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Reference
1. Capoor MR, Khanna G, Nair D, Hasan A, Rajni,
Deb M, Aggarwal P. Eumycetoma pedis due to
Exophiala jeanselmei. Indian J Med Microbiol.
2007;25:155-7.
data with an already included study) was included when it should have been excluded.
There were two additional studies11,12 in
which the numbers that we extracted were
slightly different from those in the report by
Bauwens et al.; we note these only as discrepancies (not errors) in extraction.
Our further review of their paper also
suggested that their labeling and description of results were misleading. Specifically,
they describe their meta-analyses as those
of relative risk of malalignment and label
their figures accordingly. In the Discussion,
they state that the available data suggest
that navigation reduces the relative risk of 3
of malalignment by 25%. This statement
is in error because their meta-analysis was
not of the relative risk of malalignment, but
rather the relative risk of alignment (i.e., the
chance that a patient has alignment after the
procedure). It would, therefore, have been
accurate for them to state that conventional
total knee arthroplasty decreases the relative
chance of alignment by 25%. When misfit,
instead of fit, is the outcome of choice, the
results are quite different from those reported by Bauwens et al. Correctly stated,
the risk of malalignment with conventional
replacement is appropriately three times
that with computer-assisted surgery.
In conclusion, our findings of data
extraction and entry errors cause us to challenge the conclusions in the article regarding
the meta-analysis of radiographic end
points following conventional compared
with navigated knee replacement surgery.
A correct data analysis demonstrates overwhelming evidence of a much lower error
rate with navigation. Reversal of some of the
extracted data and misreporting of relative
risks for fit as risks of malalignment are partially responsible for the muted difference
that Bauwens et al. described between navi-
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gated and conventional total knee arthroplasty. These errors, however, do not obviate
their other discussion points regarding the
methodological limits of the available trials,
including a dearth of evidence on long-term
outcomes, quality of life, and costs.
While we recognize and understand
the challenges inherent in performing metaanalyses, our intent is to bring these errors
to the attention of the readers of The Journal
to correct any erroneous impression that
this work may have left with the readership.
J. Bohannon Mason, MD
Thomas Fehring, MD
Kyle Fahrbach, PhD
Corresponding author: J. Bohannon Mason,
MD, OrthoCarolina Hip and Knee Center,
1915 Randolph Road, Charlotte, NC 28207,
e-mail: bo.mason@orthocarolina.com
Disclosure: In support of their research for or
preparation of this work, one or more of the
authors received, in any one year, outside
funding or grants in excess of $10,000 from
DePuy, and Johnson and Johnson, Warsaw, Indiana. Neither they nor a member of their immediate families received payments or other
benefits or a commitment or agreement to
provide such benefits from a commercial entity. No commercial entity paid or directed, or
agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit
organization with which the authors, or a
member of their immediate families, are affiliated or associated.
LETTERS
TO
THE EDITOR
Materials and Methods section of our paper, where we stressed that the numbers of
patients were extracted from histograms
whenever possible. This may explain most
of the differences that they noted between
their and our data sets. Additional differences might be related to different handling
of the unit of interestthat is, the patient or
the knee. Bolognesi and Hofmann9 did indeed report the alignment of the femoral
and the tibial component rather than the
mechanical axis. However, if navigation improves both femoral and tibial component
alignment, it is very likely that the resulting
mechanical axis will be optimized as well.
Since the observed effects were consistent
with others, we decided to include that
study in our analysis. We definitely identified and excluded some kinship studies, but
we could not retrieve a dual publication by
Mielke et al.10.
When posing a null hypothesis, it is
important to define the accepted standard of
care. Risk ratios and other relative measures
are asymmetric. This was the reason why we
also provided risk differences, which can be
used for calculating the number needed to
treat. Currently, navigation is an experimental add-on and may either decrease the risk
of malalignment or increase the chance of
alignment. It is, however, not justified to argue that conventional surgery would increase the relative risk of malalignment over
that associated with navigated component
placement. With regard to health-policy decisions, this is a dangerous statement since it
would imply that all patients who are not
operated on with computer assistance but
undergo conventional total knee arthroplasty by an experienced surgeon are at a
higher risk of having malalignment when
compared with those who undergo total
knee arthroplasty with navigated component placement.
Importantly, our analyses and plots
showed a significant advantage of navigated
over conventional knee replacement in
terms of radiographic surrogates, so we are
in complete agreement with Mason et al.
Yet, unless these advantages are consistent
with improved outcomes, we think that our
conclusion Navigated knee replacement
provides few advantages over conventional
surgery on the basis of radiographic end
points is valid.
