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Paediatric Orthopaedics An
Based Approach to Clinical Questions 1st Edition Sattar Alshryda
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To every child and parent including mine: Daniel, Hannah, Jasmine, Ania, Maria and Jaber.
Sattar Alshryda
For my parents, for their steadfast support.
James S. Huntley
To my parents for their support and encouragement. Paul Banaszkiewicz
Foreword
Surgeons have always wanted to do the best for their patients. However, determining what is best for the patient is not always clear leading to many treatments options for most orthopaedic conditions. Moreover, because Paediatric Orthopaedics is one of the most varied of the Orthopaedic disciplines due to the many rare conditions with myriad presentations often afflicting the entire child, deciding with the child and parents among the many treatment options is particularly complex.
Treatment options need to provide on average better health outcomes than alternative or no treatment. Each treatment option comes with a range of benefits and risks, dependant on the child, setting, skill and experience of the surgeon. To make these complex decisions surgeons and families need the best evidence. While there are many factors that enter into critical appraisal of research studies and deciding what constitutes best evidence, surgeons recognise that, in general, randomised are better than non-randomised studies, prospective are better than retrospective studies, and controlled are better than uncontrolled studies.
In recent years there has been a focus on Evidence-based Orthopaedics. Evidence-based orthopaedics, with an emphasis on systematic overviews and randomized clinical trials, uses the best evidence to make the decisions with families. However, randomised trials are difficult in Paediatric Orthopaedics for several reasons including the rarity of many conditions therefore requiring multicentre studies that further increases the complexity of any trial. However, the quality of orthopaedic literature continues to improve and this should result in better outcomes for children.
While not every condition is covered and not every area has definitive evidence, this text will provide surgeons with practical advice on the best treatment, or treatment options, for most paediatric orthopaedic conditions. The key to each chapter is found at the end where treatment recommendations are provided with an attached strength of recommendation. Not only will this book be an invaluable and useful text for practising surgeons, it also highlights areas of research for the future. Please enjoy reading this book as much as I have enjoyed being a part.
James G. Wright
Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Acknowledgements
• We would like to thank all people who helped us through various stages of writing this book. We are particularly grateful to Mrs. Ania Milkowski, for her help in producing high quality art works for the book.
• We are grateful for the librarians of the Central Manchester University Hospitals for their support in obtaining published papers that used in this book.
• We are also grateful to Dr. James Wright (Oxford) and Mr. Matt Nixon (Chester) for their general advice on various aspects of the book including contents, designs and layout.
• The following figures are courtesy of S&A Medics Ltd. (9.2; 12.1–12.4; 13.1; 14.1;14.2; 14.5, 20.1–20.3; 32.2; 34.2; 34.3; 43.1–43.4; 46.1–46.7; 48.1;48.2; 51.1–51.5)
1
2
Sattar Alshryda, James S. Huntley, and Paul Banaszkiewicz
Raymond Pollock and Arkan S. Sayed-Noor Part II
3
5
Ultrasound
Richard O.E. Gardner, Sattar Alshryda, Simon P. Kelley, and John Wedge
Daniel
Anthony Cooper and James A. Fernandes
Murnaghan
Sarah
and Manoj Ramachandran
Mohamed Kenawey and Hossam Hosny
14 What Is the Best Treatment for Blount’s Disease?
Sonia Chaudhry and Paul A. Banaszkiewicz
15 Evidence-Based Treatments for Fractures Around the Knee Joint 141 Ibrar Majid and Talal Ibrahim
Part IV The Foot and Ankle
16 Evidence-Based Treatment for Clubfoot 151 Munier Hossain and Naomi Davis
17 What is the Best Treatment for Congenital Vertical Talus?
Munier Hossain and Naomi Davis
18 Evidence-Based Treatment for Metatarsus Adductus
Munier Hossain and Naomi Davis
19 Evidence-Based Treatment of Flexible Flat Foot in Children 171 Farhan Alvi and Neil Wilson
20 Evidence-Based Treatment for Tarsal Coalition 175 Anastasios Chytas, Samena Chaudhry, and Sattar Alshryda
21 Evidence-Based Treatment for Pes Cavus 183 Munier Hossain and James S. Huntley
22 Evidence-Based Management of Ankle Fractures in Children .
Kenan Dehne, Amy Robinson, and Sattar Alshryda
Part V The Spine
23 Evidence-Based Treatment of Adolescent Idiopathic Scoliosis
David Lebel
24 Evidence-Based Treatment of Neuromuscular Scoliosis
Jason J. Howard and Jane Farrelly
25 Evidence-Based Treatment for Congenital Scoliosis 229 Firoz Miyanji
26 Evidence-Based Treatment of Spondylolysis and Spondylolisthesis 237 Athanasios I. Tsirikos and George Mataliotakis
27 Evidence-Based Treatment of Spina Bifida 255 Emmanouil Morakis and James Wright
28 Evidence-Based Treatment of Spinal Trauma
Morag Harris, Peter Millner, and Odhrán Murray
Part VI The Shoulder
29 Evidence-Based Treatment of Congenital Clavicular Pseudarthrosis
James S. Huntley
30 Evidence-Based Treatment of Sprengel Deformity
Talal Ibrahim and Abdelsalam Hegazy
Part VII The Elbow
31 Evidence-Based Treatment of Glenohumeral Dysplasia Caused by Obstetric Brachial Plexus Injuries
Philip Holland and Matthew F. Nixon
32 Evidence-Based Treatments of Paediatric Elbow Fractures .
Emily J. Mounsey and Andrew Howard
33 Evidence-Based Treatment of Madelung’s Deformity
David H. Hawkes and Matthew F. Nixon
34 Evidence-Based Treatments of Congenital Radio-Ulnar Synostosis
Wei Y. Leong and Matthew F. Nixon
Part VIII The Wrist and Hand
35 What Is the Best Treatment for Paediatric Trigger Thumb (Acquired Thumb Flexion Contracture)?
James S. Huntley
36 Evidence-Based Treatment of Forearm Fractures in Children
Oluwarantimi O Ayodele and Alwyn Abraham
37 Evidence-Based Treatment of Wrist Fractures in Children
Assad A. Qureshi and Alwyn Abraham
Part IX Neuromuscular Diseases
38 The Value of Gait Analysis in Decision Making About Surgical Treatment of Cerebral Palsy
Clare Carpenter and Alfie Bass
39 The Evidence Base for Botulinum Toxin Injection for the Treatment of Cerebral Palsy–Related Spasticity in the Lower Limb: The Long-Term Effects 369 James S. Huntley and Lyndon J. Bradley
