Advertisement

Editorial Commentary: When a Tie Is Still a Win: Systematic Reviews Showing No Difference Between Treatments May Not Be Generalizable to Individual Patients

      Abstract

      When a systematic review finds no difference between treatment options for a particular disorder, this could mean more than you think. Individual patients requiring shoulder Bankart repair are unique with respect to their demands and expectations and pathology. Surgeons should combine published principles with understanding of their own skills and their specific patient to optimize a treatment outcome.
      Systematic reviews and meta-analyses may review the literature to compare different treatments of orthopaedic conditions. Many studies show some differences between treatment outcomes,
      • Harris J.D.
      • Brand J.C.
      • Cote M.P.
      • Dhawan A.
      Research pearls: The significance of statistics and perils of pooling. Part 3: Pearls and pitfalls of meta-analyses and systematic reviews.
      and some find no difference between treatments. Is “no difference” a bad thing?
      Brown, Rothermel, Joshi, and Dhawan in their study, “Recurrent Instability After Arthroscopic Bankart Reconstruction: A Systematic Review of Surgical Technical Factors,”
      • Brown L.
      • Rothermel S.
      • Joshi R.
      • Dhawan A.
      Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
      found no difference in the risk of recurrent instability after arthroscopic Bankart reconstruction, looking at many different variables. Their review included 26 studies that met the inclusion criteria and showed that although some individual studies and even prior published systematic reviews suggest the contrary,
      • Rendell P.
      • Ramone V.
      • Carminati S.
      • Casita P.
      Risk factors for recurrence after Bankart repair a systematic review.
      the composite analysis of the most recently reviewed and published literature shows no difference in risk of recurrent shoulder instability after arthroscopic Bankart reconstruction surgery, with or without rotator interval closure, and regardless of the number of anchors used, or the use of knotless versus standard anchors, or the use of bioabsorbable versus nonabsorbable anchors.
      What does this mean? Does it mean that any method you choose to repair a Bankart lesion leads to the same result? Or on the contrary, does it mean that there are many different ways of treating shoulder instability and treatment outcome depends on determining the nuances of each patient's demographics and pathology, and selecting the proper method of treatment for each individual patient. I believe it is the latter.
      All orthopaedic surgeons do not come from the same mold. Each orthopaedic surgeon is very uniquely different but what is similar is that we all receive similar training on the basic principles of treatment. So when it comes to repair of a Bankart lesion, I am not surprised that a review of the literature shows “no difference.”
      No true double-blind surgical study can ever be performed because a surgeon cannot be blinded to the treatment or implants used. Even randomized studies on shoulder instability are difficult to perform with equipoise, because surgeons have strong opinions based on knowledge and experience with regard to the best treatment for their unique patients.
      Reviews are only good as the articles included. Brown et al.
      • Brown L.
      • Rothermel S.
      • Joshi R.
      • Dhawan A.
      Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
      included articles with varied level of evidence, which like all research, may result in inherent bias. And like it or not, because systematic reviews and meta-analyses are increasingly being used to determine health policy, it is important that we include only the highest quality articles in systematic reviews. A recent editorial commentary by Plancher discussed a randomized trail considering different arm sling positions and the outcome on shoulder rotator cuff repair. He stated that although the results of the study showed no difference in positions, studies have flaws and surgeons should consider the literature but not change a treatment that is effective in their hands on their patients based on studies that may not be generalizable.
      • Bal F.
      • Boilie P.
      The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.
      Researchers much perform studies of a high level of evidence with quality methods including properly selected outcome measures. And individual surgeons must thoroughly assess and address the uniqueness of each patient, and tailor our treatment based on that patient's age, activity and sport level, and other demographics, as well as that patient's pathology.
      • Kibler W.B.
      Value on the front end: Making the effective diagnosis for optimal treatment.
      • Rossi M.J.
      • Lubowitz J.H.
      • Brand J.C.
      • Provencher M.T.
      Making the right treatment decision requires consideration of utility and reconsideration of value.
      • Dhawan A.
      • Brand J.C.
      • Provencher M.T.
      • Rossi M.J.
      • Lubowitz J.H.
      Research pearls: The significance of statistics and perils of pooling.
      This means understanding the principles of treatment in determining the best methods to use in each of our hands and applying it to a particular patient.
      • Kibler W.B.
      Value on the front end: Making the effective diagnosis for optimal treatment.
      • Rossi M.J.
      • Lubowitz J.H.
      • Brand J.C.
      • Provencher M.T.
      Making the right treatment decision requires consideration of utility and reconsideration of value.
      • Dhawan A.
      • Brand J.C.
      • Provencher M.T.
      • Rossi M.J.
      • Lubowitz J.H.
      Research pearls: The significance of statistics and perils of pooling.
      • Plancher K.D.
      Editorial commentary: Better care, better health, better cost: Is scientific evidence negatively impacting the transformation of health care?.
      If we do this, when we treat patients with a Bankart lesion and shoulder instability, then the decisions as to whether to close the rotator interval, or determine how many or what type of suture anchors to use, will make a difference when the goal is to achieve the best result for the individual patient in our individual hands.

      Supplementary Data

      References

        • Harris J.D.
        • Brand J.C.
        • Cote M.P.
        • Dhawan A.
        Research pearls: The significance of statistics and perils of pooling. Part 3: Pearls and pitfalls of meta-analyses and systematic reviews.
        Arthroscopy. 2017; 33: 1594-1602
        • Brown L.
        • Rothermel S.
        • Joshi R.
        • Dhawan A.
        Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
        Arthroscopy. 2017; 33: 2081-2092
        • Rendell P.
        • Ramone V.
        • Carminati S.
        • Casita P.
        Risk factors for recurrence after Bankart repair a systematic review.
        Knee Surg Sport Traumatol Arthrosc. 2012; 20: 2129-2138
        • Bal F.
        • Boilie P.
        The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.
        J Bone Joint Surg Br. 2007; 89: 1470-1477
        • Kibler W.B.
        Value on the front end: Making the effective diagnosis for optimal treatment.
        Arthroscopy. 2017; 33: 493-495
        • Rossi M.J.
        • Lubowitz J.H.
        • Brand J.C.
        • Provencher M.T.
        Making the right treatment decision requires consideration of utility and reconsideration of value.
        Arthroscopy. 2017; 33: 239-241
        • Dhawan A.
        • Brand J.C.
        • Provencher M.T.
        • Rossi M.J.
        • Lubowitz J.H.
        Research pearls: The significance of statistics and perils of pooling.
        Arthroscopy. 2017; 33: 1099-1101
        • Plancher K.D.
        Editorial commentary: Better care, better health, better cost: Is scientific evidence negatively impacting the transformation of health care?.
        Arthroscopy. 2017; 33: 1627-1628

      Linked Article