Finally, we regret that Mason et al.,
after receiving our data set (the sending of
which shows our openness and willingness
to engage in scientific debate), did not contact us again to compare both data sets and
to discuss, explore, and resolve any possible
differences jointly before submitting a Letter
to the Editor challenging our scientific reputation. We are sorry that Dr. Masons group
could not publish their paper, but we are
deeply disappointed in their behavior.
Dirk Stengel, MD, PhD, MSc
Kai Bauwens, MD
Gerrit Matthes, MD
Michael Wich, MD
Florian Gebhard, MD, PhD
Beate Hanson, MD, MPH
Axel Ekkernkamp, MD, PhD
Corresponding author: Dirk Stengel, MD,
PhD, MSc, Department of Trauma and Orthopedic Surgery, Center for Clinical Research, Unfallkrankenhaus Berlin, Warener
Strasse 7, 12683 Berlin, Germany, e-mail:
dirk.stengel@ukb.de
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LETTERS
TO
THE EDITOR
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LETTERS
TO
THE EDITOR
References
1. Bthis H, Perlick L, Tingart M, Lring C, Zurakowski D, Grifka J. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery
with the conventional technique. J Bone Joint Surg Br.
2004;86:682-7.
2. Perlick L, Bthis H, Lerch K, Lring C, Tingart M,
Grifka J. [Navigated implantation of total knee endoprostheses in secondary knee osteoarthritis of
rheumatoid arthritis patients as compared with conventional technique]. Z Rheumatol. 2004;63:140-6.
German.
3. Saragaglia D, Picard F, Chaussard C, Montbarbon
E, Leitner F, Cinquin P. [Computer-assisted knee
arthroplasty: comparison with a conventional procedure. Results of 50 cases in a prospective randomized study]. Rev Chir Orthop Reparatrice Appar Mot.
2001;87:18-28. French.
4. Sparmann M, Wolke B, Czupalla H, Banzer D, Zink
A. Positioning of total knee arthroplasty with and without navigation support. A prospective, randomised
study. J Bone Joint Surg Br. 2003;85:830-5.
5. Chauhan SK, Scott RG, Breidahl W, Beaver RJ.
Computer-assisted knee arthroplasty versus a
conventional jig-based technique. A randomised,
prospective trial. J Bone Joint Surg Br. 2004;86:
372-7.
6. Confalonieri N, Manzotti A, Pullen C, Ragone V.
Computer-assisted technique versus intramedullary
and extramedullary alignment systems in total knee
replacement: a radiological comparison. Acta Orthop
Belg. 2005;71:703-9.
7. Kim SJ, MacDonald M, Hernandez J, Wixson RL.
Computer assisted navigation in total knee arthroplasty: improved coronal alignment. J Arthroplasty.
2005;20(7 Suppl 3):123-31.
8. Perlick L, Bthis H, Tingart M, Perlick C, Grifka J.
Navigation in total-knee arthroplasty: CT based implantation compared with the conventional technique.
Acta Orthop Scand. 2004;75:464-70.
9. Bolognesi M, Hofmann A. Computer navigation
versus standard instrumentation for TKA: a singlesurgeon experience. Clin Orthop Relat Res. 2005;
440:162-9.
10. Mielke RK, Clemens U, Jens JH, Kershally S.
[Navigation in knee endoprosthesis implantation
preliminary experiences and prospective comparative study with conventional implantation technique].
Z Orthop Ihre Grenzgeb. 2001:139:109-16. German.
11. Anderson KC, Buehler KC, Markel DC. Computer
assisted navigation in total knee arthroplasty: comparison with conventional methods. J Arthroplasty.
2005;20(7 Suppl 3):132-8.
12. Haaker RG, Stockheim M, Kamp M, Proff G,
Breitenfelder J, Ottersbach A. Computer-assisted navigation increases precision of component placement
in total knee arthroplasty. Clin Orthop Relat Res.
2005;433:152-9.
13. Gregori A, Holt G. Letter regarding Navigated
total knee arthroplasty. A meta-analysis. (2007;
89:261-269). J Bone Joint Surg Am. epub 2007
Mar 27. http://www.ejbjs.org/cgi/eletters/89/2/
261#31862.
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LETTERS
TO
THE EDITOR
ble patients was mentioned in the Discussion of our article. The quality of reduction
was studied in this paper and in our paper in
Lancet1 as well. In both studies, there was no
relationship between the occurrence of
complex regional pain syndrome and the
need to undergo fracture reduction. Moreover, the quality of reduction did not influence the chance of complex regional pain
syndrome developing. We performed the
current study because, to our knowledge,
there have been no published studies since
19991 that either confirm or refute our original findings.