40 Evidence-Based Treatment for Feet Deformities in Children with Neuromuscular
Emmanouil Morakis and Anne Foster
41 Upper Limb Problems in Children with Cerebral Palsy
Jonathan A. Baxter and Matthew F. Nixon
Part X Musculoskeletal
42 Evidence-Based Treatment for Musculoskeletal Infection
Megan Mignemi, Lawson Copley, and Jonathan Schoenecker
43 Evidence-Based Treatment of Simple Bone Cyst
Sattar Alshryda and James Wright
44 Evidence-Based Treatment for Malignant Paediatric Bone Tumours .
Andrew J. Graydon, Michael M. Hanlon, and Caitlin E. Bodian
46 Evidence-Based Management of Limb Length Discrepancy 475 Mohamed Kenawey, Ghulam Abbas, and Farhan Ali
47 Evidence-Based Treatment of Accessory Navicular Bone 487
Ling Hong Lee and Akinwande Adedapo
48 Evidence-Based Treatment of Ingrown Toenails 495 Arif Razak and Mubashshar Ahmad
49 Evidence-Based Treatment of Deformity in Multiple Osteochondromatosis 499
Daniel Porter and Li Fei
50 Evidence-Based Treatment for Musculoskeletal Disorders in Children with Down’s Syndrome 519
Christopher Talbot and Sattar Alshryda
Part XII Epilogue
51 Epilogue
James S. Huntley, Sattar Alshryda, and Paul Banaszkiewicz
Index
Contributors
Ghulam Abbas Royal Manchester Children’s Hospital, Manchester, UK
Alwyn Abraham Leicester Royal Infirmary, Leicester, UK
Akinwande Adedapo James Cook University Hospital, Middlesbrough, UK
Mubshshar Ahmad Royal Manchester Children’s Hospital, Manchester, UK
Farhan Ali Royal Manchester Children’s Hospital, Manchester, UK
Sattar Alshryda Royal Manchester Children’s Hospital, Manchester, UK
Farhan Alvi Royal Manchester Children’s Hospital, Manchester, UK
Oluwarantimi O Ayodele Milton Keynes University Hospital, Milton Keynes, UK
Paul A. Banaszkiewicz Queen Elizabeth Hospital, Gateshead, UK
Alfie Bass Alder Hey Hospital Children’s, Liverpool, UK
Jonathan A. Baxter Royal Manchester Children’s Hospital, Manchester, UK
David Bodansky Alder Hey Hospital Children’s, Liverpool, UK
Caitlin E. Bodian Starship National Children’s Hospital, Auckland, New Zealand
Lyndon J. Bradley Whangarei Hospital, Whangarei, New Zealand
Clare Carpenter Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
Samena Chaudhry The Alexandra hospital Redditch, Birmingham, UK
Sonia Chaudhry Connecticut Children’s Medical Center, Hartford, CT, USA
Anastasios Chytas Bristol Royal Hospital for Children, Bristol, UK
Anthony Cooper BC Children’s Hospital, Vancouver, Canada
Lawson Copley Vanderbilt University Medical Center, Nashville, TN, USA
Naomi Davis Royal Manchester Children’s Hospital, Manchester, UK
Matthew Debenham Middlemore Hospital, Auckland, New Zealand
Kenan Dehne Birmingham Children’s Hospital, Birmingham, UK
Laura Deriu Leed’s Children Hospital, Leeds, UK
Deborah M. Eastwood Great Ormond Street Hospital for Children, London, UK
Jane Farrelly Sidra Medical and Research Centre, Doha, Qatar
Li Fei First Affiliated Hospital of Tsinghua University, Beijing, China
Kim Ferguson Royal Hospital for Sick Children, Glasgow, UK
James A Fernandes Sheffield Children’s Hospital, Sheffield, UK
Anne Foster Royal Manchester Children’s Hospital, Manchester, UK
Richard O.E. Gardner Cure International, Addis Ababa, Ethiopia
Mark Gaston Royal Hospital for Sick Children, Edinburgh, UK
Andrew J. Graydon Starship National Children’s Hospital, Auckland, New Zealand
Michael M. Hanlon Starship National Children’s Hospital, Auckland, New Zealand
Morag Harris Leeds Teaching Hospitals NHS Trust, Leeds, UK
David Hawkes Countess of Chester Hospital, Chester, UK
Abdelsalam Hegazy Hamad Medical Corporation, Doha, Qatar
Philip Holland Countess of Chester Hospital NHS Foundation Trust, Chester, UK
Hossam Hosny Sohag University, Sohag, Egypt
Munier Hossain Royal Manchester Children’s Hospital, Manchester, UK
Andrew Howard Hospital for Sick Children’s, Toronto, Canada
Jason J. Howard Weill Cornell Medical College, Sidra Medical and Research Center, Doha, Qatar
James S. Huntley Sidra Medical and Research Center, Doha, Qatar
Talal Ibrahim Hamad Medical Corporation, Doha, Qatar
Simon P. Kelley The Hospital for Sick Children, Toronto, Ontario, Canada
Mohamed Kenawey Sohag University, Sohag, Egypt
Gavin De Kiewiet Sunderland Royal Infirmary, Sunderland, UK
David Lebel Dana-Dwek Children’s Hospital, Tel Aviv, Israel
Ling Hong Lee Royal Victoria Infirmary, Newcastle, UK
Wei Y. Leong Countess of Chester Hospital, Chester, UK
Ibrar Majid Royal Manchester Children’s Hospital, Manchester, UK
George Mataliotakis Royal Hospital for Sick Children, Edinburgh, UK
Megan Mignemi Vanderbilt University Medical Center, Nashville, TN, USA
Peter Millner Leeds Teaching Hospitals NHS Trust, Leeds, UK
Firoz Miyanji BC Children’s Hospital, Vancouver, Canada
Emmanouil Morakis Royal Manchester Children’s Hospital, Manchester, UK
Emily J Mounsey The Hospital for Sick Children, Toronto, Ontario, Canada
Claire F. Murnaghan Royal Hospital for Sick Children, Glasgow, UK
M. Lucas Murnaghan The Hospital for Sick Children, Toronto, Ontario, Canada
Odhrán Murray Queen Elizabeth University Hospital, Glasgow, UK
Matthew F. Nixon Royal Manchester Children’s Hospital, Manchester, UK
Daniel Perry Alder Hey Children’s Hospital, Liverpool, UK
Raymond Pollock University Hospital of North Tees and Hartlepool, Stockton-on-Tees, UK
Charles A. Popkin Columbia University, New York, NY, USA
Daniel Porter First Affiliated Hospital of Tsinghua University, Beijing, China
Assad A. Qureshi Leicester Royal Infirmary, Leicester, UK
Manoj Ramachandran The Royal London & Barts, Barts Health NHS Trust, London, UK
Arif Razak Royal Manchester Children’s Hospital, Manchester, UK
Amy Robinson Royal Manchester Children’s Hospital, Manchester, UK
Sarah Rubin The Royal London & Barts, Barts Health NHS Trust, London, UK
Arkan S. Sayed-Noor Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
Jonathan Schoenecker Vanderbilt University Medical Center, Nashville, TN, USA
Christopher Talbot Royal Manchester Children’s Hospital, Manchester, UK
Kai Tsang Royal stoke hospital, Stoke-on-Trent, UK
Athanasios I. Tsirikos Royal Hospital for Sick Children, Edinburgh, UK
John Wedge The Hospital for Sick Children, Toronto, Ontario, Canada
Andrew Wheelton Royal Manchester Children’s Hospital, Manchester, UK
Neil Wilson Royal Hospital for Sick Children, Glasgow, UK
James Wright Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Jonathan Wright Great Ormond Street Hospital, London, UK
ListofAbbreviations
Order
A
B
Abbreviations Meaning
ABD
Abduction, Pronation abduction type injury
AFO Ankle Foot Orthoses
AK Above Knee
AAOS The American Academy of Orthopaedic Surgeons
AHA Assisted Hand Assessment
AHO Acute Hematogenous Osteomyelitis
AIS Adolescent Idiopathic Scoliosis
AAI Atlanto-Axial Instability
AARF
Atlanto-Axial Rotatory Fixation
ADM Abductor Digiti Minimi
AE Adverse Event
AER
Apical Epidermal Ridge
AMC Arthrogryposis Multiplex Congenita
ANC Absolute Neutrophile Count
AP Antero-Posterior
ARIF Arthroscopic Reduction and Internal Fixation
ASIS Anterior Superior Iliac Spine
ATFL
Anterior Talo-Fibular Ligament
ATiFL Anterior Tibio-Fibular Ligament
AVN Avascular Necrosis (see also ON)
AP Antero-Posterior
BrAIST
Bracing in Adolescent Idiopathic Scoliosis Trial
BK Below Knee
C C Centigrade
CDK Congenital knee dislocation
CEA Centre Edge Angle
CFL Calcaneo-ofibular Ligament
CFD Congenital Femoral Deficiency
CI Confidence Interval
CMC
Carpametacarpal Joint
CNS Central Nervous System
CORA
Centre of Rotation of Angulation
CP Cerebral Palsy
CR Closed Reduction
CRPP
CRUS
Closed Reduction and Percutaneous Pinning
Congenital Radio-Ulnar Synostosis
CSF Congenital Short Femur
CTEV Congenital Talipes Equinovarus (Club foot)
CV Coxa Vara
CVS Cardiovascular System
Order Abbreviations
D
DASH
Meaning
Disabilities of the Arm, Shoulder and Hand
DFO Dorsal First metatarsal Osteotomy
Dexa Dual-energy X-ray absorptiometry
DMD Duchene Muscular Dystrophy
DVT Deep Venous Thrombosis
E ED Emergency Department
EWS Classic Ewing’s Sarcoma
ESFT Ewing’s Sarcoma Family Tumours
ESIN Elastic Stable Intramedullary Nailing (see also FIN)
F FAV Femoral Anteversion
FDS Flexor Digitorum Superficialis
FIN Flexible Intramedullary Nailing (see also ESIN)
FPA Foot Progression Angle
G g Gram
GA General Anaesthetic
GCS Glasgow Coma Scale
GHJ Gleno-Humeral Joint
GP General Practitioner
I IGHL Inferior Gleno-Humeral Ligament
IJO Idiopathic Juvenile Osteoporosis
II Image Intensifier
IMN Intramedullary Nailing
Intraop Intra-operative
ITB Ilio-Tibial Band
IU International Unit
K Kg Kilogram
KAFO Knee Ankle Foot Orthoses
L LoE Level of Evidence
LOS Length of Stay
LLD Leg Length Discrepancy
LRR Lateral Retinacular Release
M M Meter(s)
MBD Metabolic Bone Diseases
MCPJ Metacarpaphalangeal Joint
MD Mean Difference
MED Metaepiphyseal Dysplasia
MGHL Middle Gleno-Humeral Ligament
min Minute(s)
MOI Mechanism of Injury
mPFL Medial Patella-Femoral Ligament
MS Marfan Syndrome
MSKI Musculoskeletal Infection
MTPJ Metatarsal Phalangeal Joint
MVC Motor Vehicle Collision
N NB Nerve Block
NAT Non-Accidental Trauma
NF Neurofibromatosis
Ng nanogram
NSAID Non Steroidal Anti-inflammatory Drugs List of Abbreviations
Order
Abbreviations
Meaning
O OA Osteoarthritis
OCF Occipitocervical Fracture
ON Osteonecrosis (see also AVN), Ossific Nucleus
OR Odds Ratio; Open Reduction; Operating Room
ORIF Open Reduction and Internal Fixation
OSA Obstructive Sleep Apnoea
P P P-value
PB Peroneus Brevis
