Research Agenda
The Netherlands Orthopaedic Association (NOV), revised her Orthopaedic Research Agenda including her top priorities regarding Health Care Evaluation. In this new orthopaedic research agenda 2019-2022 we address unanswered questions. The focus is on addressing uncertainties about the effects of a treatment (healthcare evaluation) but also innovation is included.
Orthopaedics keeps people moving, from young to old, that is the mission of the Netherlands Orthopaedic Association (NOV). Based on this principle, the NOV encourages its members to provide orthopaedic care that is of excellent scientific quality, that is effective and that is offered with compassion. Furthermore, the NOV explicitly included in its strategic plan that orthopaedic care should be evaluated and developed further based on the outcomes of scientific research with an international appeal. In this context, the project “Health Care Evaluation Orthopaedics” was started to create an inventory of where evaluation of care is necessary in order to guarantee an even better quality of care for the patient based on scientific substantiation.
At the moment, many recommendations in guidelines have a low level of scientifically substantiated evidential value. As it is not always possible to substantiate all procedures with level I-II evidence-based methods, there is room for improvement from the patient’s perspective, which would clarify the added care value for him or her. The project “Health Care Evaluation Orthopaedics” resulted in an agenda prioritised unanswered questions from the daily practice of the patient and the orthopaedic surgeon. Scientific research is then the method to obtain answers to these questions. These scientific insights result in improved insights in the various diagnostic and treatment pathways, which enables the patient and the doctor to make a better choice.
For more information in English on the topic Health Care Evaluation in the Netherlands we recommend the Advisory Report Health Care evaluation – From project to process. A product of the Health Care Evaluation Steering committee 2016, Federation of Medical Specialists, The Netherlands.
We also published an English summary of the approach/methodology and our prioritised unanswered questions 2015-2018.
Would you like more information on the prioritised questions or are you interested in collaboration on one of the topics, please contact the research coordinator of the Netherlands Orthopaedic Association: CORE@orthopeden.org or call +31 (0)73 700 34 10
Orthopaedics keeps people moving, from young to old, that is the mission of the Netherlands Orthopaedic Association (NOV). Based on this principle, the NOV encourages its members to provide orthopaedic care that is of excellent scientific quality, that is effective and that is offered with compassion. Furthermore, the NOV explicitly included in its strategic plan that orthopaedic care should be evaluated and developed further based on the outcomes of scientific research with an international appeal. In this context, the project “Health Care Evaluation Orthopaedics” was started to create an inventory of where evaluation of care is necessary in order to guarantee an even better quality of care for the patient based on scientific substantiation.
At the moment, many recommendations in guidelines have a low level of scientifically substantiated evidential value. As it is not always possible to substantiate all procedures with level I-II evidence-based methods, there is room for improvement from the patient’s perspective, which would clarify the added care value for him or her. The project “Health Care Evaluation Orthopaedics” resulted in an agenda prioritised unanswered questions from the daily practice of the patient and the orthopaedic surgeon. Scientific research is then the method to obtain answers to these questions. These scientific insights result in improved insights in the various diagnostic and treatment pathways, which enables the patient and the doctor to make a better choice.
For more information in English on the topic Health Care Evaluation in the Netherlands we recommend the Advisory Report Health Care evaluation – From project to process. A product of the Health Care Evaluation Steering committee 2016, Federation of Medical Specialists, The Netherlands.
We also published an English summary of the approach/methodology and our prioritised unanswered questions 2015-2018.
Would you like more information on the prioritised questions or are you interested in collaboration on one of the topics, please contact the research coordinator of the Netherlands Orthopaedic Association: CORE@orthopeden.org or call +31 (0)73 700 34 10
Health care evaluation questions
| Adolescent idiopathic scoliosis (AIS): is standard radiological follow-up necessary? If so, at which frequency? |
| Prioritised 13x (10x NOV member, 3x patient representative) There is no recent guideline for this subject. Approximately 2-3% of children in the Netherlands aged between 10 and 18 years has adolescent idiopathic scoliosis (AIS). Both the conservative and the surgical treatment are usually followed up by conventional X-ray imaging. There is no scientific evidence to support this follow-up. At the moment, this young population is frequently exposed to (X-ray) examinations. It is not known how frequently and for what length of time this follow-up is required to confirm progression or post-operative complications (1). In addition, the question remains whether this follow-up using X-ray imaging is necessary, or whether there are suitable alternatives. Based on the currently available experimental research, alternatives could include an ultrasound examination (2).
