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A meta-analysis is a comprehensive systematic review in which statistical analyses are used to combine the results of two or more homogeneous clinical trials1-4. In the paradigm of evidence-based orthopaedics, meta-analysis can be an invaluable tool to increase study power and improve precision when study results are combined appropriately5. Evidence from a meta-analysis, however, is highly dependent on the quality of the primary studies included and on the overall methodological rigor6. Meta-analyses have impacted clinical practice, paved the way for clinical practice guidelines and health policies, and guided subsequent research6,7. The extent to which meta-analyses in joint arthroplasty—one of the most commonly performed elective procedures in orthopaedics—are of high quality remains largely unknown. Previous reviews have examined orthopaedic meta-analyses in general, with little specific focus on joint arthroplasty (involving the hip, knee, ankle, shoulder, elbow, wrist, and metacarpophalangeal joints)5,8. We are aware of no study that has focused on the numerous subcategories within arthroplasty, including pharmacology (thromboprophylaxis, blood conservation, antibiotic treatment, and bisphosphonate treatment), anesthesia, surgical outcome, radiology, rehabilitation, education, and the hip, knee, ankle, shoulder, elbow, wrist, and metacarpophalangeal joints. Thus, it is difficult to make precise recommendations about the quality of reporting in the arthroplasty literature. The purpose of our study was to assess the scientific rigor of meta-analyses involving arthroplasty, the overall quality of reporting, and the extent to which the results of these meta-analyses were perceived to be important to clinical practice. Our systematic review was conducted with adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines for systematic reviews, as outlined below9. ### Search Strategy and Eligibility Criteria We aimed to identify all published meta-analyses in the field of arthroplasty, including those involving the hip, knee, ankle, shoulder, …

Background: Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures. Methods: Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported. Results: There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors. Conclusions: The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital’s burden of their choices for higher cost devices under the Medicare payment system. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

In 2007, the British Medical Journal reported the fifteen most important medical milestones since the inception of that journal in 18401. Included were the discovery of DNA, the development of vaccinations and of antibiotics, the use of anesthetics for surgery, and evidence-based medicine. The practice of evidence-based medicine can be conceptualized as the integration of the best available research evidence, the clinical circumstances, and the values and preferences of the patients. Clinical expertise is critical to the practice of evidence-based medicine, allowing the sensible and skilled application of best evidence to patients. The use of best evidence implies a hierarchy. This hierarchy, described by Sackett et al.2 in 1996, can be visualized as a pyramid of evidence with randomized trials on top (Level I) and expert opinion on the bottom (Level V). For a therapy, Level-I evidence obtained from randomized controlled trials remains the highest standard for the most valid information. Yet, there is a discrepancy between the apparent validity of medical knowledge and the actual facts. Only about 15% of medical interventions are supported by verifiable scientific data3. Even when evidence is available, physicians are often slow to adopt changes in thinking. There have been ten trials of bed rest after spinal puncture that have demonstrated no change in headache with bed rest and an increase in back pain. However, 80% of the protocols in neurology units in the United Kingdom continued to recommend bed rest after lumbar puncture as of 1998, despite earlier evidence-based reports4. In the case of orthopaedic medicine, any drug or implantable device to be used in humans should logically undergo the same scrutiny of evidence before widespread application. It would seem appropriate that high-quality confirmatory evidence about safety and efficacy from randomized trials be obtained prior to …