PCR Polymerase Chain Reaction
PE Pulmonary Embolism
PETS
Percutaneous Ephiphysiodesis with Transphyseal Screws
PF Patellofemoral/Planter Fasciotomy
PH Pavlik Harness
PIPJ Proximal Interphalangeal Joint
PL Peroneus Longus
POA Periacetabular Osteotomy
PPC Premature Physeal Closure
PNET primitive Neuroectodermal Tumours
PTFL Posterior Talo-Fibular Ligament
PTiFL Posterior Tibio-Fibular Ligament
Postop Postoperative
Preop Preoperative
PSACH Pseudoachondroplasia
PTH Parathyroid Hormone
R RTA Road Traffic Accident
RCT(s) Randomised Controlled Trial(s)
RD Risk Difference
ROM Range of Motion
RR
Risk Ratio
S SA Spinal Anaesthetic
SBC Simple Bone Cyst
SBSQ Spina Bifida Spine Questionnaire
SCIWORA
Spinal Cord Injury Without Radiological Abnormality
SD Standard Deviation
SED Spondoepiphyseal Dysplasia
SH Salter-Harris
SRS Scoliosis Research Society
T TAL Tendoachilles Lengthening
TAT Transfer of Tibialis Anterior Tendon
TCC
Talocalcaneal Coalition
TT Tourniquet Time
TL Thoracolumbar
TLSO Thoracolumbosacral Orthosis
TT-GT
Tibial Tubercle-Trochlear Groove Distance
V vs. Versus
VDRO
Varus Derotation Osteotomy
VMO Vastus Medialis Obliqus
U UCL
Ulnar Collateral Ligament
UV Ultraviolet
X χ2
z ZPA
Chi square
Zone of Polarising Activity
Introduction to Evidence-Based Orthopaedics
Sattar Alshryda, James S. Huntley, and Paul Banaszkiewicz
Abstract
Practising surgeons may be unable to keep up with current practice – what seems up to date today can be redundant tomorrow. In paediatric orthopaedics, and the setting of a busy clinical practice, it is challenging to find time to retrieve the best available studies, let alone analyse them, or synthesise the resulting information into a form applicable to one’s own practice. We are hardly alone in this regard (eg, Narayanan and Wright [1]), so this book is a collective effort to probe the common questions arising in our speciality – and look critically for answers within the literature. In this work, we are proud to have brought together the thinking of more than fifty leading paediatric orthopaedic surgeons to assemble the evidence underpinning elements of current practice. The approach has been that of the ‘evidence-based medicine’ pragmatist, written by frontline practitioners.
Keywords
Orthopaedics • Levels of evidence • Grades of recommendation
Practising surgeons may be unable to keep up with current practice – what seems up to date today can be redundant tomorrow. In paediatric orthopaedics, and the setting of a busy clinical practice, it is challenging to find time to retrieve the best available studies, let alone analyse them, or synthesise the resulting information into a form applicable to one’s own practice. We are hardly alone in this regard (eg, Narayanan and Wright [1]), so this book is a collective effort to probe the common questions arising in our speciality –and look critically for answers within the literature. In this work, we are proud to have brought together the thinking of more than fifty leading paediatric orthopaedic surgeons to
S. Alshryda (*)
Royal Manchester Children’s Hospital, Manchester, UK
e-mail: Sattar.alshryda@cmft.nhs.uk
J.S. Huntley
Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
e-mail: huntleyjs@gmail.com
P. Banaszkiewicz
Queen Elizabeth Hospital, Gateshead, UK
e-mail: pbanaszkiewicz@hotmail.com
assemble the evidence underpinning elements of current practice. The approach has been that of the ‘evidence-based medicine’ pragmatist, written by frontline practitioners. Evidence-based medicine is ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett et al. [2]). Therefore, it involves the thoughtful integration of the best available research, the clinical circumstances and patients’ own values and preferences. A clearly defined relevant question is required, followed serially by (i) identification of the studies/evidence by a thorough search of the literature, (ii) a critical appraisal of available evidence and its applicability to the clinical situation, and (iii) a balanced conclusion to the clinical problem and particular patient. A mnemonic for the process is the 5 ‘A’s (Wright et al. [3]): Assess the patient to determine the clinical issues. Ask a clear question to be pursued. Acquire the evidence. Appraise the evidence for its worth/validity. Apply the evidence to the particular patient. Broadly, this has been the suggested approach for the text, albeit with generalisation of the patient, and followed by a synthesis of the conclusions according to both level of evidence and grade of recommendation.
Editing this book has been a challenge on several levels. Authors vary in their understanding, experience of evidencebased medicine and modes of analysis of the literature. As far as possible we have sought to maintain the general format and quality of questions and chapters, whilst recognizing that, as with most multi-author texts, there are bound to be differences in emphasis, analysis and style. We have tried not to allow our own prejudices to influence the authors’ ‘open hand’ to potentially contentious areas of practice.
In some areas, rather than there being a definitive guide to practice, it is clear that there is a lack of evidence; ‘confusion’ may simply represent the current state of knowledge, not least because: ‘development of new treatment choices has far outpaced our capacity for determining what procedures are beneficial…’ (Wenger [4]). Paediatric orthopaedics, as a field of endeavour, has moved forward at a rapid pace over the last two decades, often outstripping our abilities to define best practice per se. Defining a dearth of evidence is a natural pre-requisite to addressing it in the future. Conversely
where evidence does exist, it is vital that those who care for children keep up to date.
We are immensely grateful to all the authors who have given so generously of their time, effort and expertise in assembling the material for this book.
References
1. Narayanan U, Wright JG. Evidence-based medicine: a prescription to change the culture of pediatric orthopaedics. J Pediatr Orthop. 2002;22:277–8.
2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996;312:71–2.
3. Wright JG, Kocher MS, Sanders JO. Evidence-based pediatric orthopaedics: an introduction, part 1. J Pediatr Orthop. 2012;32:S83–90.
4. Wenger DR. Limitations of evidence-based medicine: the role of experience and expert opinion. J Pediatr Orthop. 2012;32:S187–92.
S. Alshryda
Critical Appraisal of a Published Paper
Raymond Pollock and Arkan S. Sayed-Noor
Abstract
Critical appraisal is a systematic process used to identify the strengths and weaknesses of a research article. It enables the validity of research findings to be determined. It is just one step in the process of evidence based medicine – the use of best evidence in making decisions about patient care. The validity of a research study depends on its design and quality. Study designs are classified according to a hierarchical ranking called levels of evidence. To facilitate critical appraisal, checklists that ask questions about the research have been developed enabling the reader to judge its validity. Critical appraisal checklists can be divided into generic and study type specific lists. In this chapter a generic tool is described that is appropriate for the novice reviewer. For the experienced reviewer study specific checklists for each of the main study types are then described. Not only does this chapter provide the tools needed for critical appraisal of published work, it should also be of help when conducting and publishing research by ensuring that the checklists for that study type are taken into account during the design phase.
Keywords
Critical appraisal • Evidence based medicine • Hierarchy of evidence • Checklist • Case report • Case series • Cross-sectional study • Case control • Cohort • Randomized controlled trial • Systematic review • Meta-analysis
Critical appraisal (CA) is a systematic process used to identify the strengths and weaknesses of a research article and thereby determine the study’s validity. It is important when reading a published paper to keep a degree of skepticism. This means being open-minded and willing to be convinced but only if authors can adequately back up their claims. The critical reader is not put off by the limitations of a study but will expect authors to interpret their results in a way that takes account of the limitations.
R. Pollock (*)
University Hospital of North Tees and Hartlepool, Hardwick Road, Stockton on Tees, TS19 8PE, UK
e-mail: raypoll@pollock.org.uk
A.S. Sayed-Noor
Department of Surgical and Perioperative Sciences, Umeå University, 90187 Umeå, Sweden
e-mail: arkansam@yahoo.com
The validity of a research study depends on its design and quality. Study designs are classified according to a hierarchical ranking called levels of evidence. The classification varies depending on whether the study type is therapeutic, prognostic, diagnostic or economic/decision analysis. For therapeutic studies randomized controlled trials (RCTs) and meta-analyses of RCTs are at the top of the hierarchy and can be considered best evidence. Descriptive studies (qualitative studies, case reports, case series, cross sectional studies) are the lowest level of evidence. Observational studies (case-control and cohort) are in the middle (Fig. 2.1). These study types will be described in detail later.
