Urban Legends versus Evidence-Based Medicine in Total Joint Arthroplasty
At ICJR’s recent Winter Hip & Knee Course, faculty undertook the challenge of identifying the aspects of total joint arthroplasty that are based on sound evidence and those that have taken on the quality of an urban legend. Dr. Bryan Springer provides an overview that sets the stage for articles that will be published throughout this month.
The vanishing hitchhiker
The killer in the back seat
The babysitter and the calls coming from inside the house
Urban legends, each and every one.
Just as there are urban legends – fictional tales that become deeply rooted in popular culture – in everyday life, there are plenty of urban legends in total joint arthroplasty, said Bryan D. Springer, MD, at ICJR’s Winter Hip & Knee Course.
The antidote to urban legends, he said, is evidence-based medicine (EBM) and practice guidelines. But data suggest that EBM and practice guidelines are followed less than 50% of the time.
For example, the evidence is overwhelming that using press-fit stems to treat femoral neck fractures dramatically increases the risk of periprosthetic fracture (13.5 times’ higher risk).  Yet in the US, surgeons predominantly use cementless stems in these patients regardless of patient age. In contrast, the practice of prescribing oral antibiotics for patients who have undergone a 2-stage exchange procedure was quickly adopted following publication of a study showing it reduces the reinfection rate from 20% to 5%. 
How surgeons practice medicine is likely driven by a number of factors, the primary one being what they are taught during residency and fellowship, Dr. Springer said. Later in their careers, they are influenced by practice patterns, their partners, industry promotions, and professional meetings. Unfortunately, many of the beliefs and practices that have become entrenched in healthcare may not be based in science – it’s possible they continue to be done simply because they have been done the same way for years.
The concept of EBM was developed in 1980 to help determine what is sound medical evidence based on the quality of the underlying studies. Dr. Springer quoted Dr. David Sackett, who in 2000 described EBM as, “the integration of best evidence with our clinical expertise and our patients’ best unique values and expertise.”
But today’s EBM may be tomorrow’s malpractice. In 2014, Dr. Karen Sibert described how European research led to the mandated use of beta-blockers prior to surgery, a practice that may have led to thousands of deaths in Europe over a 5-year period. 
And not all research is Level I evidence. In fact, more than half of the most-cited articles in the orthopaedic literature are Level IV evidence. But as Dr. Seth Leopold said in an editorial published in 2013, a good retrospective case series may serve as the backbone for future research – and while it may not drive innovation it may warn against it. 
Click the image above to watch Dr. Springer’s presentation. And check back Tuesday through Friday for more discussions of EBM and urban legends in the preoperative, intraoperative, and postoperative periods of total joint arthroplasty.
Dr. Springer has no disclosures relevant to this presentation.
- Tejwani NC, Immerman I. Myths and legends in orthopaedic practice: are we all guilty? CORR 2008 Nov;466(11):2861-72. doi: 10.1007/s11999-008-0458-2
- Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32,644 primary total hip arthroplasties: a 40-year experience. Bone Joint J.2016 Apr;98-B(4):461-7. doi: 10.1302/0301-620X.98B4.37201.
- Frank JM, Kayupov E, Moric M, el al. The Mark Coventry, MD, Award: Oral antibiotics reduce reinfection after two-stage exchange: A multicenter, randomized controlled trial. CORR. 2017 Jan;475(1):56-61. doi: 10.1007/s11999-016-4890-4.
- Sibert KS. The dark side of quality. Anesthesia Business Consultants, Spring 2014.
- Leopold SS. Editorial: Let’s talk about Level IV: The bones of a good retrospective case series. CORR. 2013 Feb; 471(2): 353–354. Nov 21. doi: 10.1007/s11999-012-2703-y