Results: One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven(4.6%)requiredimplantexchangeorbone-graftingbecauseofnonunion.Amongallpatients,105inthereamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidenceinterval,0.71to1.15).Inpatientswithclosedfractures,forty-five(11%)of416inthereamednailinggroupand sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures,sixtyof206inthereamednailinggroupandforty-sixof194intheunreamednailinggroupexperiencedaprimary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0.16). Conclusions: The present study demonstrates a possible benefit for reamed intramedullary nailing in patients with closed fractures. We found no difference between approaches in patients with open fractures. Delaying reoperation for nonunion for at least six months may substantially decrease the need for reoperation. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Background: Bone stimulation represents a $500 million market in the United States. The use of electromagnetic stimulation in the treatment of fractures is common; however, the efficacy of this modality remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the effect of electromagnetic stimulation on long-bone fracture-healing. Methods: We searched four electronic databases (MEDLINE, EMBASE, CINAHL, and all Evidence-Based Medicine Reviews) for trials of electromagnetic stimulation and bone repair, in any language, published from the inception of the database to April 2008. In addition, we searched by hand seven relevant journals published between 1980 and April 2008 and the bibliographies of eligible trials. Eligible trials enrolled patients with long-bone lesions, randomly assigned them to electromagnetic stimulation or a control group, and reported on bone-healing. Information on the methodological quality, stimulation device, duration of treatment, patient demographics, and all clinical outcomes were independently extracted by two reviewers. Results: Of 2546 citations obtained in the literature search, eleven articles met the inclusion criteria. Evidence from four trials reporting on 106 delayed or ununited fractures demonstrated an overall nonsignificant pooled relative risk of 1.76 (95% confidence interval, 0.8 to 3.8; p = 0.15; I2 = 60.4%) in favor of electromagnetic stimulation. Single studies found a positive benefit of electromagnetic stimulation on callus formation in femoral intertrochanteric osteotomies, a limited benefit for conservatively managed Colles fracture or for lower limb-lengthening, and no benefit on limb-length imbalance and need for reoperation in surgically managed pseudarthroses or on time to clinical healing in tibial stress fractures. Pain was reduced in one of the four trials assessing this outcome. Conclusions: While our pooled analysis does not show a significant impact of electromagnetic stimulation on delayed unions or ununited long-bone fractures, methodological limitations and high between-study heterogeneity leave the impact of electromagnetic stimulation on fracture-healing uncertain. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Background: While it is widely accepted that scientific factors may render a study more likely to be accepted for publication, it is less clear whether nonscientific factors may also be associated with publication. The purpose of this study was to identify the nonscientific factors associated with acceptance for publication by The Journal of Bone and Joint Surgery (American Volume). Methods: A total of 1173 manuscripts submitted to The Journal of Bone and Joint Surgery between January 1, 2004, and June 30, 2005, for publication as scientific articles were analyzed as part of a study on publication bias in the editorial decision-making process. Information was collected on nonscientific factors plausibly associated with acceptance for publication, including study location, conflict-of-interest disclosure, sex of the author, primary language, and the number of prior publications by the corresponding author in frequently cited orthopaedic journals. The final disposition term (acceptance or rejection) was recorded, and logistic regression was used to identify factors associated with acceptance for publication. Results: Manuscripts from countries other than the United States or Canada were significantly less likely to be accepted (odds ratio, 0.51; 95% confidence interval, 0.28 to 0.92; p = 0.026). Factors positively associated with acceptance for publication were conflict-of-interest disclosure involving a nonprofit entity (odds ratio, 1.92; 95% confidence interval, 1.35 to 2.73; p < 0.001) and ten or more prior publications in frequently cited orthopaedic journals by the corresponding author (odds ratio, 2.01; 95% confidence interval, 1.33 to 3.05; p = 0.001). We did not find a significant association between acceptance and conflict-of-interest disclosure involving a for-profit company, sex of the corresponding author, or primary language. Conclusions: Manuscripts submitted to The Journal of Bone and Joint Surgery were more likely to be accepted if they were from the United States or Canada, reported a conflict of interest related to a nonprofit entity, or were authored by an individual with ten or more prior publications in frequently cited orthopaedic journals.

Background: Hip fractures in the elderly are a common and costly problem, with intertrochanteric fractures accounting for almost half of these fractures. Most intertrochanteric fractures are treated with either a plate-and-screw device or an intramedullary nail device. We assessed the degree of geographic variation in use of intramedullary nailing for intertrochanteric femoral fractures among Medicare beneficiaries between 2000 and 2002. Methods: Medicare 100% files (hospital and physician claims, and enrollment) for 2000 through 2002 were used to identify beneficiaries, sixty-five years of age or older, who had undergone inpatient surgery for the treatment of an intertrochanteric femoral fracture with a plate-and-screw device or an intramedullary nail. We used multiple logistic regression analysis to model the use of an intramedullary nail (as opposed to a plate-and-screw device) by state and year, after adjusting for patient age, sex, race, subtrochanteric fracture, comorbidities, and Medicaid-administered assistance. The odds ratios of receiving an intramedullary nail device are reported. The adjusted state rates of intramedullary nailing per 100 Medicare patients with an intertrochanteric fracture are reported for 2000 through 2002. Results: In this study, 212,821 claims for operations to treat patients with an intertrochanteric fracture from 2000 through 2002 met the inclusion criteria. There was considerable geographic variation in intramedullary nail use by state across all years. The mean adjusted intramedullary nailing rate per 100 Medicare patients with an intertrochanteric fracture increased nationally from 7.84 in 2000 to 16.98 in 2002. In 2000, surgeons in sixteen states used an intramedullary nail in fewer than one of every twenty Medicare patients with an intertrochanteric fracture. By 2002, surgeons in only two states used an intramedullary nail in fewer than one of every twenty patients with an intertrochanteric fracture, and in eight states they used an intramedullary nail in more than one of every four patients with an intertrochanteric fracture. Conclusions: There was substantial geographic variation in the use of intramedullary nailing by state from 2000 through 2002 that was largely not explained by patient-related factors.