Low-level evidence is more likely to be subject to bias. Bias is a systematic error that can make the results invalid. There are many kinds of bias but important ones in orthopedics are selection bias, response bias, recall bias and bias due
to confounding. These will be explained later on. This systematic error only results in bias when the inaccuracy affects comparison groups unequally. In theory a well conducted RCT should be free of bias because the process of randomisation is used to assign patients to treatment groups and this should result in the groups being balanced in all factors.
As the level of evidence hierarchy is descended, bias is increasingly likely and you need to be aware of this when you critically appraise articles.
Selection bias, sometimes referred to as sampling bias is error due to the improper process of selecting a study population i.e. the way subjects were identified, selected and included in a study.
Response bias or loss to follow-up bias can result in differences in the characteristics e.g. socio-demographic characteristics, of patients included in a study and those excluded or between selected comparison groups e.g. case and control. For example, response to follow-up may be dependent on sociodemographic characteristics of patients (sex, age, ethnicity, social class). Those who respond may be different from those who do not, leading to bias in the results. Response bias is common in case series and cross sectional study types. Wherever possible, analysis of the demographics of non-responders should be carried out to determine if they differ significantly from responders. In all study types response rates should be high, at the very least 70 % to minimize this type of bias.
Another type of bias is recall bias. This is particularly common in cross-sectional and case-control studies. Patients may not be able to remember correctly past events. Wherever possible any information obtained from patients should be verified from other sources such as patient records.
Confounding bias occurs when part of an observed relationship between 2 variables or factors involved in a disease
is due to the action of a third, which is the actual factor responsible. Confounding arises because many aspects of behavior and health are related. Frequent confounders are gender, age, socio-economic status and co-morbidity. In RCTs randomisation ensures that potential confounding factors, known or unknown are evenly distributed among the study groups. This is why this study type is highly regarded.
The Process of Critical Appraisal
Critical appraisal to determine the validity of research findings is an established method used in evidence-based medicine (EBM). It is just one step in the process of EBM – the use of best evidence in making decisions about patient care. To facilitate CA, checklists that ask questions about the research have been developed enabling the reader to judge its validity. Critical appraisal checklists can be divided into generic and study type specific lists. For the novice reviewer a generic tool is appropriate until more experience is gained. When you are confident and able to identify the study type, you will be able to progress to using the study specific checklists described later in this chapter. The checklists in this chapter are generally from our own experience.
The Anatomy of a Scientific Manuscript
Manuscripts in orthopedic journals have a standard format as follows but with minor variations depending on the particular journal:
• Abstract (structured or unstructured with Medical Subject Heading (MeSH) keywords – keywords are sometimes at the end of the article before the references instead). MeSH keywords are used to describe precisely the content of journal articles
• Sponsorship/competing interests (usually on the title page).
• Introduction.
• Methods (or materials and patients, materials and methods, patients and methods).
• Results.
• Discussion.
• Conclusion (sometimes absent).
• References.
Appraisal for the New Reviewer
For those new to CA it may be best to start with a more general appraisal until confidence is gained. Read through the whole paper quickly first. Does it seem clearly written and easy to understand or does it appear that it has been rushed?
Fig. 2.1 Levels of evidence hierarchy for therapeutic studies
You will probably find papers describing RCTs and metaanalyses the most structured because journals usually have guidelines as to how they should be formatted.
Next, you should be aware of the quality of the journal in which the research is published. This is partly measured by its impact factor (IF). Because it is based upon the number of citations of its papers it is not a fixed value but can vary from year to year.
For orthopedic journals an IF of 2.8 is regarded as high (e.g. JBJS (Br), recently renamed as The Bone & Joint Journal). For general medical journals it is much higher – the BMJ is currently about 16.
Basically a journal is considered to be of good quality if is peer reviewed – that is each paper is reviewed by at least one expert in the subject area prior to acceptance of publication in the journal. In the higher impact journals it is often reviewed independently by 3 experts including a statistician if the work involved statistical tests.
To be accepted, a paper usually has to be approved by all reviewers although the editor does have the final decision, for example if one of the reviewers is doubtful.
Look also at the author names as given on the title page. You may be familiar with certain authors from your attendance at conferences etc. Related to the authors, is the institution – is it a center of excellence in orthopedics? This will give you more confidence in the validity of the research.
Conflict of interest is particularly important to look out for. This is usually at the bottom of the title page along with authors’ affiliations. The most common conflict of interest is that the authors have a financial affiliation with a company that manufactures the products used in the research. For example many orthopedic surgeons are actively involved in design of new implants for which they get remuneration or gifts (e.g. holidays) for their involvement. This is an important part of the evolution of new devices for patient benefit. But it can lead to conscious or unconscious behavior that undermines the integrity and validity of research that involves such appliances.
When there is conflict of interest it is important that it has been recognized and dealt with. For example it might be stated that sponsors had no input into the protocol or conduct of the study. The reader must then decide whether any conflicts are important and might have influenced the validity of the study findings.
After reading through the whole paper, look in detail at each section as follows:
Introduction
What were the aims of the study? Look for this in the introduction or discussion (where it is often reiterated). It may be stated as a formal hypothesis (the null hypothesis). For example “there is no difference in outcome between patients
in the two treatments” that the study aims to reject. More usually it is stated as a general research question such as “the purpose of this study was to determine if treatment A is more effective than treatment B”.
Papers that do not have a clearly focused research question may be data dredging i.e. performing multiple statistical tests on the resulting data to see if anything of significance surfaces. This is bad science.
Methods
How were the patients selected for the study? Remember selection/sampling bias here. What were the exclusion criteria?
Are the details of statistical analysis described and appropriate? If so, what types of tests were used e.g. t-test, Pearson’s, and were they the most appropriate for the data types? For continuous data were efforts made to check the data for normality and if they were then a parametric test should have been used. If the data were non-normal, then the median rather than the mean should be quoted and nonparametric tests used. Statistical significance should be stated and is almost always given as P < 0.05 with confidence intervals (CI) at 95 %.
Was a sample size calculation made? This will not be relevant for case reports and series but applies for cross sectional and other studies higher in the hierarchy of evidence. If the sample size is too small for the effect size difference expected, then the study is unlikely to show statistical significance. A sample size calculation estimate should include the size of the minimum difference between the groups that is considered clinically significant (the effect size). For example, a 3-point decrease on the 0 to 10 visual analogue scale (VAS) for pain, would be regarded as clinically significant.
In case series, where a number of patients are reviewed and comparisons are made between subgroups of patients, it is possible to perform a post-hoc (after the analysis) power analysis. This may show that the results of no difference in the groups for a particular outcome may be due to insufficient sample size rather than the difference does not actually exist.
Other things to look out for in the methods are details of the surgical or other interventions used. Are they adequately described? What about the measures used to assess outcome? For example, if questionnaires have been used are they established ones or did the authors use their own questionnaires specifically designed for the study that may have not been validated?
Methods of measurements should be described in detail e.g. was a goniometer used for measuring straight leg raise or the less reliable visual estimation.
Be particularly critical of cross sectional survey type studies that the questions used are valid and reliable. How
was the questionnaire developed? Was it piloted for reliability and validity? For example does the questionnaire have content validity i.e. are the questions asked relevant and how did the results compare with similar validated questionnaires (criterion validity)? Did the same questionnaire give similar results when repeated soon after on the same patients (reliability)? Where standard questionnaires have been used (e.g. SF-36) then this should not be a problem assuming they have been used before in that particular patient group: questionnaires designed for adults may not be valid and reliable when used with children. Were answers to questions involving recall verified using other data sources such as patient records? This raises confidence in the results.
Results
Are the demographics of patients described in detail (age, sex, pathology etc) and a breakdown for the groups where relevant e.g. study and control groups. Remember confounding factors.
What was the response rate? It is recommended to be at the very least 70 %, otherwise there could be sampling bias. Were the demographics of the non-responders, where known, given and were they similar to the responders. Otherwise this means the responders may be atypical and the results will be biased.
Are any deviations from the protocol described e.g. unexpected events, patient drop out?
Are confidence intervals (CI) given for values? These are more informative than just P values as they indicate the possible range of values in the general population. Just a note here: if a P value is not significant then the CI should include zero (i.e. no difference) so just check these – It may be that the statistics are not up to scratch. Always look at the statistical tables and figures carefully (e.g. graphs – see below on interpreting tables and graphs) and see if there are unusual values that don’t quite (metaphorically) add up (e.g. CI and P values – see above). Concerning P values, the smaller the value the less likely the result is due to chance, e.g. a P < 0.01 rather than P = 0.048 which is only bordering on significance. Not all papers quote the exact P value but use the expression P < 0.05.
Look for data dredging involving post-hoc analysis where tests are done on the data to look for interesting results – only tests should be performed that were stated in the original hypothesis e.g. to look for age or sex differences. Otherwise some of the significant results may be due to chance. This is because P = 0.05 signifies that chance could create the result 1 time in 20.
