1. Evidence Based Orthopaedics- The Best Practice Standards
Dr Hitesh Gopalan U
Editor, Evidence Based Orthopaedic Principles
Editor,
Visiting Professor, McMaster University, Ontario, Canada
Expert Advisor, OrthoEvidence
SICOT India Scientific Chairman

2. Disclosures
Nil

3. 10 pathbreaking discoveries in last 500 years

4. Why EBM? One of the most highly searched medical word on Google
Change in existing Practice

5. Hierarchy of Evidence Randomized Trials Prospective Cohort Studies
Meta-analysis
Randomized Trials
Level 1
Prospective Cohort Studies
Level 2
Level 3
Case Control Studies
Retrospective Case Series
Level 4
Opinion
Level 5

6. Randomization
Tx A
Outcome R
Patients
Tx B
Outcome
Forward in Time

7. Randomized Trials Aren’t Always Practical or Feasible
Ethical 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 expertise
The Primary Question
Prognosis
Cost
We’ll never raise enough money to pull this off

8. Hierarchy of Evidence Randomized Trials Prospective Cohort Studies
Level 1
Prospective Cohort Studies
Level 2
Level 3
Case Control Studies
Retrospective Case Series
Level 4
Opinion
Level 5

9. Cohort Study ? Forward in Time Exposed A Outcome Patients Exposed B

10. Hierarchy of Evidence Randomized Trials Prospective Cohort Studies
Level 1
Prospective Cohort Studies
Level 2
Level 3
Case Control Studies
Retrospective Case Series
Level 4
Opinion
Level 5

11. Case-Control Study Backward in Time Infection Prognostic Factor
Outcomes
Infection
Prognostic
Factor
Start Here
No Infection
Prognostic Factor
Backward in Time

12. What is Evidence-based Medicine?
conscientious
requires clinical expertise
current best evidence
implies hierarchy of evidence
health care decisions
patient values

13. Hierarchy of Evidence Randomized Trials Prospective Cohort Studies
Case Control Studies
Retrospective Case Series
Opinion

14. Hierarchy of Evidence Randomized Trials Prospective Cohort Studies
Meta-analysis
Randomized Trials
Less Bias
Level 1
Prospective Cohort Studies
Level 2
Level 3
Case Control Studies
Retrospective Case Series
Level 4
Opinion
Level 5
More Bias

15. Average No of Publications
6400
Across 64 pubmed Index Orthopaedic
Journals

16. Countless Articles and Books
Springer: 150 Orthopaedic books per year
Thieme: another 50….

17. Big Data

18. Industry Funded Research
Drug trials

19. VTE Prophylaxis ACCP Vs AAOS Debates: last 10 years
LMWH, Dabigatran, Fondaparinux, Rivaroxaban, Apixaban
Recent Addition: Aspirin + Mechanical Prophylaxis

20. Evidence Pyramid

21. AVN Femoral head

22. 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

23. 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

24. 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.

25. AVN Hip
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

26. Downgrade
Serious (-1) or very serious (-2) limitation to study quality
Important inconsistency (-1)
Some(-1) or major (-2) uncertainty about directness
Imprecise or sparse data (-1)
High probability of reporting bias

27. Levels of Evidence-2003

30. EBM: Who Discovered?
Gordon Guyatt
David Sackett( )

31. Navigated TKR Vs Conventional

32. Navigation 1mm deviation from mechanical axis
Femoral and tibial component alignment as perfect as possible
Cost Effectiveness??

33. Eminence Vs Evidence: Hi Flex
38% femoral component loosening
Han HS, J Bone Joint Surg Br Nov;89(11):

35. Clavicle Trial Explosion in clavicle fracture ORIF
Extended indications

36. Thank You