Background: Hip fractures occur in 280,000 North Americans each year. Although surgeons have reached consensus with regard to the treatment of undisplaced fractures of the hip, the surgical treatment of displaced fractures remains controversial. Identifying surgeons' preferences in techniques, and the rationale for their choices, may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the operative treatment of displaced fractures of the femoral neck. Methods: We used a cross-sectional survey design and a sample-to-redundancy strategy to examine surgeons' preferences in the treatment of displaced femoral neck fractures. We mailed this survey to members of the Orthopaedic Trauma Association and European-AO International-affiliated trauma centers. Results: Of 442 surgeons who received the questionnaire, 298 (67%) responded. The typical respondent was a North American man over the age of forty years who was in academic practice, supervised residents, had fellowship training in trauma, and worked in a low-volume center (

Periprosthetic bone loss following total joint arthroplasty may threaten the survival of the implant. Bisphosphonates are effective in reducing bone loss in conditions associated with accelerated bone turnover. To determine the current understanding of the effect of bisphosphonates on periprosthetic bone mineral density after total joint arthroplasty, we conducted computerized searches for randomized controlled trials evaluating the use of bisphosphonates in patients treated with primary total joint arthroplasty.We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the web site of the United Kingdom National Research Register, and the archives of the American Academy of Orthopaedic Surgeons annual meetings (1989 through 2003), and we conducted hand searches of the bibliographies of relevant articles. We assessed methodological quality and abstracted relevant data. When necessary, we contacted authors to provide additional information.Of 386 citations that were initially identified, six (five complete papers and one abstract), which included a total of 290 patients, met our inclusion criteria. Those papers showed that significantly less periprosthetic bone loss had occurred in the bisphosphonate-treated patients than in the control patients at three months (152 patients; weighted mean difference, 3.3%; 95% confidence interval, 1.9% to 4.7%; p0.01), six months (248 patients; weighted mean difference, 4.5%; 95% confidence interval, 1.6% to 7.4%; p0.001), and twelve months (197 patients; weighted mean difference, 4.2%; 95% confidence interval, 1.5% to 6.9%; p = 0.03). Bisphosphonates appeared to have a larger effect on bone loss following arthroplasties with cement than on bone loss following arthroplasties without cement (difference, 0.1%, 5%, and 5.4% at three, six, and twelve months; significant difference [p0.001] at one year only) and a larger effect on bone loss following total knee arthroplasties than on bone loss following total hip arthroplasties (difference, 4.1%, 11.5%, and 7.1% at three, six, and twelve months; significant difference [p0.001] at six months only). None of the studies related the effects of bisphosphonates on bone mineral density to clinically relevant outcomes.A meta-analysis of six randomized controlled trials suggested that bisphosphonates have a beneficial effect with regard to maintaining more periprosthetic bone mineral density than that in controls. However, the limitations of the available studies and the lack of analyses of clinically relevant outcomes (functional outcomes, revision rates, and quality of life) necessitate the planning and conduct of a sufficiently sized, methodologically sound study with clinically relevant end points. Until this has been done, the current evidence regarding the beneficial effects of bisphosphonates on periprosthetic bone after total joint arthroplasty should be interpreted with caution.

