Níveis de evidência da cirurgia de joelho em periódicos nacionais

rev bras ortop.2014;49(1):13–16

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Review

Article

Level

of

evidence

of

knee

surgery

in

national

journal

夽

,

夽夽

Davi

Araújo

Veiga

Rosário

_,

_Guilherme

_Conforto

_Gracitelli,

Marcus

Vinícius

Malheiros

Luzo,

Mario

Carneiro

Filho,

Moisés

Cohen,

Carlos

Eduardo

da

Silveira

Franciozi

DepartamentodeOrtopediaeTraumatologia,EscolaPaulistadeMedicina,UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil

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Articlehistory:

Received28February2013 Accepted13May2013

Keywords:

Evidence-basedmedicine Knee

Bibliometricindicators

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SelectthestudiesrelatedtokneesurgeryintheorthopedicliteraturepublishedbyActa OrtopédicaBrasileira(AOB)andtheRevistaBrasileiradeOrtopedia(RBO)andclassifythem accordingtothelevelsofevidence.Weselectedallstudiespublishedfrom2000to2011 relatedtokneesurgeryinAOBandRBO.Thefollowingcategorizationwasadopted:level 1:systematicreview;level2:clinicaltrial;level3:cohortstudiesandcase–control;level4: numberofcases;level5:narrativereviewandothers.Wefoundinthenationalliterature selected255studiesrelatedtokneesurgery.IntheSoutheastweredeveloped212articles (83.1%),30publicationsintheSouth(11.7%),Northeast5(2%),NorthandCentralWest2jobs each(0.8%).Fourworkperformedinothercountry(1.6%).Themostcommonissuewasthe anteriorcruciateligamentin58studies(22.7%)andarthroplastyin55studies(21.5%).Most studiespresentedevidencelevelIV(27.8%)andV(50.2%).Thenationalscientific produc-tionrelatedtokneesurgerypresentsitselfexpandingwithpredominantexpressioninthe Southeast.Moststudiesrelatedtokneesurgerypublishedinnationaljournalshavelowlevel evidenceandfocusesontheapproachoftheanteriorcruciateligamentandarthroplasty.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Níveis

de

evidência

da

cirurgia

de

joelho

em

periódicos

nacionais

Palavras-chave:

Medicinabaseadaemevidências Joelho

Indicadoresbibliométricos

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Selecionarosestudosrelacionadosàcirurgiadojoelhopublicadosnaliteraturaortopédica nacionalpormeiodaActaOrtopédicaBrasileira(AOB)edaRevistaBrasileiradeOrtopedia (RBO)eclassificá-losdeacordocomosníveisdeevidência.Foramselecionadostodosos estudospublicadosde2000a2011.Aseguintecategorizac¸ãofoiadotada:nível1-revisão sistemática;nível2-ensaioclínico;nível3-estudosdecoorteecaso-controle;nível4-série decasos;nível5-revisãonarrativaeoutros.Foramencontrados255.NaregiãoSudesteforam 212artigos(83,1%),naSul30(11,7%),naNordestecinco(2%),naNorteenaCentro-Oeste doiscada(0,8%).Quatrotrabalhosforamdesenvolvidosnoexterior(1,6%).Otemamais

夽_{Pleasecitethisarticleas:RosárioDAV,GracitelliGC,LuzoMVM,FilhoMC,CohenM,FrancioziCEdaS.Níveisdeevidênciadacirurgia}

dejoelhoemperiódicosnacionais.RevBrasOrtop.2014;49:13–16. 夽夽

StudyconductedatKneeGroup,DepartmentofOrthopaediaandTraumatology,EscolaPaulistadeMedicina,UniversidadeFederalde SãoPaulo,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:daviveiga@hotmail.com(D.A.V.Rosário).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

14

comumfoiligamentocruzadoanterior,em58estudos(22,7%),eartroplastias,em55estudos (21,5%).AmaiorpartedosestudosapresentouníveldeevidênciaIV(27,8%)eV(50,2%).A produc¸ãocientíficanacionalrelacionadaàcirurgiadojoelhoapresenta-seemexpansão, compredomíniodeexpressãonaregiãoSudeste.Amaioriadosestudostembaixonívelde evidênciaeconcentra-senaabordagemdoligamentocruzadoanterioredasartroplastias. ©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

The concept of evidence-based medicine (EBM) was introduced in 2001 and since then has raised the inter-est of the scientificcommunity.1 _{These concepts began to} appearinmajorconferencesandsymposiafrom2003.2,3

Unlike traditional medicine, this new branch is not groundedinintuition,inunsystematicclinicalexperiencenor inpathophysiologicalrationale assufficientreasons forthe processofclinicaldecision-making.Evidence-basedmedicine requiresnewskillsofthephysician,includingknowledgeof researchinthe literature,theirtoolsand the evaluationof clinicalevidence.Therewasanincreaseintheproductionof articlesthatinstructthephysicianonhowtoaccess,evaluate andinterpretmedicalliterature.3,4_{Thiscriticalsensebecomes} mandatory,consideringthelargenumberofpublicationsand frequentmethodologicalpitfallswhichmayleadthereader tomisleadingandpotentiallydangerousconclusionsforhis orherclinicalandsurgicalpractice.5,6

Theorthopedicliteraturefollowedthelineofinternational publicationsinthesearchofbetterlevelsofevidenceinthe publications,and themethodologicalquality ofthe articles begantobeanalyzedundermorerigorouscriteria.4_However, todate,thenationalliteraturelackscriticalstudiesoflevelsof evidenceinorthopedicsandtraumatology.

