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

Transcription

1 Sean T. Grambart, DPM, FACFAS Ankle and Foot Surgery Carle Clinic Association Evidenced-Based Medicine: Where Does it Fit in Foot and Ankle Surgery? MODULE: Calcaneal 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 1: Calcaneal Fracture 54 y/o male fell 5 feet off ladder Left foot pain [Worker s Compensation] PMH: HTN, Hypercholesterolemia PSH: None Meds: Lisinopril, Zocor, ASA NKDA Social: 1+ppd x 34 yrs

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23 ?? Next Step??

24 ?? Treatment Options?? ORIF Casting

25 Concerns ORIF Infection Arthrosis Casting Function Arthrosis

26 341 closed fractures [ ] 39 open fractures [ ] Retrospective Review Rate of infection 1.8% Closed 7.7% Open JOT 18(1), 2004

27 Define Displaced Fracture If you can see the fracture, it is displaced S.K. Benirschke, MD

28 Problems Retrospective study Author bias Opinion

29 424 patients; 471 fractures 262 conservative 249 ORIF 309 patients; 371 fractures with minimum 2 yr follow-up RCT!!! JBJS 84A(10), 2002

30 Non-Operative Treatment No Closed Reduction R,I,C,E Operative Treatment Lateral Extensile Incision Variety of Internal Fixation Bone graft Optional JBJS 84A(10), 2002

31 Patient Self Administered Questionnaire Visual Analog Scale Return to Work Perform Normal Work Need for Repeat Surgery CT Evaluation JBJS 84A(10), 2002

32 Operative treatment as a whole provides no improvement over non-operative treatment in displaced intra-articular calcaneal fractures JBJS 84A(10), 2002

33 Different Types of Calcaneal Fractures Patient Bias Surgeon Expertise; Surgeon Bias Analyzed Subgroups Patient Value JBJS 84A(10), 2002

34 Meta-Analysis 20 Relevant Articles Insufficient evidence JOT 19(5), 2005

35 ?? My Treatment??

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

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

38 THANK YOU!