Background: The optimal choice for the stabilization of displaced femoral neck fractures remains controversial, with al- ternatives including arthroplasty and internal fixation. Our objective was to determine the effect of arthroplasty (hemiar- throplasty, bipolar arthroplasty, and total hip arthroplasty), compared with that of internal fixation, on rates of mortality, revision, pain, function, operating time, and wound infection in patients with a displaced femoral neck fracture. Methods: We searched computerized databases for randomized clinical trials published between 1969 and 2002, and we identified additional studies through hand searches of major orthopaedic journals, bibliographies of major or- thopaedic textbooks, and personal files. Of 140 citations initially identified, fourteen met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data, including information on revision and mortality rates. Results: Nine trials, which included a total of 1162 patients, provided detailed information on mortality rates over the first four postoperative months, which ranged from 0% to 20%. We found a trend toward an increase in the rela- tive risk of death in the first four months after arthroplasty compared with the risk in the first four months after inter- nal fixation (relative risk, 1.27). At one year, the relative risk of death was 1.04. The risk of death after arthroplasty appeared to be higher than that after fixation with a compression screw and side-plate but not higher than that after internal fixation with use of screws only (relative risk = 1.75 and 0.86, respectively; p < 0.05). Fourteen trials that in- cluded a total of 1901 patients provided data on revision surgery. The relative risk of revision surgery after arthro- plasty compared with the risk after internal fixation was 0.23 (p = 0.0003). Pain relief and the attainment of overall good function were similar in patients treated with arthroplasty and those treated with internal fixation (relative risk, 1.12 for pain relief and 0.99 for function). Infection rates ranged from 0% to 18%, and arthroplasty significantly in- creased the risk of infection (relative risk, 1.81; p = 0.009). In addition, patients who underwent arthroplasty had greater blood loss and longer operative times than those who were treated with internal fixation. Conclusions: In comparison with internal fixation, arthroplasty for the treatment of a displaced femoral neck fracture significantly reduces the risk of revision surgery, at the cost of greater infection rates, blood loss, and operative time and possibly an increase in early mortality rates. Only larger trials will resolve the critical question of the impact on early mortality. Level of Evidence: Therapeutic study, Level I-2 (systematic review of Level-I randomized controlled trials (studies were homogeneous)). See Instructions to Authors for a complete description of levels of evidence.

There has been considerable debate in several major medical journals regarding whether there is a need for explicit reporting of author contributions 1. Journal editors have supported the idea of reporting author contributions to limit irresponsible authorship, honorary authorship, ghostwriting, authors' refusals to accept responsibility for articles, and duplicate publication 1. The stimulus for reporting authors' roles has been increased by studies showing poor adherence to authorship rules as set forth by the International Committee of Medical Journal Editors (ICMJE) 2,3. While major medical journals have adopted the strategy of reporting author contributions, no major surgical journals are currently utilizing this approach. Opponents of reporting individual author contributions believe that readers are not interested in this information and that doing so may lead to hair-splitting negotiations among authors regarding the amount of work done 4. To whom is the order of authorship important? While relative transparency in authorship contribution may or may not be important to journal readers, it is certainly important to the authors themselves and to those who make decisions regarding academic promotions. It is imperative that, in such situations, academic promotion committee members recognize those who truly performed the work in a research paper. We hypothesized that, in the absence of explicit reporting of authors' contributions to a paper, readers would have variable perceptions of the authors' roles based solely on authorship order. To test our hypothesis, we surveyed members of the American editorial board of The Journal of Bone and Joint Surgery. We developed a survey to assess readers' perceptions of authors' roles based on authorship order and corresponding author. A fictitious study title with fictitious authors was created ( Fig. 1 ). The authors' first names were written as initials only, to avoid the potential for gender-biased responses by …

• Investigators who perform a systematic review address a focused clinical question, conduct a thorough search of the literature, apply inclusion and exclusion criteria to each potentially eligible study, critically appraise the relevant studies, conduct sensitivity analyses, and synthesize the information to draw conclusions relevant to patient care or additional study. • A meta-analysis is a quantitative (or statistical) pooling of results across eligible studies with the aim of increasing the precision of the final estimates by increasing the sample size. • The current increase in the number of small randomized trials in orthopaedic surgery provides a strong argument in favor of meta-analysis; however, the quality of the primary studies included ultimately reflects the quality of the pooled data from a meta-analysis. The conduct and publication of systematic reviews of the orthopaedic literature, which often include statistical pooling or meta-analysis, are becoming more common. This article is the third in a series of guides evaluating the validity of the surgical literature and its application to clinical practice. It provides a set of criteria for optimally interpreting systematic literature reviews and applying their results to the care of surgical patients. Authors of traditional literature reviews provide an overview of a disease or condition or one or more aspects of its etiology, diagnosis, prognosis, or management, or they summarize an area of scientific inquiry. Typically, these authors make little or no attempt to be systematic in formulating the questions that they are addressing, in searching for relevant evidence, or in summarizing the evidence that they consider. Medical students and clinicians seeking background information nevertheless often find these reviews very useful for obtaining a comprehensive overview of a clinical condition or area of inquiry. When traditional expert reviewers make recommendations, they often disagree with one another, and their advice frequently lags behind, or …

