Mohit Bhandari

BackgroundThe purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events.MethodsEmbase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion.ResultsTen studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a …

Introduction Hyperparathyroidism is a common endocrine disorder that can be secondary to a single or multiple abnormal parathyroid glands and can occur in the context of chronic kidney disease (CKD). There are three types of hyperparathyroidism, and all are definitively managed via surgical extirpation of abnormal parathyroid gland tissue. Intraoperative parathyroid hormone (IOPTH) monitoring was introduced over three decades ago and has been shown to improve clinical outcomes in patients with primary hyperparathyroidism (PHPT). As the incidence of PHPT rises due to improving screening globally and the incidence of CKD rises, it will be important to optimize adoption and standardization of IOPTH within endocrine surgery centers around the world. We will perform a cross-sectional survey study of surgeon rationale, operational details, and barriers associated with IOPTH adoption across North America. Methods and analysis We will utilize a convenience sampling technique to distribute an online survey to head and neck surgeons and endocrine surgeons across North America. This survey will be distributed via email to three North American professional societies (i.e., Canadian Society for Otolaryngologists–Head and Neck Surgeons, American Head and Neck Society, and American Association of Endocrine Surgeons). The survey will consist of 30 multiple choice questions that are divided into three concepts: (1) participant demographics and training details, (2) details of surgical adjuncts during parathyroidectomy, and (3) barriers to adoption of IOPTH. Descriptive analyses and multiple logistic regression models will be used to …

Intraoperative parathyroid hormone (iPTH) monitoring is standard-of-care in the surgical management of hyperparathyroidism. It involves real-time determination of circulating PTH levels to guide parathyroid gland excision. There exists several iPTH monitoring criteria, such as the Miami criteria, and a lack of standardization in the timing of post-parathyroid gland excision samples. We present a protocol of a systematic review and network meta-analysis of diagnostic test accuracy to identify the iPTH criteria and post-gland excision timepoint that best predicts surgical cure in hyperparathyroidism. The database search strategy will be developed in conjunction with a librarian specialist. We will perform a search of Medline (Ovid), EMBASE (Ovid), CINAHL, Cochrane Collaboration, and Web of Science from 1990-present. Studies will be eligible if they include adult patients diagnosed with hyperparathyroidism who undergo parathyroidectomy with iPTH monitoring. We will only include studies that report diagnostic test properties for iPTH criteria and/or post-excision sampling timepoints. All screening, full-text review, data extraction, and critical appraisal will be performed in duplicate. Critical appraisal will be performed using QUADAS-2 instrument. A descriptive analysis will present study and critical appraisal characteristics. We will perform evaluation of between-study heterogeneity using I 2 and Cochrane Q and where applicable, we will perform sensitivity analysis. Our network metaanalysis will include Bayesian hierarchical framework with random effects using multiple models.Ethics approval is not required. This proposed systematic review will …

BackgroundThe optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature.MethodsMEDLINE, EMBASE and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for a FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder re-dislocations, cumulative shoulder instability as well as subsequent shoulder stabilization surgery.ResultsThirty-four studies with 2,222 …

IntroductionSystematic reviews with network meta-analysis (NMA; ie, multiple treatment comparisons, indirect comparisons) have gained popularity and grown in number due to their ability to provide comparative effectiveness of multiple treatments for the same condition. The methodological review aims to develop a list of items relating to biases in reviews with NMA. Such a list will inform a new tool to assess the risk of bias in NMAs, and potentially other reporting or quality checklists for NMAs which are being updated.Methods and analysisWe will include articles that present items related to bias, reporting or methodological quality, articles assessing the methodological quality of reviews with NMA, or papers presenting methods for NMAs. We will search Ovid MEDLINE, the Cochrane library and difficult to locate/unpublished literature. Once all items have been extracted, we will combine conceptually similar items …

IntroductionHyaluronic acid (HA) use to treat knee osteoarthritis (OA) has been extensively investigated in the literature. There are also multiple economic assessments comparing intra-articular HAs with oral anti-inflammatory medicines and other conservative measures (NSAIDs), as well as different types and formulations of HA. Owing to the broad landscape of evidence across this area, it is important to further understand the empirical data comparing HA products, as well as the health economic implications that exist between commercially available HAs. This systematic review aims to identify and summarize the available evidence comparing commercially available HA products in the USA, as well as the health economic evidence and socioeconomic outcomes associated with HA use for knee OA.MethodsA systematic literature review within the OVID Medline, Embase, HealthStar, and Cochrane EBM HTA …

