dr hitesh gopalan u editor, evidence based orthopaedic principles editor, visiting professor,

Dr Hitesh Gopalan UEditor, Evidence Based Orthopaedic

PrinciplesEditor, www.orthopaedicprinciples.com

Visiting Professor, McMaster University, Ontario, Canada

Expert Advisor, OrthoEvidenceSICOT India Scientific Chairman

Disclosures

Nil

10 pathbreaking discoveries in last 500 years

Why EBM?One of the most highly searched

medical word on Google

Change in existing Practice

Randomized Trials

Prospective Cohort Studies

Retrospective Case Series

Case Control Studies

Opinion

Level 1

Level 2

Level 3

Level 4

Level 5

Meta-analysis

Randomization

Patients

Tx A

Tx B

R

Outcome

Outcome

Forward in Time

Randomized Trials Aren’t Always Practical or FeasibleEthical Issues

“Is it ethical to randomize patients”Outcomes are too rare?

“We’ll never be able to recruit so many patients!” Surgeon “buy in”

Differential expertiseThe Primary Question

PrognosisCost

We’ll never raise enough money to pull this off

Randomized Trials

Prospective Cohort Studies

Retrospective Case Series

Case Control Studies

Opinion

Level 1

Level 2

Level 3

Level 4

Level 5

Cohort Study

Patients

Exposed A

Exposed B

?

Outcome

Outcome

Forward in Time

Randomized Trials

Prospective Cohort Studies

Retrospective Case Series

Case Control Studies

Opinion

Level 1

Level 2

Level 3

Level 4

Level 5

Case-Control Study

Start Here

InfectionPrognostic

Factor

No Infection

Prognostic Factor

Backward in Time

Outcomes

What is Evidence-based Medicine?

conscientiousrequires clinical expertise

current best evidence implies hierarchy of evidence

health care decisionspatient values

Randomized Trials

Prospective Cohort Studies

Retrospective Case Series

Case Control Studies

Opinion

Randomized Trials

Prospective Cohort Studies

Retrospective Case Series

Case Control Studies

Opinion

Level 1

Level 2

Level 3

Level 4

Level 5

Meta-analysis

Less Bias

More Bias

Average No of Publications6400

Across 64 pubmed Index Orthopaedic Journals

Countless Articles and Books

Springer: 150 Orthopaedic books per yearThieme: another 50….

Big Data

• Industry Funded Research

• Drug trials

VTE ProphylaxisACCP Vs AAOS Debates: last 10 years

LMWH, Dabigatran, Fondaparinux, Rivaroxaban, Apixaban

Recent Addition: Aspirin + Mechanical Prophylaxis

Evidence Pyramid

AVN Femoral head

GRADE Recommendations

High = Further research is very unlikely to change our confidence in the estimate of effect

Moderate = Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

High = Further research is very unlikely to change our confidence in the estimate of effect

Moderate = Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

GRADE Recommendations

Low = Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490.

AVN HipLow = Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Downgrade

Serious (-1) or very serious (-2) limitation to study quality

Important inconsistency (-1)Some(-1) or major (-2) uncertainty about

directnessImprecise or sparse data (-1)High probability of reporting bias

Levels of Evidence-2003

EBM: Who Discovered?Gordon Guyatt

David Sackett(1934- 2015)

Navigated TKR Vs Conventional

Navigation1mm deviation from mechanical axis

Femoral and tibial component alignment as perfect as possible

Cost Effectiveness??

Eminence Vs Evidence: Hi Flex

38% femoral component loosening

Han HS, J Bone Joint Surg Br 2007 Nov;89(11):1457-61

Clavicle TrialExplosion in clavicle fracture ORIF

Extended indications

Thank You