Background: Research abstracts are frequently referenced in orthopaedic textbooks and influence orthopaedic care. However, little is known about the quality of information provided in the abstracts, the frequency of publication of complete papers after presentation of abstracts, or any discrepancies between abstracts and published papers. The objective of this study was to determine the quality of information provided in orthopaedic abstracts, rates of publication of full-text articles after presentation of abstracts, predictors of publication of full-text articles, and consistency between abstracts and full-text articles. Methods: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. For each abstract, we recorded the completeness of reporting and key features of the study design, conduct, analysis, and interpretation. A computerized Medline and PubMed search established whether the abstract had been followed by publication of a full-text article. Finally, we evaluated the consistency of reporting between abstracts and final publications. Results: The program included 465 abstracts, 66% of which were on prognostic studies. All abstracts described the study design, and 70.7% of the designs were observational. Key methodological issues were reported in less than half of the abstracts, and information on data analysis was reported in

The randomized controlled trial permits valid inferences concerning treatment effect and can thus have a powerful and immediate impact on patient care1. For clinicians to apply the results of randomized controlled trials to their patients, the published report should provide information concerning the study participants and the design, conduct, and analysis of the trial2. In essence, the authors should provide enough information for clinicians to judge whether there were important deficiencies that threaten the validity of the trial and whether they can confidently apply the results to their own patients. In a recent effort to improve the reporting of randomized controlled trials, a group of methodologists and journal editors developed the consolidated standards of reporting trials (CONSORT) statement, which was first published in JAMA (The Journal of the American Medical Association) in 19962. CONSORT provides a checklist and flow diagram to guide authors in the preparation of reports on their randomized controlled trial. The CONSORT checklist consists of twenty-one items that pertain mainly to the methods, results, and discussion in a report of a randomized controlled trial and that identify key pieces of information necessary to evaluate the internal and external validity of the report. While many reputable journals, including JAMA, BMJ (The British Medical Journal), The Lancet , and Annals of Internal Medicine, have adopted CONSORT standards, the rigor of enforcement varies3. The editors of JAMA expect manuscripts reporting randomized controlled trials to include all of the information in the CONSORT checklist and to be accompanied by the checklist as well as the numbers of the pages in the manuscript on which each item can be found. Other journals that have endorsed CONSORT provide minimal checks on compliance. Critical reviews of published clinical trials in general medical journals have documented widespread …

Prognosis studies are investigations examining the possible outcomes of a disease or operative procedure and the probability with which they can be expected to occur. Primary guides for assessing the validity (study methodology) of a prognosis study are: Was there a representative sample of patients? Were the patients sufficiently homogeneous with respect to prognostic risk? If not, did the investigators provide estimates for all clinically relevant subgroups? Secondary guides for assessing the validity (study methodology) of a prognosis study are: Was follow-up sufficiently complete? Were objective and unbiased outcome criteria used? You are an orthopaedic surgeon consulting on the case of a seventy-seven-year-old woman with osteoarthritis in the right hip causing pain and functional impairment who was referred to you by a local family physician. The woman had a left total hip arthroplasty twelve years ago, with a good result. For the present problem, she received a course of conservative therapy including anti-inflammatory medications and physiotherapy. She currently uses a cane to walk and is no longer able to do housework. On examination, she is found to be moderately overweight (67 kg) and 5 ft (152.4 cm) tall. She has a 2-cm limb-length discrepancy and a severely restricted range of motion of the right hip. Examination of anteroposterior radiographs of the pelvis and the right hip reveal advanced osteoarthritis with large osteophytes, subchondral cysts, and decreased joint space. Additional evaluation of the radiograph of the right hip reveals a femoral canal-flare index (the canal width 20 mm proximal to the geometric center of the lesser trochanter divided by the canal width at the isthmus of the femur) of 2.0. Evaluation of a radiograph of the left hip, in which a so-called hybrid hip arthroplasty (fixation of the acetabular component without cement and the femoral component with cement) was done, reveals …