BackgroundInterpreting clinical relevance of randomized clinical trials (RCTs) is challenging when P-values are marginally above or below the P = .05 threshold. This study examined the robustness of statistically insignificant mortality events from RCTs comparing hemiarthroplasty femoral fixation for displaced intracapsular hip fractures through the reverse fragility index (RFI).MethodsRCTs were identified using Pubmed, OVID/Medline, and Cochrane databases. Mortality endpoints were stratified into 3 categories: (1) within 30-days, (2) within 90-days, and (3) at latest follow-up. The RFI was derived by manipulating reported mortality events utilizing a contingency table while maintaining a constant number of participants. The reverse fragility quotient (RFQ) was quantified by dividing the RFI by the study sample.ResultsEight RCTs (2,494 participants) were included. The median RFI and RFQ within 30-days was 3.0 …

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo …

BackgroundMovement disorders (Parkinson’s disease, essential tremor, primary dystonia) are a debilitating group of conditions that are progressive in nature. The mainstay of treatment is best medical therapy; however, a number of surgical therapies are available, including deep brain stimulation. Economic evaluations are an important aspect of evidence to inform decision makers regarding funding allocated to these therapies.ObjectiveThis systematic review and meta-analysis evaluated the cost effectiveness of including deep brain stimulation compared with best medical therapy for movement disorder indications in the adult population.MethodsOvid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials were queried. Only economic evaluations reporting incremental cost-effectiveness ratios for including deep brain stimulation versus best medical …

Bien expliquer le concept de l’excellence du rende ment dans le domaine chirurgical n’est pas chose simple, et ce qui définit précisément une personne hyperperformante peut faire l’objet de débats. Cela dit, on retrouve souvent les éléments suivants: une excellente capacité à résoudre des problèmes, une communication efficace, de l’autonomie, une capacité d’adaptation, de la flexibilité et une motivation intérieure ferme. En règle générale, les personnes hyperperformantes maintiennent une attitude positive, sont axées sur l’atteinte des objectifs, font preuve d’une grande constance dans les efforts qu’elles déploient, sont ouvertes à la critique constructive de sources fiables ou de confiance, possèdent un ensemble de compétences établies dans un domaine spécifique, sai sissent fréquemment des occasions de croissance profes sionnelle, et terminent toujours les projets qu’elles commencent. Bien qu’il soit …

ObjectiveAssessment of the certainty of evidence (CoE) from network meta-analysis is critical to convey the strength of inferences for clinical decision-making. Both the GRADE Working Group (GWG) and the CINeMA framework have been designed to assess the CoE of treatment effects informed by network meta-analysis; however, the concordance of results is uncertain.Study design and settingWe assessed the CoE for treatment effects of individual opioids on pain relief and physical functioning from a network meta-analysis for chronic noncancer pain using the GWG approach and the CINeMA framework. Both approaches evaluate the CoE as high, moderate, low or very low. We quantified the number of discrepant CoE ratings between approaches, and the magnitude of the difference (i.e., 1-level, 2-levels, or 3-levels).ResultsAcross 105 comparisons among individual opioids for pain relief, the GWG and CINeMA …

ObjectiveGiven the key role that pilot and feasibility (PAF) trials play in addressing the challenges of surgical trials, adequate reporting completeness is essential. Our aim was to assess completeness of reporting and evaluate if the items of the CONSORT extension for PAF trials have been reported in surgical PAF trials.Study DesignThis is a meta-research study reported according to PRISMA guidelines. Studies were included if they were pilot or feasibility randomized trials evaluating a surgical intervention. The primary outcome was overall adherence to the CONSORT statement extension to randomized PAF trials checklist. A Poisson regression was performed to explore the association between research factors and reporting completeness.SettingMedline, Embase, and CENTRAL were searched from January 1-December 31, 2011 and 2021.ResultsAfter screening 1,991 citations, 38 studies from 2011 and 34 …