Do the tables, figures and graphs match up with any description in the main text? Do the values add up within the tables, figures and graphs?
Discussion
Have the authors discussed how their findings fit in with what is already known about the subject? Do the results fit in with previous findings and if not is there an explanation by the authors. Are you aware of similar studies that have been omitted and are contradictory to their findings? Do the findings appear plausible from a medical viewpoint.
Look for any overstatement of the findings i.e. overextrapolation of the results which may only be the authors opinion.
Have they discussed the strengths and weaknesses of their findings?
Interpreting Figures, Tables and Graphs
Tables and graphs are time consuming and difficult to produce. Even with the help of word processor templates it is easy for errors to creep in. But they often improve the clarity of a paper. Tables often contain a lot of information and may be difficult to decipher. Look for:
• Self-explanatory title with units of measurements.
• Labelling of rows and columns.
• Are the rows/columns ordered e.g. by age.
• Numbers rounded to 2 significant figures e.g. 72.8 not 72.799. This will give you some indication of the standard of statistical input to the paper.
For figures make sure the appropriate type of figure has been used, that is graphs, histograms, bar charts, scatter plots or box plots. The axes should be labeled with the units. With graphs watch out for scales that don’t start at zero –this may deceptively emphasize an effect. Histograms are for continuous grouped data e.g. age groups. They show the symmetry of the data and give some indication of the normality. This symmetry is related to the use of an appropriate statistical test. Parametric tests should be used for normal (symmetrical) data and non-parametric for non-normal (skewed) data.
Scatter plots and graphs show how 2 variables relate to each other. Bar charts are for discrete data e.g. blood groups, whereas graphs are for continuous data e.g. blood pressure or age. When data is grouped e.g. age in 5-year intervals, information is lost within the groups and this may hide important information that was in the original raw data. Scatter plots are for showing the relationship between 2 variables and often a correlation coefficient is given for the strength of the relationship. With scatter plots look out for outliers (extreme values e.g. age 99 instead of 9) that may have distorted summary values (e.g. means) listed in tables. Such outliers may be erroneous values that should have been screened out during data cleaning or an explanation given for their inclusion. R.
Advanced Critical Appraisal
Although the foregoing generic appraisal guidelines are relevant for the less experienced reader, detailed study specific checklists are needed for a more robust critical appraisal.
The main epidemiological study types are:
• Qualitative research.
• Case reports.
• Case series.
• Cross sectional.
• Case control.
• Cohort.
• RCT.
• Systematic review/meta-analysis.
Advanced critical appraisal necessitates identifying the study type used in the paper. This may be given in the title or in the introduction or methods section. Often apart from RCTs and systematic review/meta-analyses it may not be explicitly mentioned and you will need to decide for yourself. This will only come from experience.
If the paper has keywords and these are MeSH terms, then the type of study should be stated so it is best to look their first. But not all study types have a MeSH term e.g. case series is not given a term although case report is.
Most of the checklists detailed below are the ones we use from our own experience of carrying out research and publication. Before submission we ensure that we have covered the relevant check points mentioned for each study type.
The Study Types
Qualitative Research
This is rarely found in the orthopedic literature.
It provides information on qualities that are difficult to measure for example patient experience, emotions, social interactions, attitudes, and behaviour. Qualitative studies have their own study types such as descriptive, phenomenology and ethnography. Qualitative studies are often combined with quantitative methods.
Qualitative studies are prone to bias and for this reason are at the bottom of the hierarchy. A description of these and their detailed appraisal is beyond the scope of this chapter.
Case Reports
This type of study is common in orthopedics. It is a type of qualitative research and in the hierarchy of evidence it is at a low level. This study type is easy to identify as often they are
in a separate section of a journal. They are regarded as having low validity but have been important in alerting clinicians to unusual events such as adverse reactions to treatment or conditions not seen before.
They are communicated in a narrative fashion e.g. “a 11 year old girl suffered a fall from standing and subsequently developed pain and …” that has unusual or novel outcome. They often do not have the standard format of research papers, usually having a discussion and conclusion after the case report itself.
Case reports can lead to generation of new hypotheses that can be tested using a study higher in the hierarchy of evidence for example by an RCT. They also have a strong educational component providing unusual things to watch out for in your own patients. This is enhanced by the fact that many case reports also include a literature review of the subject.
There are journals (such as Case Connector of the JBJS (Am), www.caseconnector.jbjs.org) entirely devoted to case reports while some other journals do not include them at all e.g. International Orthopaedics. Because there publication adversely affects impact factor, their numbers are restricted. Because of their simplicity case reports usually do not have conflict of interest statements.
The following checklist for the CA of a case report is modified from Chan and Bhandari [1]:
• Does the case report include a literature review usually in the discussion section?
• Does it describe how its findings fit in with what is already known?
• What makes this case different from other cases? How is it unusual?
• Does the case challenge or confirm currently held beliefs?
• Are the results biologically plausible?
• Does the study reveal principles that might be applied to other patients?
• How was diagnosis made? How were treatments chosen?
• How accurate and thorough was the data collection and reporting?
Case Series
This is another common type of study in orthopedics and is an extension of case reports but of multiple patients. Again, it is low level evidence due to lack of any controls. Because of its frequency in the orthopedic literature, it is important to be able to appraise these articles. Many case series reports are quite large with hundreds of cases but they are prone to bias, particularly selection bias, as they are not a random sample of all cases. For example, a female clinician may attract more female patients who feel more comfortable with her.
Case series are easy to conduct and require less time and financial resources than other studies higher in the hierarchy, hence their popularity. In most cases they are the only practical way to determine the effectiveness of surgical procedures because of the impracticality of conducting a RCT, for example comparing a surgical procedure with no (sham) procedure.
Case series can either be prospective in which patients are followed through their treatment while outcomes are recorded or retrospective in which archived records of patient outcomes are correlated with their treatment. They may describe the outcomes of a particular method of treatment or of complications related to treatment for example.
Case series should be reported scientifically based on a protocol with a hypothesis. They are of value by acting to generate hypothesis that can be tested using other studies higher in the hierarchy of evidence.
This study type can be identified by not having controls and either follows consecutive patients through their treatment prospectively or looks back at their treatment retrospectively using patient records. There is no MeSH term for case series.
Checklist for Case Series
Introduction
Is there a clear study aim or research question (this may be stated as a null hypothesis)?
Methods
Is the study prospective or retrospective? The former is less liable to recall bias.
Are the inclusion/exclusion criteria there?
What was the time interval for recruitment? This should be over a short time as possible to minimize the effect of changes in care. For example pre and post-operative care may change over time even though the surgical procedure is the same.
There should be consecutive patient enrollment to avoid selection bias.
Full details of the intervention(s) used.
Details of outcome measure(s) used – were they validated ones?
Details of statistical methods and were they appropriate for that data type?
Results
Demographics analysis such as age and sex included often in a table?
Look for a high follow-up rate. This avoids selection bias.
Discussion
Are the strengths and weaknesses of the study listed? How do the authors interpret and discuss their results in relation to
those of related studies. Are the conclusions justified considering the inherent limitations of this type of study?
Cross-Sectional Studies
These are commonly called surveys and measure the prevalence of a problem at one particular period in time, which may be a single day or the time period it takes to collect the data. Surveys take a sample of the population and the results should be representative of the wider population providing the survey has been carried out correctly. The way the sample is obtained is crucial to the validity of the results. Look for the MeSH term “cross-sectional”.
Checklist for Cross-Sectional Studies
Introduction
Is the reason why the survey is being carried out clearly stated?
Are there any hypotheses that the survey will answer? There should be clear questions about what the survey hopes to answer. This will avoid data dredging during the analysis phase.
Methods
Is the sampling frame (i.e. population from which sample is taken) and sample described? This is important to minimize selection/sampling bias.
How was the sample selected? Were patients selected from a register and if so, how complete was it? Ideally the register should contain the majority of patients who have undergone that procedure or with that disease. For example if the trust/hospital records for that region were used, it is important that efforts were made to check on the completeness and validity of the data.
Was a sample size calculation included? This is important and although for surveys it is a relatively crude calculation –it should be included. It is usually calculated on the basis of an expected minimum response rate (e.g. 70 %) and power to detect a yes/no response to questions of 50 %. This ensures that negative results to questions will not be due to an underpowered study.
Was the method used to obtain the sample from the larger population (e.g. a register) described – was some form of random selection used (e.g. using a random number table/ generator). This means a probability sample has been used. If a convenience sample has been used then it is unlikely the results can be relied upon. For example interviewing people who only attend a private clinic will recruit atypical patients.
Surveys are usually carried out using questionnaires which may be self-administered or by an interviewer. Is the questionnaire a validated one? If not was the development of
R. Pollock and A.S.
the questionnaire described and how was it tested for reliability and validity. Was it piloted on a small sample first? If physical measurements were made e.g. muscle strength, was the technique standardized among investigators?
