Download - Dr Hitesh Gopalan U Editor, Evidence Based Orthopaedic Principles Editor, Visiting Professor,
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Dr Hitesh Gopalan UEditor, Evidence Based Orthopaedic
PrinciplesEditor, www.orthopaedicprinciples.com
Visiting Professor, McMaster University, Ontario, Canada
Expert Advisor, OrthoEvidenceSICOT India Scientific Chairman
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Disclosures
Nil
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10 pathbreaking discoveries in last 500 years
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Why EBM?One of the most highly searched
medical word on Google
Change in existing Practice
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Randomized Trials
Prospective Cohort Studies
Retrospective Case Series
Case Control Studies
Opinion
Level 1
Level 2
Level 3
Level 4
Level 5
Meta-analysis
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Randomization
Patients
Tx A
Tx B
R
Outcome
Outcome
Forward in Time
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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
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Randomized Trials
Prospective Cohort Studies
Retrospective Case Series
Case Control Studies
Opinion
Level 1
Level 2
Level 3
Level 4
Level 5
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Cohort Study
Patients
Exposed A
Exposed B
?
Outcome
Outcome
Forward in Time
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Randomized Trials
Prospective Cohort Studies
Retrospective Case Series
Case Control Studies
Opinion
Level 1
Level 2
Level 3
Level 4
Level 5
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Case-Control Study
Start Here
InfectionPrognostic
Factor
No Infection
Prognostic Factor
Backward in Time
Outcomes
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What is Evidence-based Medicine?
conscientiousrequires clinical expertise
current best evidence implies hierarchy of evidence
health care decisionspatient values
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Randomized Trials
Prospective Cohort Studies
Retrospective Case Series
Case Control Studies
Opinion
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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
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Average No of Publications6400
Across 64 pubmed Index Orthopaedic Journals
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Countless Articles and Books
Springer: 150 Orthopaedic books per yearThieme: another 50….
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Big Data
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• Industry Funded Research
• Drug trials
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VTE ProphylaxisACCP Vs AAOS Debates: last 10 years
LMWH, Dabigatran, Fondaparinux, Rivaroxaban, Apixaban
Recent Addition: Aspirin + Mechanical Prophylaxis
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Evidence Pyramid
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AVN Femoral head
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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
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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
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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.
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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
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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
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Levels of Evidence-2003
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EBM: Who Discovered?Gordon Guyatt
David Sackett(1934- 2015)
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Navigated TKR Vs Conventional
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Navigation1mm deviation from mechanical axis
Femoral and tibial component alignment as perfect as possible
Cost Effectiveness??
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Eminence Vs Evidence: Hi Flex
38% femoral component loosening
Han HS, J Bone Joint Surg Br 2007 Nov;89(11):1457-61
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Clavicle TrialExplosion in clavicle fracture ORIF
Extended indications
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Thank You