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| Reduced distal radius fractures: lower rates of secondary fracture dislocation following treatment with a circular cast than with a plaster splint? |
| Prioritised 12x (10x NOV member, 2x stakeholder) Is linked to the guideline on Distal Radius Fractures The question is whether repositioned distal radius fractures in patients of all ages - treated with a circular cast instead of a splint - exhibit lower rates of secondary fracture dislocation, resulting in lower rates of surgery, fewer complications and lower costs. Twenty percent of all fractures are localised in the distal radius (1). Dislocated distal radius fractures are usually reduced in the Accident and Emergency department and immobilised by a cast on the forearm. This forearm cast is applied either as a circular cast, or as a splint. The Guideline on Distal Radius Fractures does not state a preference for either casting method (2). A recent survey revealed that a splint is fitted in 69% of Dutch hospitals and a circular cast in 31% of Dutch hospitals. Reduced distal radius fractures exhibit secondary fracture dislocation in 36% of the patients (3). In the past, a second attempt to reduce the fracture often took place, but nowadays surgery is more commonly performed. A previous study with inclusion of 72 patients revealed that the position of the fracture is maintained more effectively by a circular cast than by a plaster splint (4). Better evidence is required to answer this unanswered question. Whilst this health care evaluation query - use of a circular cast - aims to prevent secondary dislocation of a repositioned distal radius fracture in patients of all ages, the ongoing DART study (SEENEZ) aims to answer the question about what is the best treatment of secondary dislocated intra-articular distal radius fractures in patients over the age of 65 years.
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| Dislocations of the proximal interphalangeal joint: does functional follow-up treatment result in improved functioning and fewer symptoms than treatment with buddy tape? |
| Prioritised 7x (5x NOV member, 1x patient representative, 1x stakeholder) Is linked to the guideline on Hand Fractures (NVvH, draft) The use of buddy taping compared to an extension block splint for PIP dislocation was examined in a randomised study. Immediate exercising of the fingers in buddy tape yielded at least comparable results to immobilisation of the fingers (1). Therefore, the working group specified the question to compare buddy taping to immediate exercising. This question has a high priority, because dislocations of the proximal interphalangeal (PIP) joint belong to the most common hand injuries. This can cause chronic pain, stiffness, deformities and premature arthritis (2). Being able to prevent this results in reduced invalidity for the patient and lower costs for absenteeism from work. The treatment of PIP dislocations is not clear-cut and varies from surgical repair of the volar plate to immediate exercise without protection. Previous studies have compared various methods and immobilisation periods in a (quasi) randomised manner. These were included in a Cochrane review. The conclusion was that there is insufficient evidence to determine the best treatment for PIP dislocations (3). Another study involving patients with a PIP dislocation compared immediate exercise with immobilisation. This quasi-randomised study with moderate follow-up found no difference between both groups (4). In conclusion, the time is ripe for a well-designed study in which patients with a PIP dislocation are randomised between immediate exercise and treatment with buddy tape.
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| Hip dysplasia (DDH): whether or not to use hip splinting treatment for children with mild Graf Type II hip dysplasia? |
| Prioritised 23x (19x NOV member, 4x patient representative) Is linked to the guidelines: 1. JGZ – hip dysplasia, 2018 2. Hip dysplasia, under development DDH occurs in 1 out of every 1,000 live births. In the Netherlands, 1 to 4% of infants develops DDH before the age of 6 months (1). Inadequate treatment of DDH can result in pain, invalidity and/or early onset hip arthritis in adulthood. By contrast, mild DDH can develop into a normal hip joint spontaneously. DDH is diagnosed by means of ultrasound examination before the age of 9 months, using the Graf classification (2). This unanswered question concerns mild Graf Type 2 DDH. There is no international consensus for the treatment of this group. The NOV Working Group on Paediatric Orthopaedics has over the past year developed a uniform treatment flow chart for the treatment of DDH during the first year of life. The observation that mild DDH can develop into a normal hip joint without treatment, but with accurate follow-up, requires further investigation. The NOV has started a project group to answer this question. The NOV will further elaborate this question together with the Radiological Society of the Netherlands, Physicians for Youth Healthcare in the Netherlands (AJN) and the Association for Abnormal Hip Development (VAH).