Inthepresentstudy,wecarriedoutareviewwiththeaim ofselecting articles related to knee surgeryand published from2000to2011inthenationalorthopedicliteraturebyActa OrtopédicaBrasileira(AOB)andRevistaBrasileiradeOrtopedia (RBO),andclassifythemaccordingtolevelsofevidence.These twojournalswerechosenbecauseoftheirinsertionintothe nationalscenarioandalsoforbeingindexed,viaSciELO,asan internationalbibliographicdatabase.

Secondaryvariablestobeobserved:thenumberofstudies publishedperyear,theregioninwhichtheyweredeveloped, andthemainissueaddressedinthestudy.

Materials

and

methods

For evaluation, this review has taken into consideration studiespublishedinthenationalorthopedicliterature:Acta OrtopédicaBrasileira(AOB)andRevistaBrasileirade Ortope-dia(RBO).Allpublishedstudiesfrom2000to2011relatedto kneesurgerywereselected.

Theinclusioncriteriawere:kneesurgery-relatedstudies, selectedmanuallyinthepublishededitionscontaininginthe title:knee, distalfemoralandproximaltibialfracture,knee arthroscopy,meniscus,anteriorcruciateligament,posterior cruciateligament,patella,posterolateralcomplexorcorner,

knee arthroplasty, and knee biomechanics.Exclusion crite-riawerearticleswithtopicsnotrelatedtokneesurgery.This studywasapprovedbytheresearchethicscommittee (num-ber:120,790).

Theidentificationofthestudieswaselectronicallydone, editionbyedition,byidentifyingthoseitemswhichfitinthe inclusion criteria. Anewselectionwasmade basedon the summaryandonthefulltext.Doubtsintheselectionof arti-cles were resolved byconsensus betweentwo researchers, DavidRosarioVeigaandGuilhermeAraújoConfortoGracitelli (DAVRandGCG).Havingpersistenceofdoubt,athirdreviewer was consulted:Carlos Eduardo da Silveira Franciozi(CESF). Aftertheidentification ofthestudies,tworeviewers(DAVR andGCG)independentlycollectedthequalitative characteris-ticsofthestudies:journal(AOBandRBO),yearofpublication (before2005andbefore2011)andregionofthecountrywhere theywereconducted.

Afterselection,theitemswerecategorizedbytworaters according tolevelofevidenceand typeofstudy.The cate-gorization wasmadeafterthe readingoftheentirearticle. Thefollowingcategorizationwasadopted:level1–systematic review,level2–clinicaltrial;level3–cohortandcase–control studies,level4–numberofcases;level5–narrativereviewand others(example:abiomechanical,anatomical,ofaccuracy,or ofbasicsciencestudy).Thepossibledoubtsonthe categoriza-tion ofarticleswere resolvedbyconsensusbetweentwoof theresearchers(DAVRandGCG).Havingpersistenceofdoubt, athirdreviewerwasconsulted(CESF).

Thedescriptionsofthearticlesweremadewiththeuseof absoluteandrelativefrequenciesforpresentationofdataby yearofpublication,regionofthecountry,mainthemeofthe article,andtypeofstudy.Theresultsareillustratedgraphically forpresentation.Thedescriptivestatisticalanalysiswasdone usingtheExcel2007program.

Results

The evidence-based medicine requires concern, bypart of researchers,regardingthequalityofthestudies.From2000 to2011255studiesrelatedtokneesurgerywerefoundinthe nationalliteratureevaluated.

Overtheyears,weobservedanincreasingnumberof pub-licationsinnationaljournals(Fig.1).In2000,only11papers related tokneesurgeryinthe nationalliteraturewere pre-sentedtothescientificcommunity;thisnumberreached26 in2005and50in2011.

r e v b r a s o r t o p . 2014;49(1):13–16

15

0

2000 2002 2004 2006 2008 2010

10 20 30 40 50

Fig.1–SumofpublicationsonkneeinAOBandRBO journals.

SE, Southeast, NE, Northeast, ST, South, NO, North, MW, Midwest, INTER, International. 83.10%

2%

SE NE ST NO MW INTER 11.70%

0.80%0.80% 1.60%

Fig.2–Scientificproductionbyregion.SE,Southeast;NE, Northeast;ST,South;NO,North;MW,Midwest;INTER, International.

each(0.8%).Fourprojectsdevelopedabroadwerepublishedin nationaljournals(1.6%).

Regardingthemaintopicapproached,itbecameclearthe interestinpublicationson thetopics“anterior cruciate lig-ament”,with58studies(22.7%),and“arthroplasty”,with55 studies(21.5%).Otherissueshavethedistributionshownin

Fig.3.

