses after the title for each section.
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  Clinical Trials in Orthopaedics Research. Part II. Prioritization for Randomized Controlled Clinical Trials
Katz JN, Wright JG, Losina E
J. Bone Joint Surg Am. 2011 Apr 6;93 (7):e30 1-6

The American Academy of Orthopaedic Surgeons (AAOS) and Orthopaedic Research Society (ORS) Clinical Trials in Orthopaedics Research Symposium had three major themes including barriers to performing clinical trials, methodology of clinical trials, and prioritization of clinical questions in orthopaedics to address in randomized controlled trials. This paper addresses the latter theme. Clinical experts from the major orthopaedic specialties provided presentations on key issues in their respective fields that had been addressed with clinical trials and the clinical questions that were most appropriate and pressing for clinical trials.
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  How Useful Are Meta-Analyses in Orthopedic Trauma?
Court-Brown CM, McQueen MM
Journal of Trauma. 2011 Nov;71(5):1395-9

Background: Meta-analysis has become accepted as a methodically rigorous research tool, and as a result, many meta-analyses have been undertaken in orthopedic trauma, the implication being that their conclusions have improved surgeons' knowledge and facilitated improved clinical care. There have been criticisms of the methodology used in a number of meta-analyses; however, there has been no previous study of the clinical usefulness of their conclusions.
Methods: A study of 60 orthopedic trauma meta-analyses published during or after 2000 was undertaken. We divided the conclusions of the meta-analyses into four types depending on their innovation and potential for improving clinical care. We also separated the meta-analyses according to whether they were undertaken by the Cochrane Collaboration or by independent surgeons.
Results: Only 4 (6.7%) of the meta-analyses contained new, clinically useful, information, and 22 (36.7%) had no conclusions at all. A further 25 (41.7%) contained conclusions that were already in the standard orthopedic trauma literature. Approximately 70% of the Cochrane Collaborations had no conclusions.
Conclusions: We found considerable variability in the clinical usefulness of orthopedic trauma meta-analyses, and we question the clinical usefulness of this type of research.
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  A systematic survey of the quality of research reporting in general orthopaedic journals
Parsons NR, Hiskens R, Price CL, Achten J, Costa ML
J Bone Joint Surg Br. 2011 Sep;93(9):1154-9

The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research.
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  Prompt Operative Intervention Reduces Long-Term Osteoarthritis After Knee Anterior Cruciate Ligament Tear
Richmond JC, Lubowitz JH, Poehling GG
Arthroscopy. 2011 Feb;27(2):149-52

You can see those pictures in any magazine.
But what's the use of looking when you don't know what they mean.
Elvis Costello

We think the New England Journal of Medicine got it wrong last year. According to the Journal of the American Medical Association, “Accurate presentation of the results of a randomized controlled trial is the cornerstone of the dissemination of the results and their implementation in clinical practice…. However, investigators usually have broad latitude in writing their articles; they can choose which data to report and how to report them. Consequently, scientific articles are not simply reports of facts, and authors have many opportunities to consciously or subconsciously shape the impression of their results for readers, that is, to add ‘spin’ to their scientific report. Spin can be defined as specific reporting that could distort the interpretation of results and mislead readers. The use of spin in scientific writing can result from ignorance of the scientific issue, unconscious bias, or willful intent to deceive.”
In other words, with apologies to Elvis Costello, what's the use of looking at data if you don't know what the study results mean?
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  Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture - Update and Systematic Review
Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL
J Trauma. 2011 Dec;71(6):1850-68

Background: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice.
Methods: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence.
Results: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing?
Conclusions: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.
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  Significant Change in the Surgical Treatment of Distal Radius Fractures:
A Nationwide Study Between 1998 and 2008 in Finland

Mattila VM, Huttunen TT, Sillanpää P, Niemi S, Pihlajamäki H, Kannus P
J Trauma. 2011 Oct;71(4):939-42

Background: Studies from the United States report a large increase in the surgical treatment of distal radius fractures with open reduction and internal fixation using locked plates. The aim of the present study was to determine whether the same trend has occurred in a Scandinavian country by assessing the number, incidence, and surgical methods of all surgically treated distal radius fractures in Finland over a recent 11-year period.
Methods: The study covered the whole adult population (aged >19 years) in Finland during the 11-year period from January 1, 1998, to December 31, 2008. Data on surgically treated distal radius fractures were obtained from the nationwide National Hospital Discharge Registry.
Results: During the 11-year study period, a total of 14,514 surgical operations (external fixation, percutaneous pinning, or plating) for adult distal radius fractures were performed in Finland. There was a dramatic shift toward internal fixation with plating; the incidence and number of platings more than doubled between 2006 and 2008. The incidence and number of external fixations decreased correspondingly. Percutaneous pinning was used in 13% of the surgical procedures during the study period.
Conclusions: A striking shift from external fixation to plating in the treatment of distal radius fractures has occurred in Finland over the past few years, despite the fact that the scientific literature does not support plating over external fixation. In addition, the incidence and number of surgeries for distal radius fractures doubled between 1998 and 2008. The reasons for these changes are not known.
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  Recombinant Human Bone Morphogenetic Protein-2: A Randomized Trial in Open Tibial Fractures Treated with Reamed Nail Fixation
Aro HT, Govender S, Patel AD, Hernigou P, Perera de Gregorio A, Popescu GI, Golden JD, Christensen J, Valentin A
J Bone Joint Surg Am. 2011 May 4;93(9):801-8