The national identification of high performing providers in surgery is of prime importance to patients, surgeons and commissioners of healthcare. This thesis explores how high performance is identified, defined and measured nationally and attempts to identify the factors that underlie high performance in colorectal cancer surgery during the peri-operative period. An introduction into the determinants of high performance in surgery as well as defining quality as it pertains to surgery is then undertaken. Identification of available national data sources and metrics for national performance are then identified. Comparison is made between voluntary and compulsory reporting systems highlighting greater capture of peri-operative mortality in compulsory reporting datasets. A novel marker that reflects outcome following complication management is developed. This marker is based on re-operations and is derived from compulsory reporting datasets. The use of non-operative re-interventions is then assessed in oesophago-gastric cancer resections as proof of concept. An appraisal of all colorectal cancer units in England is then undertaken using a panel of metrics demonstrating that analysis on a single marker alone may be too simplistic. Identifying factors that pertain to high performance beyond those available from routinely available datasets using a novel methodological approach called HiPer (High Performance) is performed. The interview based methodology identified rich qualitative factors in a group of colorectal cancer units worldwide that may be causal in their performance status. Finally, results from the interview study were related to hard …

Evidence-based medicine demands knowledge of the best available research evidence to guide clinical decisions, which most often comes from rigorous systematic reviews and metaanalyses that identify, summarize, pool, and appraise all research evidence addressing a particular research question. While results from individual studies may appear impressive, our confidence in the body of evidence may be undermined by issues such as limitations in study designs or differences between the questions addressed in studies and the question of interest. To address such challenges, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group developed a system to evaluate the certainty (quality) of evidence—called GRADE. The GRADE approach intends to improve interpretation of evidence for decision-making [1]. The GRADE approach is applied to a body of evidence. A …

While debates in joint arthroplasty are highly popular tactics at orthopaedic conferences to entertain, they rarely provide an evidence-based strategy to resolve the controversy. How many orthopaedic meetings have you attended when “controversial issues” in orthopaedics were being discussed? Usually in these meetings, 2 speakers posit their viewpoint on a subject matter, with one in favor of the issue while another argues against it, whatever the issue may be! At the conclusion of the talks and debate, you formulate an opinion about the issue, assuming you did not have an opinion upon entering the room (which is unlikely knowing we are orthopaedic surgeons and never short of an opinion). The question that arises is how you and other attendees reach an opinion on such a matter. It appears that debates are mostly about esthetics and rarely about substance. The louder voice, better delivery of the talk, and …

BackgroundSurgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI.MethodsChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a …

BackgroundApical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.ObjectiveTo prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.MethodsIn this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test …

BackgroundBack pain is the leading cause of disability worldwide. Despite guidelines discouraging opioids as first-line treatment, opioids remain the most prescribed drugs for back pain. There is renewed interest in exploring the potential medical applications of cannabis, and with the recent changes in national legislation there is a unique opportunity to investigate the analgesic properties of cannabis.MethodsThis was a multi-center survey-based study examining patient perceptions regarding cannabis for spine pain. We included patients presenting with back or neck pain to one of three Orthopedic clinics in Ontario. Our primary outcome was perceived effect of cannabis on back pain, while secondary outcomes were perceptions regarding potential applications and barriers to cannabis use.Results259 patients participated in this study, 35.3% (90/255) stating they used cannabis medically. Average pain severity …

ObjectiveTo assess the creative potential of surgeons and surgeon trainees, as measured by divergent thinking. The secondary objectives were to identify factors associated with divergent thinking, assess confidence in creative problem-solving and the perceived effect of surgical training on creative potential, and explore the value of creativity in surgery.DesignWe used a mixed-methods design, conducting a survey of divergent thinking ability using a validated questionnaire followed by two semi-structured interviews with top-scoring participants.Participants & settingSurgeons and surgeon trainees in the Department of Surgery at McMaster University.OutcomesThe primary outcome was divergent thinking, assessed with the Abbreviated Torrance Test for Adults. Participants also self-assessed their confidence in creative problem-solving and the effect of surgical training on their creative potential. We performed …

Economic studies in healthcare are used to measure the cost and effectiveness of an intervention and are valuable in determining how healthcare resources can be distributed to achieve the greatest overall gain. Most economic studies in healthcare are cost-benefit analyses, cost-effectiveness analyses (CEAs), or cost-utility analyses (CUAs). CEAs and CUAs compare alternative interventions based on cost and effectiveness but are influenced by different methodologies and assumptions employed by researchers. The perspective from which an economic study is evaluated (the patient, the provider, the payor, or the society) should be carefully considered. The incremental cost effectiveness ratio (ICER) describes the difference between two interventions in cost and health outcomes and can be expressed in dollars per quality-adjusted life year (QALY). A threshold ICER <$50,000/QALY is often used to determine …