Fig.4illustratesthelevelofevidenceoftheselectedstudies. MostofthestudiespresentedevidencelevelIV(27.8%)andV (50.2%).Fig.5showsthesubdivisionoflevelVstudies.

Discussion

Theanalysisofthenationalliterature,insearchofpapers pub-lishedonthesubject“kneesurgery”,demonstratedasimilar trendtotheinternationalliterature,withincreasingscientific productionover the years.6,7 _{In 2000, 11 paperswere} pub-lished,increasingto26in2005andto50in2011.Thisstimulus toscientific production can beexplained by an increasing demandforevidencetojustifytheapplicationofatherapeutic

GFT 4.7% PCL 3.0% OCL 3.0%

TEND 1.0%

PLC 0.3%

FX 4.7%

ME 4.7%

OT 5.0%

PL 5.0%

PI 5.4%

TU 6.0% _OST

6.0%

OA 7.0%

ARTHRO 21.5%

ACL

22.7% ACL: anterior cruciate ligament, ARTHRO: arthroplasty, OA: osteoarthritis, OST: osteotomy, TU: tumor, PI: patellar instability, PL: patellar lesion, OT: other themes, ME: meniscus, FX: fracture, GFT: graft, PCL: posterior cruciate ligament, OCL: osteochondral lesion TEND: tendonitis, PLC: posterolateral complex.

Fig.3–Mainthemeaddressedinthestudy.ACL:anterior cruciateligament,ARTHRO:arthroplasty,OA:osteoarthritis, OST:osteotomy,TU:tumor,PI:patellarinstability,PL: patellarlesion,OT:otherthemes,ME:meniscus,FX: fracture,GFT:graft,PCL:posteriorcruciateligament,OCL: osteochondrallesion,TEND:tendonitis,PLC:posterolateral complex.

0.8%

LEVEL I

LEVEL II

LEVEL III

LEVEL IV

LEVEL V 12.2% _9.0%

27.8%

50.2%

Level I, systematic review; Level II, clinical trial, Level III, case control/cohort; Level IV, case series, Level V, other types.

Fig.4–Levelofevidencefromstudies.LevelI,systematic review;levelII,clinicaltrial,levelIII,casecontrol/cohort; levelIV,caseseries,levelV,othertypes.

23.4%

Case report

Narrative review Biomechanics

Accuracy Anatomy Transverse

Basic science

21.0% 19.0%

10.1% _9.5%

8.5% 8.5%

Fig.5–StratificationofevidencelevelV.

method.Inthepast,anexpertopinionwassufficientforthe adoptionofatreatmentprotocol.

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theyareoflowcostanddependonlittleplanning/prior knowl-edge.Thesestudiescanbepartoftheroutineofthehealthcare team,andgenerallydonotrequirelongfollow-ups,andcan beconductedinashorttime.1,8

Itshouldbeborneinmindthatopenobservational stud-iesarealsoimportant,especiallyintheearlystagesoftesting anewintervention;thesestudiescanprovidevaluable infor-mationforpatientcare.However,inthiscase,itiscrucialthat elaboratetechniquesfordataanalysisbeused,with construc-tionofmultivariateregressionmodelstocontrolforpotential confoundingfactors.5,7 _{Itisrecommended thattheauthors} makeeveryeffort anduse acontrolgroupintheirstudies, sincethis practicecansubstantially raisethe ratingofthe levelofevidenceandimprovetheconfidencewithwhichone canapply theinformationobtainedtoclinicaland surgical practice.6

A secondary endpoint showed great difference in rela-tion to the scientific production in the various regions of ourcountry.Thisdifferencehasalreadybeenmentionedin otherpapersofthenationalliterature,thatalwaysviewedthe Southeastregion(83.1%)asthenationalscientificproduction center,followedbytheSouth(11.7%).8_{Thisfindingshouldbe} viewedasanincentivetotheotherregions,toincreasetheir scientificproductionandfollowthetrendofthenationaland internationalliterature.

Anothersecondaryvariableindicatesthepreferenceofthe conductionofscientificwork onanterior cruciateligament (22.7%)andkneearthroplasties(21.5%)themes.Theenormous scientificliteraturethataddressestheseissuesmayexplain theimprovementoftechniques,intherapeuticoptions,and inthe prevalenceofincreasingly satisfactory postoperative resultsovertheyears.

Thelimitationsofthisstudyisthepossibilityofpublication ofworks relatedtoknee surgeryinother nationaljournals thatwerenotinvestigated,andthepossibilityofpublication ofstudiesdevelopedinBrazilininternationaljournalswith higherlevelofevidence.

Conclusion

Thenationalscientificproductionrelatedtokneesurgeryhas beengrowing,withpredominantexpressionintheSoutheast region.

Mostofthe studiesrelatedtokneesurgerypublishedin nationaljournalshavelowlevelofevidenceandconcentrate ontheapproachtotheanteriorcruciateligamentand arthro-plasty.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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