A Calcaneal Fracture Study Illustrates a Need for Better Statistical Methods for Orthopaedic Outcomes

Commentary We live in an era of science-based medicine. Today’s top physicians and surgeons are empowered with real data, not dogma, and are practicing evidence-based medicine1. Yet, in the report “Clinical Research Fails to Support More Aggressive Management of Pediatric Upper Extremity Fractures,” Eismann et al. purported that (1) there is a trend toward more operative treatment of upper extremity fractures in children and (2) there is little research-based support for the increasingly aggressive operative treatment of these fractures. David L. Sackett, a leading proponent of evidence-based medicine, pointed out that “Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”2 In effect, evidence-based medicine entails going to the literature to answer questions regarding the best treatment relevant to a given condition. Eismann et al. found that orthopaedic surgeons are not taking the advice offered by current orthopaedic researchers. How can this be? The Dichotomy Between Clinical Research and Clinical Practice The authors have suggested several possibilities to explain the dichotomy between clinical research and clinical practice: The authors point out that there may be some delay in the implementation of new evidence-based recommendations. They cite as evidence the many years it took to incorporate beta blockers in the treatment of patients recovering from myocardial infarction. It could be that the studies that substantiate the increased use of internal fixation in children’s upper extremity fractures have not yet made it to presentation or publication. Delay in dissemination may have a role here. The authors point out that the vastness and complexity of the research literature may be interfering with the translation of evidence into clinical practice. There are so many articles and so many studies that it is difficult to separate out the wheat from the chaff. It is difficult for a single individual to master all of the new studies that appear in the literature. Information overload may be a part of the problem. The authors suggest the possibility of the technological imperative—the advent and availability of new technologies may compel surgeons to perform more surgical procedures. It is certainly more interesting and exciting to use a newly developed internal fixation device than to pursue casting or other nonoperative treatment. Surgeons have always been susceptible to this type of influence, especially when exposed to skilled industrial technical consultants. The opportunity to use new and innovative techniques—such as intramedullary nailing—likely has an effect on decision-making. The authors suggest that advertising may cause parents or families to pressure surgeons to use new or even elaborate surgical techniques. It may also be true that advertisement has a direct effect on surgeons themselves. It is hard to resist highly touted and attractively presented new surgical implants and techniques. Advertising to surgeons likely plays a role in decision-making. The authors further suggest the possibility that the patients and parents may believe that more elaborate techniques are indicative of better care. There is often a feeling among families that more care and more aggressive care equate to better care. This may certainly have an effect on treatment decisions. The authors suggest that operative treatment may be more convenient for the treating surgeon. They suggest that if the resources needed for conservative treatment, such as conscious sedation, are limited in a particular treatment setting or if the close follow-up needed for conservative treatment is impractical for a particular patient or population, then these limitations might act as impediments to continued nonoperative care for these fractures. It is true that it is often more convenient to schedule a surgical procedure in the operating room than it is to find access for conscious sedation for a repeat closed reduction. Furthermore, it is more convenient to solve the problem of an unstable fracture by inserting hardware than it is to “hound” the fracture with frequent radiographs in the clinic and arrange for repeat closed reduction if alignment is lost. Solving the problem with internal fixation makes it easier for the surgeon to sleep at night. The authors believe that surgeons may have a financial incentive to develop and utilize surgical implants and techniques. There may be more to this than the development of techniques. Frankly, surgeon compensation for internal fixation of a forearm fracture injury involving both the radius and the ulna is greater than that of closed treatment with manipulation. Current Procedural Terminology (CPT) code 25575 describes open treatment of radial and ulnar shaft fractures with internal fixation and is reimbursed at 12.29 relative value units (RVUs). In distinction, CPT code 25565 describes closed treatment of radial and ulnar shaft fractures with manipulation and is reimbursed at 5.85 RVUs3. It is clear that there may be some financial incentive for orthopaedic surgeons to treat fractures in an open rather than closed manner. Reimbursement could play a role in the decision for treatment. Are Surgeons Ignoring the Current Literature? The question must be asked as to whether surgeons are ignoring the current literature. It is likely that, to a great extent, the surgeons who treat these upper extremity fractures in children are aware of the current literature that suggests that less aggressive treatments are successful. It is not likely that these same surgeons read every conceivable article about the topic or evaluate the associated level of evidence. The main driver of the increase in operative numbers for upper extremity fractures in children is fracture of the forearm4-6. There seems to be a consensus within the literature that, over the long term, forearm fractures that have been treated in a conservative manner have equivalent results to those that have been treated in an operative manner. Operative treatment is made less attractive due to the possibility of surgical complications, increased treatment cost, and hardware removal. The scientific literature does not support the more aggressive operative treatment of these fractures. But perhaps the scientific literature has failed to identify the human problems associated with treating upper extremity fractures in children. These involve human costs for patients and families who have to take time off from work or school, travel, report to the clinic on a frequent basis, and sit in waiting rooms. These involve human costs for the surgeon as well, as he or she must follow the unstable fracture, worry about displacement, and remain at a heightened level of diligence until the fracture heals or is fixed. It could be that convenience costs—which take into account anxieties about the reduction itself as well as the time that consequently must be diverted from reimbursable activities for the surgeon and the patient—are the more important factors in the decision-making process about upper extremity fractures. For patients and families who live far from treatment facilities, it is clear that stabilizing a fracture surgically may be a much more convenient alternative than making repetitive trips to the clinic to monitor a closed reduction. It seems clear that most of the scientific studies regarding fracture care in children with upper extremity fractures do not consider these human factors. Currently, in this era, the physician still has the opportunity to choose the fracture treatment that he or she believes is best for the situation, family, and surgeon. There is not yet an overseeing body that dictates the fracture treatment for each situation. As long as surgeons are allowed to advocate and choose for their patients, it is likely that there will be some variants from the recommendations of the current literature. Should we be alarmed that there is a dichotomy between clinical research and clinical practice? It does not seem that alarm is the correct response. However, it will be useful to track clinical practice patterns over time to see if they realign with the recommendations of clinical research. It may also be useful to look not only at the physiologic outcomes of fracture-healing but also at the human factors and the effect of treatment on patients, families, and surgeons. After all, it is only natural to prefer to avoid major disturbance and inconvenience in daily life. In summary, there is a divergence between research findings and actual practice decisions regarding the treatment of upper extremity fractures in children. The effect is an increase in the operative treatment of forearm fractures in children. There are a number of factors that may contribute to this effect, but it is appropriate to entertain the possibility that convenience plays a major role in surgical decision-making.

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