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| Patients with a total hip prosthesis, 5 years after the operation: which frequency of clinical and/or radiological follow-up is required? |
| Prioritised 6x (4x NOV member, 2x patient representative) Is linked to the guideline on Total Hip Prosthesis At the moment, approximately 28,000 total hip prostheses are fitted each year (1). The current guideline on Total Hip Prosthesis recommends routine follow-up by an orthopaedic surgeon (2). However, in the past 15 years of guideline development, it has not been possible to answer the question about the desired follow-up for total hip prostheses after 5 years based on scientific evidence. The research into this topic is limited both in quantity and generalisability (3-8). In addition, there appears to be significant practice variation and the outside world (insurance companies, Healthcare Institute) is demanding standpoints. In addition to the frequency of the long-term follow-up after a total hip prosthesis, there are more questions about this follow-up. Examples include: is a “return if experiencing symptoms” policy sufficient? Is a combination of PROMs and X-ray sufficient? And which health care professional should see the patient? (9-11)
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| Post-operative hip and knee prosthesis patients: which patients do/do not require thrombosis prophylaxis? |
| Prioritised 34x (28x NOV member, 3x patient representative, 3x stakeholder) Is linked to the guidelines: 1. Total hip prosthesis 2. Total knee prosthesis 3. Anti-thrombotic policy (NIV) Patients receiving a total hip or knee prosthesis are at risk of post-operative thrombosis (2.5% - 3.5%). Due to the large number of operations performed in the Netherlands (28,000 primary THP and 24,000 primary TKP annually (1)), approximately 1,650 patients will develop thrombosis every year. On the other hand, the incidence is also decreasing as a result of the rapid post-operative mobilisation and new treatment techniques. Thrombosis is associated with significant mortality and morbidity and 30% of all patients will suffer a recurrence within 5 years. Prevention - by means of thrombosis prophylaxis - is therefore of vital importance. However, this also poses a risk of bleeding. A lot of preliminary work has been performed since the prioritisation of the research question in 2015. This made it clear that a trial to study the duration of thrombosis prophylaxis is currently not relevant. A staggered approach is required to answer the aforementioned question. First, we need to distinguish between low-risk and high-risk patients for the development of thrombosis. Next, different thrombosis prophylaxis strategies can be used for these two patient groups. An example: the low-risk group receives a lower dose of thrombosis prophylaxis and for a shorter period, whilst the high-risk group receives (potentially) a higher dose of thrombosis prophylaxis for a longer period. This reduces the duration of anticoagulant treatment and the risk of complications - such as bleeding - for the majority of all patients, as well as the incidence of thrombosis. In order to identify the low-risk and high-risk patients, the TRiP study was started in recent years as an initial phase to answering this question. |
| Hip or knee prosthesis patients: does the return to work improve with a referral to the occupational health physician? |
| Prioritised 19x (13x NOV member, 4x patient representative, 2x stakeholder) Is linked to the guidelines 1. Total hip prosthesis and 2. Total knee prosthesis In the Netherlands, approximately 28,000 total hip prostheses (THP) and 24,000 total knee prostheses (TKP) are fitted annually (1). Estimates reveal that approximately a quarter of patients with a THP or TKP is in paid employment. These numbers will probably increase significantly in years to come. However, a substantial number of patients do not resume work after receiving a THP or TKP (2). Referral to the occupational health physician might improve the return to work. However, very little research has been performed on this subject to date. ZonMw (Efficiency Study, open round 2019, study into the cost-effectiveness of interventions) has however recently awarded a subsidy to the research group of Prof. J.R. Anema (VUMC). In this research, active referral - among others to an occupational health physician after TKP - forms part of the intervention that will be studied. The project carries the title: “Cost-effectiveness of a transmural integrated health care program for knee arthroplasty in the working population”. As this project overlaps to a certain extent with the ongoing CORE project “PaTIO”, these groups are working together closely.
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| Symptomatic flat-footedness: what is the effect of an orthotic? |
| Prioritised 13x (11x NOV member, 2x patient representative) There is no guideline for this subject. To date, no comparative research has been properly set up and performed to answer the simple question whether orthotics are effective in the treatment of symptomatic flat-footedness of children and/or adults. Roughly 45% of children up to 4 years of age, 15% of older children (1) and 30% of adults over the age of 20 years (2,3) have flat feet. It is not known how many orthotics are fitted annually in the Netherlands. We do know that they last an average of 2 years and the costs are variable, but are usually around € 200. It is known that tailor-made orthotics are only better than “off the shelf” orthotics for certain foot conditions (hollow feet, hallux valgus with pain and juvenile idiopathic arthritis). There is no evidence of this for other indications. However, most orthotics (both off-the-shelf and tailor-made) are prescribed for flat feet (4). A lot of research has been performed into the effect of orthotics “on something”; down to the smallest details. An example of this is: “Effects of orthopedic insoles on static balance of older adults wearing thick socks” (5). However, there are almost no comparative studies and if there are any, then they are of very moderate quality (6). When working on this research question, attention should therefore be paid to the accurate determination of the primary endpoint and a control group; a challenge in itself!
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| Low-grade cartilage tumours: is surgery necessary or not? RCT: MRI wait-and-see versus surgery. |
| Prioritised 10x (9x NOV member, 1x stakeholder) There is no guideline for this subject. The treatment of low-grade central cartilage tumours of the extremity (atypical cartilaginous tumours) varies per centre. Some centres opt for annual examinations and monitoring by X-ray and MRI and monitor these patients for 5-10 years sometimes. Other centres opt for a minimally invasive curettage of all cartilage tumours. There are no randomised studies comparing these treatment strategies. |
Innovation question
| Can we use pre-intervention patient characteristics for better prediction of what the intervention outcome will be, for example for: - patients who are eligible for treatment with hip/knee prosthesis; - patients with (various) degenerative spinal conditions. |
This question is a combination of three prioritised innovation questions:
The examples of hip and knee prostheses and degenerative lower spine conditions are relevant, because:
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