Recombinant human bone morphogenetic protein-2 (rhBMP-2) improves healing of open tibial fractures treated with unreamed intramedullary nail fixation. We evaluated the use of rhBMP-2 in the treatment of acute open tibial fractures treated with reamed intramedullary nail fixation.
Patients were randomly assigned (1:1) to receive the standard of care consisting of intramedullary nail fixation and routine soft-tissue management (the SOC group) or the standard of care plus an absorbable collagen sponge implant containing 1.5 mg/mL of rhBMP-2 (total, 12.0 mg) (the rhBMP-2/ACS group). Randomization was stratified by fracture severity. The absorbable collagen sponge was placed over the fracture at wound closure. The primary efficacy end point was the proportion of subjects with a healed fracture as demonstrated by radiographic and clinical assessment thirteen and twenty weeks after definitive wound closure.
Two hundred and seventy-seven patients were randomized and were the subjects of the intent-to-treat analysis. Thirteen percent of the fractures were Gustilo-Anderson Type IIIB. The proportions of patients with fracture-healing were 60% and 48% at week 13 (p = 0.0541) and 68% and 67% at week 20 in the rhBMP-2/ACS and SOC groups, respectively. Twelve percent of the subjects underwent secondary procedures in each group; more invasive procedures (e.g., exchange nailing) accounted for 30% of the procedures in the rhBMP-2/ACS group and 57% in the SOC group (p = 0.1271). Infection was seen in twenty-seven (19%) of the patients in the rhBMP-2/ACS group and fifteen (11%) in the SOC group (p = 0.0645; difference in infection risk = 0.09 [95% confidence interval, 0.0 to 0.17]). The adverse event incidence was otherwise similar between the treatment groups.
The healing of open tibial fractures treated with reamed intramedullary nail fixation was not significantly accelerated by the addition of an absorbable collagen sponge containing rhBMP-2.
Level of Evidence:
Therapeutic Level I
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  Extracorporeal shock wave therapy (ESWT) minimizes ischemic tissue necrosis irrespective of application time and promotes tissue revascularization by stimulating angiogenesis
Mittermayr R, Hartinger J, Antonic V, Meinl A, Pfeifer S, Stojadinovic A, Schaden W,
Redl H
Ann Surg. 2011 May;253(5):1024-32

To assess the time-dependent treatment effects of extracorporeal shock wave therapy (ESWT) in a standard rodent ischemic epigastric flap model.
ESWT has been shown to accelerate tissue repair in acute and chronic wounds and improve graft survival, but the mechanism remains incompletely understood.
Shock waves at 0.1 mJ/mm and 5 impulses/s (total 300 impulses) were applied to the epigastric flap ischemic region at various times pre-, immediately and 24 hours postischemic insult. Flap survival; vascular perfusion; vessel number; von Willebrand factor and smooth muscle actin protein expression as well as in vivo vascular endothelial growth factor receptor 2 expression were evaluated at 1, 3, and 7 days postoperatively in ESWT-treated and untreated controls.
Flap perfusion, microvessel number, and survival (through reduced flap contraction and necrosis) were significantly enhanced in the treated groups compared with controls, irrespective of timing of shock wave treatment (preischemia vs. postischemia). Vascular endothelial growth factor receptor 2 expression was dynamically upregulated in response to ESWT.
Shock wave preconditioning and treatment postischemic insult improves skin flap survival through neovascularization and early upregulation of angiogenesis-related growth factors.
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  The influence of scaffold architecture on chondrocyte distribution and behavior in matrix-associated chondrocyte transplantation grafts
Nuernberger S, Cyran N, Albrecht C, Redl H, Vécsei V, Marlovits S
Biomaterials. 2011 Feb;32(4):1032-40

Scaffold architecture and composition are important parameters in cartilage tissue engineering. In this in vitro study, we compared the morphology of four different cell-graft systems applied in clinical cartilage regeneration and analyzed the cell distribution (DAPI nuclei staining) and cell-scaffold interaction (SEM, TEM). Our investigations revealed major differences in cell distribution related to scaffold density, pore size and architecture. Material composition influenced the quantity of autogenous matrix used for cellular adhesion. Cell bonding was further influenced by the geometry of the scaffold subunits. On scaffolds with widely spaced fibers and a thickness less than the cell diameter, chondrocytes surrounded the scaffold fibers with cell extensions. On those fibers, chondrocytes were spherical, suggesting a differentiated phenotype. Fiber sizes smaller than chondrocyte size, and widely spaced, are therefore beneficial in terms of improved adhesion by cell shape adaptation. They also support the differentiated stage of chondrocytes by preventing the fibroblast-like and polygonal cell shape, at least briefly.
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