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Further thoughts on orthopedic guidelines
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 Augusto Sarmiento |
In the August 2010 issue of a peer-reviewed journal, I published an article I titled “Thoughts on Orthopaedic Guidelines,” in which I expressed concerns regarding what I considered a premature release of a guideline for fractures of the distal radius. I based my concerns on a superficial understanding of the guideline as published in the American Academy of Orthopaedic Surgeons’ newsletter 1 month earlier. I concluded that in its present form, the guideline might lead to complacency or encouragement to litigation. To me, it appeared to be a “mandate” rather than “advice.”
Worried that in my haste to express my views on the subject I may have been wrong, I proceeded to obtain the entire document prepared by the task force that formulated the now official guideline. I went over the 191 pages of the document by reading what I thought was pertinent and glancing at tables and charts.
Bias
The newly acquired knowledge did nothing but reinforce my original concerns. I continue to hold the strong feeling that the guideline, as presented, is biased to a significant degree, and that the reported evaluations that led to the conclusions are not as solid as suggested by the authors. I counted approximately 963 articles the authors of the guideline allegedly studied. From these, 96 were included in their final report while approximately 867 were excluded as not meeting the necessary criteria. However, a casual glance at the “included” articles show that at least 30 were unrelated to the subject of wrist fractures and dealt with views on methods of statistical analysis, while others were either descriptions of techniques in fracture management, or observations of correlations between fractures of the spine or hip with wrist fractures. Two articles dealt with the use of vitamin C in the care of fractures and both were written by the same person. In summary, the number of articles with documentation that was evidence-based was, in my opinion, very small and the overall conclusions apparently biased.
Disclosure
Although claims are made regarding the lack of conflict of interest among the authors of the guideline, several of them acknowledged association with surgical implant industries that might have, consciously or unconsciously, affected their views.
I close with a quotation from my original article, “I suggest we pause before rushing into an attempt to establish guidelines for every conceivable condition. Let us look carefully at the issue at hand and decide if the current trend is a sound one; if what some consider a problem is really a problem or a non-existing one. Are we just proposing change for the sake of change and doing something that will not be an improvement over what we already have, and end-up confronting non-anticipated consequences? Neither the Academy, journals, educational organizations, nor subspecialty societies are bodies created to dictate medical practices. They simply are avenues to disseminate knowledge, something that until now they have done in a creditable way. Let us encourage them to continue to improve their efforts.”
Reference:
- Sarmiento A. Thoughts on Orthopaedic Guidelines. Am J Orthop. 2010; 39(8):373-374.
- Augusto Sarmiento, MD, is a past president of the American Academy of Orthopaedic Surgeons. He can be reached at the Dept. of Orthopaedics and Rehabilitation, University of Miami School of Medicine 13-27, P.O. Box 016960, Miami, FL 33101; 305-666-3310; e-mail: asarm@bellsouth.net.