Results
What was the response rate? It should be at least 70 %. Lower than this suggest the results cannot be relied on.
Demographics of both responders and non-responders should have been compared to determine if selection bias has occurred e.g. non-responders may be of lower socioeconomic status. If so, this should be acknowledged in the discussion on how this may have affected the results. Was a sensitivity analysis performed in order to determine the effect on the results?
Surveys are prone to data dredging; performing numerous statistical tests to see if anything interesting drops out. Look out for this.
Confidence intervals in addition to P values should be included for all statistical tests performed. The CI gives an idea of the range in the general population so is more informative than a P value.
DiscussionandConclusion
Are the weaknesses of the study discussed e.g. possible selection bias? How do the results compare with previous studies? If similar, this instills confidence in the study.
Case Control Study
A case control study is a study that starts from the outcome (disease) and looks backwards to see what may have caused this. Patients with a disease (the cases) are compared to those without the condition (the controls) but are as similar as possible to the cases (e.g. age, sex, i.e. are matched) in order to determine what (exposure) may have caused the disease. It attempts to elucidate a potential cause from observing an effect (the disease).
Case control studies are appropriate when the disease has a long latency period because the study looks backwards making it unnecessary to wait for the disease to develop. It is also suitable for rare diseases because the investigator selects patients on the basis of their disease status rather than having to follow a large number of people and wait for the disease to develop as in cohort studies. It is also suitable for investigating outbreaks e.g. infections as it enables a quick answer to be found. It cannot be used for looking at the possible causes of multiple diseases – for this a cohort study should be used.
As with other study types, case control studies are susceptible to bias, the main ones of which are selection and recall bias.
Selection bias can arise if the diagnostic criteria used to identify the cases are not precisely defined. Selection bias can also arise if the corresponding controls are not representative and dissimilar to the cases. These must be selected from a similar population as the cases. For example hospital cases should have hospital controls (i.e. patients with other illness) and be similar in age, sex, socioeconomic status and other possible confounding variables.
In this type of study patients often have to recall past events from memory such as medication use or dietary habits or the data can be obtained from records. Both these sources of information may be inaccurate or incomplete leading to recall bias.
To identify this type of study look for the MeSH term “case-control study” in the keywords if it is not explicitly stated in the title or introduction. Be aware though that casecontrol study is used loosely in orthopedics and what is stated as a case-control study is actually only comparing a case series with a few unmatched controls. It is really only a case series study.
Checklist for Case Control Studies
Introduction
Again as with all epidemiological studies a hypothesis or aim of the study should be stated here.
Was a case control study appropriate? Or maybe a RCT would have been better?
Methods
There should be a sample size calculation. This should be based on the minimum odds ratio (OR) to be detected. For example an OR of 1.5 means the cases are 1.5 times more likely to develop the disease than controls.
SelectionofCases
The diagnostic criteria for selecting the cases should be precisely defined, for example the stage or grading of the illness.
Were the majority of the cases who were contacted included in the study? Otherwise bias may arise because patient’s who do not consent to inclusion tend to differ from those who do. So 90 % inclusion should be the minimum.
SelectionofControls
Were the controls selected from a similar population as the cases e.g. if hospital cases then the controls should be hospital patients with unrelated disease.
Were they similar in e.g. age, sex and time of hospitalisation …etc. (matched) to the cases except for not having the outcome? This will be given in the tables in the results section so look these over to determine this.
How was the exposure identified, from records or interviews/questionnaires? Interviewers/data collectors should be
blinded to patient status (i.e. case or control). This eliminates interviewer bias in which interviews or record searches may be influenced by knowledge of whether a patient is case or control.
Results
Are the demographics of cases and controls included? Also demographics of those cases and controls that refused to participate, where known, should be given in order to determine if selection bias had occurred. Data dredging is indicated if a large number of possible causative agents have been tested for significance and the same problem of chance significance occurs as it does with cross sectional studies.
The results should be expressed as odds ratio (OR). This compares the odds of the disease/outcome occurring in the cases and controls. A CI for the OR should be included. The tested association is not significant if the CI includes 1.0.
Cohort Studies
In epidemiology, this is a group of people with a common characteristic e.g. exposure, followed up over time to determine what illness happens to them because of this.
There are 2 ways of conducting a cohort study. Prospectively, in which study participants e.g. patients who have had metal implants, are followed up over time and observed as to whether the outcome e.g. cancer, occurs. This rate can be compared to the known rate in a similar general population (the control group). In retrospective cohort studies exposure and outcome has already occurred. Therefore, from medical records, patients with metal implants would be identified and if they developed cancer, again determined from records e.g. the cancer registry and whether this incidence was higher than in a similar population (e.g. matched for age, sex etc). Often a prospective study is carried out after a retrospective study has provided evidence of a link between exposure and outcome.
The main bias that cohort studies are susceptible to is loss to follow-up and this can severely affect the validity of the results. In any cohort study whether retrospective or prospective, it is necessary to exhaustively trace all patients e.g. from records or by following all members of the cohort from point of exposure to development of the outcome disease. This needs to be done for all members otherwise the results could be invalid. This can be difficult as cohort members may migrate, die or decide not to continue participation in the study.
To identify this type of study, look in the keywords for the MeSH term “cohort study”. Again beware that cohort study is used loosely in the orthopedic literature to mean a case series with follow-up either prospectively or retrospectively.
Checklist for Cohort Studies
Introduction
There should be a clear hypothesis either as the null hypothesis or as a statement of the aim of the study e.g. in patients who had a prosthesis made of metal (the cohort) is there an increased risk of cancer (the outcome) compared to the general population (the control group).
Was a cohort study appropriate or would a case control have been better? Case control studies provide much greater power than cohort studies to detect differences and thus need fewer participants. Would a RCT have been better if this was ethically possible, for example comparing non-metal vs. metal implant?
Methods
A sample size calculation should be given so that the study has sufficient power to detect the outcome of interest. The sample size depends on the incidence in the non-exposed population and the minimum relative risk (RR) regarded as important.
Were the data sources (e.g. registers) complete and accurate so that they can be relied on? Was data cleaning and checks for the correct diagnostic coding done? When using death certificates the recorded cause of death may hide the outcome of interest.
Were the appropriate data sources for assessing the outcome used? For cancer or death this will be less of a problem but for other outcomes such as juvenile arthritis a variety of data sources will have to be used e.g. GP records, hospital admissions.
Was the comparison (control) group of non-exposed individuals appropriate? Often the control group can be the general population providing the demographics are similar.
Was the follow-up time long enough for the outcome to develop? For cancer this will be many years. For treatment side effects this may only be months.
Results
The major bias in cohort studies will be due to loss to followup. Were the majority of participants followed up with every effort made to contact all patients using multiple sources? A follow up of less than 70 % is liable to have seriously affected the validity of the results. Where there was loss to follow-up, was a sensitivity analysis performed? For example, assuming those lost to follow-up all developed the outcome – the effect on the results can be determined.
DiscussionandConclusion
Is there a discussion of the limitations of the study, particularly the comparison group used and how they may differ from the cohort?
Randomized Controlled Trials
These are high in the hierarchy of the evidence pyramid and if done properly will provide results that are free of all bias. RCTs are essentially experiments in which patients are allocated to a treatment by the investigator. There are a variety of trial designs but the most common in therapeutic interventions is the parallel 2-arm trial in which patients are allocated to one of 2 treatments or to a placebo. The essence of RCTs is random assignment of patients to the intervention. This has the effect of balancing out all known and unknown confounders. However just because a study is randomized does not mean it is unbiased. If they lack methodological rigor, a variety of types of bias such as selection or loss to follow-up can creep in.
The CONSORT statement was published in 1996 with an update in 2010 [2] in order to improve the reporting of RCTs and prevent bias during trial conduct. It includes a checklist of points that should be reported so that it is possible to determine to what extent the results are valid. Although CONSORT was designed to improve the reporting of trials and was mainly developed for assessment of pharmacological treatments, it can be used as a CA tool for all types of RCTs. The checklist presented below is based on CONSORT together with that of the Cochrane bone, joint and muscle trauma group [3].
In general the quality of reporting of orthopedic trials is poor [4] so it is important to be critical when appraising them. Conducting surgical orthopedic trials presents special problems such as with blinding of treatments and surgeon learning curve when comparing a novel treatment to the traditional method for example. This is particularly true for multi-center trials.
Although randomisation should eliminate bias due to selection (allocation) and confounding, it is possible during the trial for other types of bias to creep in. In orthopedic trials, the possible sources of bias are due to lack of blinding, loss to follow-up, learning curve and surgeon expertise bias, bias due to patient crossover (when patients have a preference for one treatment over another e.g. surgery vs. conservative therapy) or patients not included in a study due to their severe illness or old age. In addition surgical orthopedic interventions are complex and usually consist of several components such as pre-treatment, anesthesia and rehabilitation such as physiotherapy. These may not be standardized between the groups and/or the participating centers in the trial thereby introducing further bias. These points need special attention when an orthopedic trial is critically appraised in addition to those that generally apply such as the details of randomisation.