To our knowledge, no prospective
study has ever demonstrated an association
between the prevalence of complex regional
pain syndrome and the quality of reduction. Retrospective studies do not have the
level of evidence that is needed. Dr. Frlke
makes a misjudgment by citing the article by
Arora et al.2. Arora et al. found that, of 114
patients followed for one year, five had typeI complex regional pain syndrome and three
had type-II complex regional pain syndrome. Thus, the prevalence of type-I complex regional pain syndrome in their study is
4.39% (not 3.5% as stated in Dr. Frlkes letter) and is higher than our overall prevalence of 4.2%; it stands in contrast with the
2.4% for all of our patients treated with vitamin C. The difference is even more striking
when the 4.39% rate is compared with the
prevalence of only 1.8% in our group receiving 500 mg of vitamin C and 1.7% in the
group receiving 1500 mg.
Why the articles by Rowbotham3, Oerlemans et al.4, and Sherry et al.5 are cited is
unclear to us. Our study is about the possible
prevention of complex regional pain syndrome after a wrist fracture in adults treated
with a prophylactic dose of vitamin C and
not about the therapy for complex regional
pain syndrome itself. The end point of our
study was defined as the presence of complex
regional pain syndrome at any time within
one year after the fracture (see the Study Design section). The article by Rowbotham3
deals with pharmacotherapy in patients with
complex regional pain syndrome.
The article by Oerlemans et al.4 is a
very well-respected trial comparing adjuvant
physical therapy with occupational therapy
for patients with complex regional pain syndrome. Here lies the difference with our fracture patients. If we had treated our patients
with physical therapy as well, we would have
created our own confounding factor. Skep-
References
1. Zollinger PE, Tuinebreijer WE, Kreis RW, Breederveld RS. Effect of vitamin C on frequency of reflex
sympathetic dystrophy in wrist fractures: a randomized trial. Lancet. 1999;354:2025-8.
2. Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar
locking-plate. J Orthop Trauma. 2007;21:316-22.
3. Rowbotham MC. Pharmacologic management of
complex regional pain syndrome. Clin J Pain.
2006;22:425-9.
4. Oerlemans HM, Oostendorp RA, de Boo T, Goris
RJ. Pain and reduced mobility in complex regional
pain syndrome I: outcome of a prospective randomised controlled clinical trial of adjuvant physical
therapy versus occupational therapy. Pain.
1999;83:77-83.
5. Sherry DD, Wallace CA, Kelley C, Kidder M, Sapp
L. Short- and long-term outcomes of children with
complex regional pain syndrome type I treated with
exercise therapy. Clin J Pain. 1999;15:218-23.
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6. The Netherlands Society of Rehabilitation Specialists. Guidelines: Complex regional pain syndrome
type I. 2006. http://www.posttraumatischedystrofie.nl/pdf/CRPS_I_Guidelines.pdf.
7. Wilder RT, Berde CB, Wolohan M, Vieyra MA,
Masek BJ, Micheli LJ. Reflex sympathetic dystrophy
in children. Clinical characteristics and follow-up
of seventy patients. J Bone Joint Surg Am. 1992;
74:910-9.
LETTERS
TO
THE EDITOR
References
1. Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-C-arm technique in upper-extremity surgery. J Bone Joint Surg
Am. 2001;83:674-8.
2. White SP. Effect of introduction of mini-C-arm image
intensifier in orthopaedic theatre. Ann R Coll Surg
Engl. 2005;87:53-4.
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THE EDITOR
References
1. Gotfried Y. Percutaneous compression plating of
intertrochanteric hip fractures. J Orthop Trauma.
2000;14:490-5.
2. Gotfried Y. The lateral trochanteric wall: a key
element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res.
2004;425:82-6.
3. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma. 2005;19:5-9.
4. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding
and Classification. J Orthop Trauma. 1996;10 Suppl
1: v-ix, 1-154.
5. Gotfried Y. Pantrochanteric hip fracture: an entity.
J Bone Joint Surg Br. (Suppl III) 2000;82:235.
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THE EDITOR
References
1. Merchant AC, Mercer RL, Jacobsen RH, Cool CR.
Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am. 1974;56:13916.
2. Merchant AC. Patellofemoral imaging. Clin Orthop
Relat Res. 2001;389:1521.
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Hasselblom S, Larson L, Nordstrom H, Stigendal L,
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