How Has Statistical Testing in Orthopedics Changed Over Time? An Assessment of High Impact Journals Over 25 Years.

BACKGROUND: It is important for physicians to be familiar with statistical techniques commonly used in published medical research. Statistical errors in medical literature are common, and there is a reported lack of understanding regarding statistical knowledge necessary for data interpretation and journal reading. As study design has become increasingly complex, peer-reviewed literature poorly addresses and explains the most common statistical methods utilized across leading orthopedic journals. METHODS: Articles from 5 leading general and subspecialty orthopedic journals were compiled from 3 distinct time periods. After exclusions were applied, 9521 remained, and a random 5% sampling of these articles, balanced across journals and years, was conducted yielding 437 articles after additional exclusions. Information regarding the number of statistical tests used, power/sample size calculation, type of statistical tests used, level of evidence (LOE), study type, and study design was collected. RESULTS: The mean number of statistical tests across all 5 orthopedic journals increased from 1.39 to 2.29 by 2018 (p = 0.007). The percentage of articles that reported power/sample size analyses was not found to differ by year, but the value has increased from 2.6% in 1994 to 21.6% in 2018 (p = 0.081). The most commonly used statistical test was the t-test which was present in 20.5% of articles, followed by chi-square test (13%), Mann-Whitney analysis (12.6%) and analysis of variance (ANOVA, 9.6%). The mean number of tests was generally greater in articles from higher impact factor journals (p = 0.013). Studies with a LOE of I used the highest mean number of statistical tests (3.23) compared to studies with lower LOE ratings (range 1.66-2.69, p < 0.001). Randomized control trials used the highest mean number of statistical test (3.31), while case series used the lowest mean number of tests (1.57, p < 0.001). CONCLUSIONS: The mean number of statistical tests used per article has increased over the past 25 years with the t-test, chi-square test, Mann-Whitney analysis, and ANOVA being the most used statistical tests in leading orthopedic journals. Despite an increase in statistical tests it should be noted that there was a paucity in advance statistical testing within the orthopedic literature. This study displays important trends in data analysis and can serve as a guide to help clinicians and trainees better understand the statistics used in literature as well as identifying deficits within the literature that should be addressed to help progress the field of orthopedics.

Publishing Characteristics of Foot and Ankle Research Over a 15-Year Time Interval: A Review of The Journal of Bone & Joint Surgery from 2004 to 2018.

BACKGROUND: As the foot and ankle subspecialty continues to grow in orthopaedics, trends in published literature provide valuable insights to help understand and strengthen the field. The current study evaluates the changes in the characteristics of foot and ankle articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS-A) from 2004 to 2018. METHODS: Foot and ankle-related articles in JBJS-A from 2004 to 2018 were identified and categorized by type of study, level of evidence, number of authors, academic degree(s) of the first and last authors, male and female authorship, number of citations, number of references, region of publication, and use of patient-reported outcomes (PROs). RESULTS: A total of 336 foot and ankle articles from 2004 to 2018 were reviewed. The type of study published has changed over time, with more clinical therapeutic evidence and less case reports. The level of evidence grades, as rated by JBJS-A and objective evaluators, have increased over the past 15 years. The total number of authors per article has increased, and female authorship has increased significantly. The number of references per article has increased, and the number of citations per year has decreased. The field of foot and ankle surgery has seen an increase in global publications. CONCLUSIONS: The results of this study suggest that the foot and ankle literature that has been published in JBJS-A has continued to increase in quality and diversity over the past 15 years.

Outcomes of Tibiocalcaneal Arthrodesis in High-Risk Patients: An Institutional Cohort of 18 Patients.

INTRODUCTION: Tibiocalcaneal (TC) arthrodesis is commonly performed in patients with severe hindfoot disease. These include severe Charcot deformities, ankle malformations, chronic osteomyelitis (COM), and avascular necrosis (AVN). The talar vascular becomes disrupted to the point that the bone can no longer be salvaged. The procedure involves performing a talectomy and fusing the tibia to the calcaneus. This helps in preserving the remaining hindfoot anatomy, while allowing the patient to regain function and mobility. Our study highlights certain risk factors that influence the rate of postoperative complication after tibiocalcaneal surgery. MATERIALS AND METHODS: We retrospectively reviewed the charts of 18 patients from a single institution who underwent tibiocalcaneal between the years of 2011 and 2019. Preoperative diagnoses, comorbidities, and post-operative outcomes were noted among all patients. Then, the rates of non-union, below-knee amputations, revision surgeries, postoperative infections, and hardware failure were recorded. These data were then analyzed to determine which preoperative and perioperative factors affected postoperative outcomes for patients after tibiocalcaneal arthrodesis surgery. RESULTS: Nonunion was the most commonly reported complication in this series. Eight of the eighteen patients were documented to have nonunion including three patients with stable pseudarthrosis. Diabetic patients had a slightly higher incidence of nonunion (4 of 7 patients) compared to those without diabetes (4 of 11 patients). Of the nine patients diagnosed with Charcot arthropathy, five had nonunion. Three of the five individuals with a BMI ranging from 25 to 30, and four of the six individuals with a BMI of greater than 30 had a nonunion. Infection was a post-operative complication for four of the eighteen patients. Two of the four patients had multiple comorbidities in addition to chronic infections in the joint which were recurrent after surgery. CONCLUSION: In conclusion, TC arthrodesis provides a viable option for high-risk patients with complicated ankle pathology who have not had successful outcomes from previous treatment. It is not without complications considering the comorbidities the patients present with before requiring this procedure. Further studies are necessary to validate the trends of outcomes and comorbidities of patients with TC arthrodesis.