Because of the logistical and practical difficulties of conducting orthopedic surgical trials, they are less commonly reported than in other fields such as drug treatments.
RCTs are easily identified from the title and MeSH keywords but it is important to be aware that not all reported trials have used randomization but are “quasi-randomized” or “stratified”. This uses, for example, date of birth or medical record number, to allocate patients to the intervention and as such are prone to selection bias and therefore confounding.
Checklist for RCTs
Introduction
A clear hypothesis should be stated preferably as a null hypothesis.
Methods
The following should be provided:
Type of trial such as parallel with 2 arms and equal allocation to each group.
Trial setting, location and time period.
A detailed description of inclusion/exclusion criteria.
A sample size calculation including power of the study to detect a difference in the primary outcome. This is very important. Otherwise the study may not have had sufficient power to detect a difference in outcome where one actually exists.
Description of primary and secondary outcomes and details of how they were measured e.g. with questionnaires.
Details of the minimum clinically significant change in outcome measures. This is required for the sample size calculation. Were these outcome measures validated and clinically relevant for this study or would alternative ones have been more appropriate?
How was randomisation achieved? This is important and should always be included. For example, use of a random number table with the numbers concealed in consecutive envelopes or a telephone randomisation service. Use of any form of quasi-randomisation or stratification puts the validity of the whole study in doubt.
Were participants blinded to their assignment status? This is not always possible in orthopedic trials.
Were the treatment providers blinded? The surgeon, nursing staff, the outcome assessors and data analyst ideally should all be blinded as to allocation of patients. In surgical trials it almost impossible for the surgeon to be blinded, but it is possible for the nurses, outcome assessor and data analyst to be.
Was there a description of how patients in the groups were cared for before (e.g. pre-operative education) and after the intervention (e.g. rehabilitation regimes) and were these identical for the trial arms?
Was follow up of sufficient duration to measure the outcome?
Were the intervention procedure(s) described and details of surgical expertise for the procedure(s) given?
Another random document with no related content on Scribd:
Boston Cooking-School Cook Book and The Care and Feeding of Children in the same breath, I should do so. I can, anyway, talk about them in the same chapter!
The Boston Cooking-School Cook Book, by Fannie Merritt Farmer, first appeared in 1896 and was most recently revised last year. It has over 800 pages and still is a volume of little more than ordinary size, no thicker than a rather long novel. The 122 illustrations are so treated as to be intelligible—and if you have ever tried photographing food, you will appreciate what this means. The pictures have been used to show what the words of the text could not make so clear; one sees at a glance the differences between kidney lamb chops, rib chops and French chops, or the precise effect of capon in aspic, rather elaborately garnished with cooked yolks and whites of eggs cut in fancy shapes, pistachio nuts, and truffles.
The book opens with a simple scientific account of the kinds of food (food being “anything which nourishes the body”) and follows with a chapter on cookery including invaluable timetables. After a chapter on beverages with its recipes there are chapters on everything from bread to ice cream, from soup to jam and jellymaking and drying fruits. Then comes a long selection of menus, a chapter on food values with the necessary tables, and a forty-eight page index which has all the utility of an absolute, all-inclusive bill-offare.
The chief thing, of course, is that every teaspoonful and every direction in the book is exact, and standard. Nor, without going into the more recondite French cookery, or into special Italian, Spanish, German and other foreign dishes, is it possible to think of any dish which The Boston Cooking-School Cook Book omits. The variety of each kind of dish is often extraordinary. For example, I have just counted seventy hot puddings. In every case there is first the table of ingredients, then the simple directions. If a personal word will add anything to the force of what has been said, I will say that the superb cook who honored me by becoming my wife tells me that in no case when following The Boston Cooking-School Cook Book formula has she failed to cook with success.
Specialized, or partly specialized, cook books are many, and one of the best and most recent is Fannie Fox’s Cook Book, by Fannie Ferber Fox, with the assistance of Lavinia S. Schwartz. Mrs. Fox is a sister of Edna Ferber, and the novelist has written an introduction for Fannie Fox’s Cook Book which has all the richly human interest of her own fiction. In a paragraph which need hurt no feelings, Miss Ferber points out the tendency to over-emphasis in one or another direction which characterizes the cookery of most lands; and she gives with humorous eloquence her personal tribute to the toothsome torte, that cake of rich and crumbling particles which is included in Mrs. Fox’s recipes. This is a cook book that covers all kinds of foods but is distinctive by its preservation of the finest recipes from Jewish cookery.
Another valuable addition to the kitchen bookshelf is Bertha E. L. Stockbridge’s Practical Cook Book, in which a notable feature is the great number of practical suggestions for menus.
iiThe Care and Feeding of Children appeared in 1894 and was also revised last year. More than a million mothers have used it, and beyond question it has saved thousands of lives in infancy. Within the last half-dozen years, a generation which was raised on the book has, in turn, begun to raise its own children with its aid. It constituted its author, Dr. L. Emmett Holt, the foremost authority on babies in America; and as the years passed he returned to the book, in its various revisions, the fruit of a wonderful experience which its prestige had brought to him. Physicians have for years bought The Care and Feeding of Children in quantity to present to their patients. The hundreds of questions that every mother must have answered are all answered in this marvelous work. Bathing, nursing, artificial feeding, changes in food, substitutes for milk, under-nourishment, health habits, weaning, diet after weaning, the training of older children, children’s diseases—nothing is left out. This, to be sure, is largely possible because of the nation-wide and prolonged use of the book, and the constant additions and slight reconstructions it has
undergone. The book has always been kept of handy size and at a low price. The thought of what Dr. Holt’s book has done and is doing tempts to eloquence; but the only eloquence which is tolerable is the eloquence of the immense fact. We talk about services to humanity; but the writing and publishing of this book was possibly the greatest service to humanity in our time.
The Home Care of Sick Children, by Dr. Emelyn Lincoln Coolidge, is likely to be as helpful to mothers who have the care and feeding of sick children as Dr. Holt’s book has been to mothers generally. Dr. Coolidge lived for many years in the Babies’ Hospital, New York, and worked there under the personal direction of Dr. Holt. As editor of the department on babies of the Ladies’ Home Journal she has had an enormous correspondence with mothers throughout America and even in foreign countries. And The Home Care of Sick Children has one great merit: it does not stop where most other books of its kind stop, with: “Give a dose of castor oil, and call a doctor.” It tells in every instance what a mother can and should do, and it invariably tells when to call the doctor in. Not only does it avoid calling the doctor unnecessarily, but it gives many detailed instructions that a physician generally has not time to give. Recipes to tempt the sick child’s appetite, amusement, clothing and the hygiene of the sickroom are all dwelt upon.
There is a book with which it would be wise to precede Dr. Holt’s. Healthy Mothers is by Dr. S. Josephine Baker, consulting director, Children’s Bureau, United States Department of Labor, an authority on babies, whose articles regularly appear in the Ladies’ Home Journal and who is constantly asked for advice by women throughout the country Healthy Mothers deals almost entirely with the mother’s care of herself, and tells explicitly how she may best meet her responsibility to her baby, how she may have better health for herself, and the finer mental attitude that comes with physical well-being. The relation of a mother to her unborn child implies a responsibility greater than that entailed in any other human relationship. It is very largely within the power of the mother to determine not only her own condition and future health, but to decide whether or not her baby is to be healthy and strong. Healthy
Mothers, without going into technical discussion, sufficiently explains the general course of pregnancy and childbirth so that the mother may have an intelligent understanding of how to care for herself, safeguard her child, and make every requisite preparation.
iii
And the growing child? Child Training, by Angelo Patri, is the book for parents who look unhappily at the child and ask themselves despondently: “What in the world makes him do that?” Or, “What is the matter with her now?” Or, “Why does he disobey me?” Or, “Why does she have such bad manners?” Or, “Why doesn’t he study?” And, at one or another time, practically all parents are faced with these questions.
Angelo Patri has been training children, and helping fathers and mothers to train them, for twenty-five years. He is principal of Public School 45, New York. This school faces a garden centered about a sun dial and fed by a tiny greenhouse. Across the street is a whole block given over to a playground, its cinder floor padded firm by the play-winged feet of thousands of children who play on it every day. The school is unusual in having a great variety of shops and workrooms as well as the usual classrooms; a swimming pool; and a library. It is constantly visited by teachers from all over the world, men and women who are anxious to see the principal and talk with him. Some of them have heard him talk to audiences, big and little; some have read his widely published articles on children; others merely know of the remarkable way in which he has brought home and school together, so that parents constantly come to him to work out the problem of their child.
