Evidenced-Based Medicine: Where Does it Fit in Foot and Ankle Surgery?

Transcription

1 Jeffrey R. Baker, DPM, AACFAS Weil Foot & Ankle Institute Des Plaines, IL Evidenced-Based Medicine: Where Does it Fit in Foot and Ankle Surgery? MODULE: Bimalleolar Equivalent Ankle Fracture

2 Evidence-Based Medicine The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient It means integrating individual clinical expertise with the best available external clinical evidence from systematic research Dr. David Sackett, 1996

3 Evidence-Based Medicine Clinical Expertise Patient Care Patient Values Best Evidence

4 Fundamental Principles Evidence is never enough Hierarchy within EBM

5 Steps In EBM Process Clinical Problem Question Resource Evaluation Patient

6 Asking the Question Foreground Question Background Question Novice Expert

7 Hierarchy of EBM Meta-Analysis Systematic Review Randomized Controlled Trial Cohort Studies Case Control Studies Case Series/Case Reports Animal Research/Laboratory Studies

8 P.I.C.O. Patient + Problem Intervention Comparison Outcome

9 Levels of Evidence January 2003 Journal of Bone and Joint Surgery American February 2005 American Academy of Orthopaedic Surgeons

10 JBJS Am Levels of Evidence I, II, III, IV, V based on design Types Therapeutic Prognostic Economic Decision Analysis

11 JBJS Am: Levels of Evidence Randomized Control Trial Level I or II Cohort Level II or III Case Control Level III Case Series Level IV Expert Opinions Level V

12 Levels of Evidence in Orthopaedic Journals Journal of Bone and Joint Surgery Am + Br Journal of Orthopaedic Trauma Journal of Shoulder and Elbow Surgery American Journal of Sports Medicine Journal of Prosthetics and Orthotics Foot and Ankle International Journal Hand Surgery Journal of Athroplasty JBJS 87A(12), 2005

13 Levels of Evidence Level I Level II Level III Level IV Am J Sports Med FAI J Arthroplasty JBJS Am JBJS Br J Hand Surg JOT JPO J Shoulder/Elbow JBJS 87A(12), 2005

14 Levels of Evidence Level I Level II Level III Level IV 10 0 JBJS 87A(12), 2005

15 Evaluation of the Foot and Ankle Literature Journal Foot and Ankle Surgery Foot and Ankle International

16 Evaluation of the Literature Jan/Feb 2005 Nov/Dec Articles 7 RCT

17 Evaluation of the Literature January 2005 November Articles 10 RCT

18 Evaluation of the Literature Target your reading to particular issues related to the patient

19 EBM Literature Sources Cochrane Database Medline UpToDate Best Evidence OVID

20 AGAINST FOR Old Hat Cook Book Medicine Population Studies Lack of Gold Standard Access Difficulty Strong Evidence One Part Patient Decision Evidence Pyramid Trained Professionals

21 MODULE: Bimalleolar Equivalent Ankle Fracture 30 y/o male jumped into the shallow end of a pool 2 days prior to initial evaluation Right ankle pain but was able to ambulate on the extremity PMH: Unremarkable PSH: None Meds: None NKDA Social: Occasional ETOH

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23 ?? Surgical Treatment Options?? Isolated ORIF of Fibular Fracture ORIF of Fibular Fracture with Primary Repair of Deltoid Ligament

24 Title: Fractures of the distal part of the fibula with associated disruption of the deltoid ligament. Treatment without repair of the deltoid ligament Baird RA, Jackson ST J Bone Joint Surg Am 1987 Level 4 evidence 24 patients 21 patients treated without repair of the deltoid ligament, 19 (90%) had good to excellent result All 3 patients treated with repair of the deltoid ligament did not have as good a result Conclusion: Exploration and repair of the deltoid ligament are not necessary unless reduction of the lateral malleolus fails to reduce the talus within the ankle mortise

25 Title: Rupture of the deltoid ligament in ankle fractures: should it be repaired? Zeegers AV, van der Werken C Injury 1989 Level 4 evidence 28 bimalleolar equivalent ankle fractures all treated operatively without exploration of the ruptured deltoid ligament 20 cases had a very good or good result No patient had any sign of medial laxity either clinically or on eversion-stress radiographs Conclusion: Limit treatment of this combined injury to ORIF of the lateral malleolus. Only if there is doubt concerning the congruity of the medial joint space on the mortise view intraoperatively is exploration of the deltoid ligament indicated.

26 Title: The repair of a ruptured deltoid ligament is not necessary in ankle fractures Stromsoe K, Hogevold, Skeldal S, Alho A J Bone Joint Surg Br Level 1 evidence 50 patients randomized into 2 groups 25 ORIF lateral side of the ankle with closed treatment of the medial side 25 ORIF lateral side of the ankle with suture treatment of the medial side Inclusion criteria: fracture of the lateral malleolus and a difference in width between the medial and lateral clear space and the the talar margins of greater than 3mm on an AP radiograph Final examination performed by a surgeon not involved in the primary treatment and a radiologist not involved in the management No difference between the 2 groups were found except a longer duration of surgery time in the repair group Conclusion: A ruptured deltoid ligament can be left unexplored without any effect either on early mobilization or on the long-term result. However, inability to achieve anatomical reduction of the medial clear space always requires exploration.

27 ?? My Treatment?? ORIF Fibular with Primary Repair of the Deltoid Ligament

28 Where Does EBM Fit with Foot and Ankle Surgery??

29 Where Does EBM Fit? ACFAS Research EBM ONLY?? Your Step

30 THANK YOU!