MacOrtho Advocates for Worldwide Research on Domestic Violence
The following is an automated translation of an article published in Diario Medico.
The services of orthopedic surgery and traumatology: watchmen of the macho violence
Research in surgery lags far behind that of other medical specialties, but in recent years the picture is changing and more surgeons are conducting quality research under the principles of evidence-based surgery. One of the main drivers of evidence-based surgery in orthopedic surgery and traumatology is Mohit Bhandari, academic director of this specialty at McMaster University in Hamilton, Canada. He runs a research program that has set the design requirements and methodology of clinical trials in this field and has promoted more than 900 studies with hospitals in 30 countries. Bhandari recently co-directed a course on surgical research at the Hebron Valley Hospital (VdH) in Barcelona. It speaks first of one of its lines of investigation: the macho violence, the main cause of non-mortal injuries in women around the world. "Our goal is to have the best evidence about its incidence in the orthopedic surgery services, because in many cases we do not know the origin of these injuries, so that we can take better care of the abused women."
It is worth noting that intimate-partner violence (IPV) studies show that "one out of every six women attending have been victims of IPV in the last year and that this is the direct cause of bone fractures in 1 in 50 cases." This was observed in the Praise study, published in The Lancet, which had about 3,000 consecutive patients from 12 orthopedic surgery and traumatology services from Canada, the United States, the Netherlands, Denmark, and India. Ernesto Guerra, deputy of Traumatology at the VdH and co-director of the course, laments that "in Spain we do not have prospective studies of this type," but announces that his hospital could participate in a second phase of the Praise.
According to Bhandari, the challenge is for orthopedic surgeons to "lead" IPV injury detection, "since we are in a privileged position to do so. Most women do not reveal anything about the origin of their injuries in the ER. However, her relationship with the orthopedic surgeon is longer, so we must take advantage of that second chance."
To promote it, it calls for specific training in this area, "which will help us to be more vigilant and to know how to ask women about what they feel and about their relationship." In fact, another international study by his team, the Positive, indicates that three out of four women seen in orthopedic surgery and traumatology services believe they should be asked about this type of violence.
A third indispensable element are the instruments for detecting cases, such as protocols and guidelines for action, "of which not all centres are available," as well as working together with social services.
Opening the focus to surgical research, it recognizes that it lags behind that developed by clinical specialties, which adopted "a decade earlier" principles of evidence-based medicine. In addition, the learning of surgery has historically been based on pupillary and manual and technical skill, a scenario in which research was relegated. "But for years we have known that, beyond skill, we need the best scientific evidence to fine-tune our decision-making."
In this sense, Ernesto Guerra recalls that, "according to estimates, only 60 percent of treatments of medical specialties are justified in the scientific evidence – a percentage that drops to 30 percent in the case of surgery." However, in the last decade surgical research has taken a step forward with the intensification of the training of surgeons in this area and their commitment to CBE, the methodological rigor and the size of the series evaluated.
"In fact," notes Bhandari, "some of the great trials underway are surgeon-driven." This is the case of Inormus, which is part of the WHO priority to know the burden of musculoskeletal injuries caused by traffic accidents in developing countries. Also sponsored by the McMaster team, this trial will recruit 40,000 patients from Africa, Asia and Latin America to determine mortality and reintervention and infection rates within 30 days of hospital admission.
Obviously, the traumatic patient - "especially the polytraumatic one, whose therapeutic management is still subject to many doubts", points out Guerra - is the main subject of the surgical investigation. Not surprisingly, trauma is the leading cause of death in the first three decades of life. The other major research topic is osteoporosis fractures in elderly patients.
In this field, Bhandari underlines the evidence provided by the recent Faith study on displaced femoral neck fractures. More than a thousand patients have compared the effectiveness of hip-sliding screw implantation and conventional treatment with the exclusive use of cannulated screws. Another example is the Sprint trial on tibial diaphyseal fractures. This work confirms that the treatment of choice is the endomedular nailing milling (on non-milling).
They are two reference examples of what this dynamic of global surgical research advocates: the evolution from "eminence-based to evidence-based orthopedic surgery." It has three partners: the evidence-based vision as a priority for the current surgical community, training in research of orthopedic traumatologists and orthopedic surgeons worldwide and international collaboration. "When we commit globally to respond to the questions our clinical practice poses to us beyond inertia, evidence-based surgery takes off," says Mohit Bhandari.
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