Background: Recent studies have suggested that high-pressure irrigation may have adverse effects on bone. However, the use of low-pressure irrigation may not remove all adherent bacteria from bone. The type of irrigating solution may be an important factor in the removal of adherent bacteria with pulsatile lavage. In this study, we compared the effects of various irrigating solutions on the number and function of osteoblasts and osteoclasts and we examined the effectiveness of these solutions in removing adherent bacteria from bone. Methods: To examine the effect of irrigating solutions on the number and activity of osteoblasts, we isolated calvarial cells from newborn C57BI/6 mice and exposed the cells to equivalent concentrations of ethanol, povidone-iodine, liquid soap, antimicrobial wash (50 U/L of bacitracin), or chlorhexidine gluconate, for two, ten, or twenty minutes. The cells were then cultured in the presence of bone-nodule-enhancing medium (b-glycerophosphate and ascorbic acid) for twenty-one days. The medium was changed every three or four days. Mineralized nodules were stained with alizarin red S, and osteoblasts were stained with a histochemical stain for alkaline phosphatase. Osteoclasts were identified with tartrate-resistant acid-phosphatase staining. In a second experiment, canine cortical tibiae were contaminated with Staphylococcus aureus for six hours and subjected to different irrigating solutions with or without low-pressure lavage. Bacterial colony-forming units were quantitated under each set of conditions. Results: Each solution resulted in a time-dependent decrease in the number of calvarial osteoblasts and osteoclasts compared with that in the controls. The 1% soap solution resulted in greater preservation of both alkaline-phosphatase activity and bone-nodule formation than did the other solutions. Moreover, the soap solution preserved the number of osteoclasts to the greatest extent. The povidone-iodine and chlorhexidine-gluconate solutions resulted in the largest decline in bone-nodule formation, alkaline-phosphatase activity, and number of osteoclasts. Low-pressure pulsatile lavage with the soap solution removed the most bacteria from the contaminated tibia when compared with either the soap solution alone or low-pressure irrigation with saline solution. Conclusions: Our findings suggest that certain solutions may be more effective in removing bacteria from bone than mechanical irrigation with saline solution alone. Among the various solutions examined, the soap solution preserved the number and activity of osteoblasts the most. Low-pressure lavage with the soap solution resulted in the greatest removal of adherent bacteria from bone. Clinical Relevance: Meticulous debridement is regarded as the most important initial step in the management of open tibial fractures. The optimal technique for bone debridement should maximize the removal of adherent bacteria while preserving the structure and function of bone. It has been shown that low-pressure irrigation results in significantly less macroscopic and microscopic damage to bone and is as effective as high-pressure lavage in removing bacteria within three hours after contamination. However, irrigation is often delayed beyond three hours. In the current study, we report that debridement with low-pressure irrigation and detergent solutions can be effective for up to six hours after contamination.

To The Editor: We have been encouraged by the explicit emphasis on evidence-based orthopaedics in The Journal, and we read with great interest “Meta-Analyses in Orthopaedic Surgery. A Systematic Review of Their Methodologies” (83-A: 15-24, Jan. 2001), by Bhandari et al. This article raised some important points, one being that adherence to strict scientific methodology can limit bias and improve the validity of meta-analyses. However, we would like to comment on the methodology and consequent findings of their study. The first issue is their omission of relevant studies published in the Cochrane Database of Systematic Reviews. As Bhandari et al. stated, they consulted this database in their search for meta-analyses, yet some thirty to fifty systematic reviews available in this database in 1999 were not included, which we find puzzling. Omission of these reviews, which, if included, would have more than doubled the number of reviews of fracture treatment, results in a distorted picture of the information that is available to the orthopaedic specialist. Moreover, as acknowledged by Bhandari et al., there is evidence that these reviews have higher scientific quality than …

Question: In patients with open tibial shaft fractures, what is the effectiveness of external fixation, plating, and reamed or unreamed intramedullary nailing on rates of reoperation, nonunion, and infection? Data sources: Studies were identified by searching Medline (1969 to 1998), SCISEARCH, and the Cochrane Library; by hand-searching major orthopaedic journals and proceedings; and by contacting experts in the field. Study selection: Randomized or quasi-randomized controlled trials (RCTs or QRTs) comparing external …