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
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
Evidence-Based Medicine Clinical Expertise Patient Care Patient Values Best Evidence
Fundamental Principles Evidence is never enough Hierarchy within EBM
Steps In EBM Process Clinical Problem Question Resource Evaluation Patient
Asking the Question Foreground Question Background Question Novice Expert
Hierarchy of EBM Meta-Analysis Systematic Review Randomized Controlled Trial Cohort Studies Case Control Studies Case Series/Case Reports Animal Research/Laboratory Studies
P.I.C.O. Patient + Problem Intervention Comparison Outcome
Levels of Evidence January 2003 Journal of Bone and Joint Surgery American February 2005 American Academy of Orthopaedic Surgeons
JBJS Am Levels of Evidence I, II, III, IV, V based on design Types Therapeutic Prognostic Economic Decision Analysis
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
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
Levels of Evidence 80 70 60 50 40 30 20 10 0 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
Levels of Evidence 60 50 40 30 20 Level I Level II Level III Level IV 10 0 JBJS 87A(12), 2005
Evaluation of the Foot and Ankle Literature Journal Foot and Ankle Surgery Foot and Ankle International
Evaluation of the Literature Jan/Feb 2005 Nov/Dec 2008 334 Articles 7 RCT
Evaluation of the Literature January 2005 November 2008 810 Articles 10 RCT
Evaluation of the Literature Target your reading to particular issues related to the patient
EBM Literature Sources Cochrane Database Medline UpToDate Best Evidence OVID
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
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
?? Next Step??
?? Treatment Options?? ORIF Casting
Concerns ORIF Infection Arthrosis Casting Function Arthrosis
341 closed fractures [1994-2000] 39 open fractures [1989-2000] Retrospective Review Rate of infection 1.8% Closed 7.7% Open JOT 18(1), 2004
Define Displaced Fracture If you can see the fracture, it is displaced S.K. Benirschke, MD
Problems Retrospective study Author bias Opinion
424 patients; 471 fractures 262 conservative 249 ORIF 309 patients; 371 fractures with minimum 2 yr follow-up RCT!!! JBJS 84A(10), 2002
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
Patient Self Administered Questionnaire Visual Analog Scale Return to Work Perform Normal Work Need for Repeat Surgery CT Evaluation JBJS 84A(10), 2002
Operative treatment as a whole provides no improvement over non-operative treatment in displaced intra-articular calcaneal fractures JBJS 84A(10), 2002
Different Types of Calcaneal Fractures Patient Bias Surgeon Expertise; Surgeon Bias Analyzed Subgroups Patient Value JBJS 84A(10), 2002
Meta-Analysis 20 Relevant Articles Insufficient evidence JOT 19(5), 2005
?? My Treatment??
Where Does EBM Fit with Foot and Ankle Surgery??
Where Does EBM Fit? ACFAS Research EBM ONLY?? Your Step
THANK YOU!