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Author Reply to “Can’t See the Right Forest Plot for the Wrong Trees!”

Published:September 23, 2020DOI:https://doi.org/10.1016/j.arthro.2020.07.045
      We thank Ishoi et al. for bringing to our attention the reporting error in the article by Palmer et al.
      • Palmer A.J.R.
      • Ayyar Gupta V.
      • Fernquest S.
      • et al.
      Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicentre randomised controlled trial.
      —one of the studies included in our meta-analysis of operative versus nonoperative outcomes for femoroacetabular impingement syndrome (FAIS).
      As Ishoi et al. state, and Palmer et al. acknowledge in their BMJ Rapid Response publication,
      • Palmer A.J.R.
      • Ayyar Gupta V.
      • Fernquest S.
      • et al.
      Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicentre randomised controlled trial.
      the adjusted between-group treatment effect for the International Hip Outcome Tool-33 (iHOT-33) score in the original Palmer et al.
      • Palmer A.J.R.
      • Ayyar Gupta V.
      • Fernquest S.
      • et al.
      Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicentre randomised controlled trial.
      publication ought to read 20.4 (95% confidence interval [CI] 13.2 to 27.6) rather than 2.0 (95% CI 1.3 to 2.8) as initially reported. We included the originally reported incorrect value in our meta-analysis to calculate the standardized mean difference in iHOT-33 scores across studies. This resulted in a falsely diminished difference in our primary outcome comparing operative and nonoperative treatments for patients with FAIS. Given that this error was discovered after the publication of our meta-analysis, we take this opportunity to submit our revised results and conclusions based on the insight by Ishoi et al. and the subsequent correction by Palmer et al.
      When assessing for heterogeneity between the 3 included studies with the corrected results, the I2 value exceeds 50%, indicating significant heterogeneity. Accordingly, as per our previously published methodology,
      • Dwyer T.
      • Whelan D.
      • Shah P.S.
      • et al.
      Operative versus nonoperative treatment of femoroacetabular impingement syndrome: A meta-analysis of short-term outcomes.
      we have used a random-effects model for meta-analysis (Fig 1).
      Figure thumbnail gr1
      Figure 1Revised random-effects meta-analysis of postoperative iHOT-33 scores comparing operative versus nonoperative treatment of femoroacetabular impingement syndrome.
      In comparison to our initial reported treatment effect, this updated meta-analysis more substantially favors operative management over nonoperative management for FAIS. The mean difference of 11.7 exceeds the minimally clinically important difference for the iHOT-33,
      • Kemp J.L.
      • Collins N.J.
      • Roos E.M.
      • et al.
      Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery.
      indicating a clinically significant difference in operatively treated patients over the nonoperative group at a mean follow-up of 10 months.
      We thank Ishoi et al. for pointing out this change.

      Supplementary Data

      References

        • Palmer A.J.R.
        • Ayyar Gupta V.
        • Fernquest S.
        • et al.
        Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicentre randomised controlled trial.
        BMJ. 2019; 364: 1185
        • Dwyer T.
        • Whelan D.
        • Shah P.S.
        • et al.
        Operative versus nonoperative treatment of femoroacetabular impingement syndrome: A meta-analysis of short-term outcomes.
        Arthroscopy. 2020; 36: 263-273
        • Kemp J.L.
        • Collins N.J.
        • Roos E.M.
        • et al.
        Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery.
        Am J Sports Med. 2013; 41: 2065-2073