There are about two hundred chapters or sections—chapterettes, rather—in Angelo Patri’s Child Training. Each of them is so short that it can be read in five minutes or less. Each carries pointed wisdom about the child, and not only for the father or mother but for the uncle, aunt, teacher, or anyone having to do with children. Very often the point is conveyed by an anecdote—there are a good many smiles and chuckles in the book. But Mr. Patri can speak out with
definiteness. Perhaps his finest wisdom is shown in a point that he makes more than once: children do certain things that bother us because it is time for them to do these things. When this is true, Mr. Patri is bent on showing just what should be done to help the youngster over a hard place. Talks to Mothers is another treasury of Mr. Patri’s helpful wisdom.
Another new book on child training which will appeal to all those who believe in the power of suggestion is Auto-Suggestion for Mothers, by R. C. Waters, lecturer in English to the Nancy School of Applied Psychology. This is a practical book on the application of Emil Coué’s method. The technique to be used is explained clearly and simply. The possibilities of Coué’s method of auto-suggestion when applied to the correction of habits, to disease, to education and play are set forth and examples are cited. Auto-Suggestion for Mothers has been translated into French by Mme. Coué and has been adopted by the Coué School as a text.
iv
Every home should have one or more books on keeping well. The old family medical book, a chamber of horrors, has been made obsolete by a few general books with, thank heaven, a greatly different emphasis. But among recent books on the art of keeping well, I know of none more satisfactory than Dr. S. M. Rinehart’s The Commonsense of Health. Dr. Rinehart, who is the husband of Mary Roberts Rinehart, was a general practitioner in Pittsburgh for over twenty years. Later he was in charge of tuberculosis hospitals in western Pennsylvania, and during the war he was put in charge of all army tuberculosis hospitals in the United States. Recently he has been in the United States Public Health Service. His book is wholly popular in character, cheerful, good-natured, and not in the least afraid of an occasional joke. It is precisely the thing for general reading by both sexes at all ages. Common and worrisome ailments, such as colds, are dealt with, as well as certain fairly common and serious diseases, like pneumonia and tuberculosis. But the range of the book is wide, and there are discussions of nerves, how hard one
should work, and besetting fears. The information is sound and the style is entertaining. One class of unfortunate will be particularly helped by the book—the unhappy man or woman termed by Dr. Rinehart a “symptom hunter.” We each know at least one!
vI cannot close this chapter without a short word about books and the home. You who make the home, you women who are overwhelmingly the book readers of America, know how necessary books are to make the home complete. Read yourself, and discuss what you read. Never urge or compel a child to read a book. If you read the right books and talk about them afterward (they ought to move you to talk about them) the boy or girl will read them also. Buy books. In general, never buy them in “sets.” You ought to know an author, even a classic author, a little better than to have to do that. Keep abreast of the new books—one of the easiest things in the world to do, and one of the most fascinating. It is fair that you should ask that at least as much money go into the purchase of books for the home as goes into the purchase of magazines, or radio apparatus, or as is expended in mere diversions such as the picture shows. Last year thirty cents per person was spent for books in America—far too little. You can change all that, and no simple change that I can think of will pay you better.
BOOKS FOR THE HOMEMAKER
Choice Recipes for Clever Cooks, by Lucy G. Allen. More than 500 original recipes for those who already know how to cook and appreciate the best in food and flavor. By the director of the Boston School of Cookery. Illustrated.
Table Service, by Lucy G. Allen. A concise exposition of the waitress’s duties by the director of the Boston School of Cookery New revised edition, with illustrations and diagrams.
The Candy Cook Book, by Alice Bradley A new edition, revised, containing over 300 recipes and covering the subject completely. By the principal of Miss Farmer’s School of Cookery. Illustrated.
One-Piece Dinners, by Mary D. Chambers. Recipes for dinners where the meat, vegetables and other accessories are cooked all together and make a complete, well-balanced and sufficient meal. Directions are also given for optional salads and fruit desserts. Illustrated.
Cooking for Two: A Handbook for Young Housekeepers, by Janet McKenzie Hill. Instructions for young housekeepers and a collection of practical recipes for two, grouped according to food values. Fully illustrated.
Colette’s Best Recipes: A Book of French Cookery, by Marie Jacques. This new cook book, by a Breton whose culinary achievements have won her renown in France, contains recipes for the most delicious and palate-tickling dishes, from French consomme to the French pastries, of crispness or creaminess unsurpassed. Illustrated.
The Science of Eating, by Alfred W. McCann. A comprehensive book by an authority on foods; what to eat and why.
What to Eat and How to Prepare It, by Elizabeth A. Monaghan. This combines very definite information on food values with many recipes and instructions for cooking.
What to Drink, by Bertha E. L. Stockbridge. Recipes for several hundred beverages—ades, punches, fizzes, shrubs, milk drinks, icecreams, sundaes, sherbets, etc.
Food and Cookery for the Sick and Convalescent, by Fannie Merritt Farmer. A book for those whose duty it is to care for the sick, and of equal importance to those who see in correct nutrition the way of preventing much of the illness about us. Important chapters on infant and child feeding and suggestions as to diet in special diseases. By the author of The Boston Cooking-School Cook Book. Illustrated.
Canning, Preserving and Jelly Making, by Janet McKenzie Hill. “Aims to present the latest ideas on the subject using the methods found to be simplest and shortest by the experiments of the U. S. Department of Agriculture, State universities, and cooking experts.”—Booklist of the American Library Association. Illustrated.
Marketing and Housework Manual, by S. Agnes Donham. Clear and concise information on these everyday subjects.
Spending the Family Income, by S. Agnes Donham. “A guide to wise use of the family or personal income by means of a carefully thought-out and tested budget. Principles are laid down which apply equally well to large and small incomes.”—Booklist of the American Library Association. Illustrated with eight pages of charts in color.
The Prospective Mother, by J. Morris Slemons, M.D. Written especially for women who have no knowledge of medicine by a physician who has made this subject his specialty. Food, exercise, clothing, the adaptation of daily work, and recreation are fully covered.
Healthy Babies, by S. Josephine Baker, M.D., Consulting Director, Children’s Bureau, U. S. Department of Labor. The methods and advice given are intended to be used in keeping babies well, from the minute they are born until they are past the babyhood stage. The book shows how mother-love can be directed into the wisest and sanest channels. It contains three sets of baby record forms. Illustrated.
Healthy Children, by S. Josephine Baker, M.D., Consulting Director, Children’s Bureau, U. S. Department of Labor. Deals with the period of childhood between babyhood and school age. As its purpose is to accentuate health, it shows the mother how she may give the child of pre-school age the same health care available for the baby. Illustrated.
The Mothercraft Manual, by Mary L. Read. A young mother’s guide written by the former director of the School of Mothercraft, Peoria. Some of the chapters are on heredity and eugenics, the care
and feeding of children, home nursing, education of the child, games, toys, and story telling for children. Illustrated.
Nutrition and Growth in Children, by William R. P Emerson, M.D. Dr. Emerson has won nation-wide recognition by his pioneer work in organizing nutrition clinics in American cities. His study of the malnourished child is of the highest importance alike to the mother, the social worker and the public official. Illustrated.
How to Know Your Child, by Miriam Finn Scott. “A book that should be in every home where there are children. It is comprehensive and authoritative, and represents years of experience and study by a foremost expert. The very best manual on its subject obtainable at any price.”—Ladies’ Home Journal.
A Text-Book of Nursing, by Clara S. Weeks-Shaw. A book on home nursing which gives the non-professional nurse full directions for the hygiene of the sick-room, bathing, observance of symptoms, medicines and their administration, disinfection, surgical nursing, the care of sick children, etc. Illustrated.
Sewing and Textiles, by Annabel Turner. All the stitches, seams and finishes which go to make up the fundamentals of good sewing. Patching, sewing and darning are taught on samplers, but otherwise the methods are applied on useful garments. Materials are also studied and tests for shoddy are given. The author is instructor in home economics in the University of Wisconsin.
Tinkering With Tools, by Henry H. Saylor. Comment on tools and their care, with many suggestions as to their use for those who like to set their hands to such crafts as woodworking, painting, plumbing, masonry, electric wiring, etc. With illustrations and diagrams.
8. A Great Impersonation by E. Phillips Oppenheim
The other evening I picked up a novel called The Lighted Way, which, although it was published in May, 1912, I hadn’t chanced ever to read. The page blurred slightly before my eyes, I think, because in going back over it some of the names and particulars seemed entirely changed. But this, as I took it in first, was the way it ran:
“Mr. E. Phillips Oppenheim, sole proprietor of the firm of E. Phillips Oppenheim & Nobody, wholesale entertainers of London and Europe, paused suddenly on his way from his private office to the street. There was something which until that second had entirely slipped his memory. It was not his title, for that, tastefully chosen, was already under his arm. Nor was it the Plot, for that, together with the first chapter, was sticking out of his overcoat pocket, the shape of which it completely ruined. As a matter of fact, it was more important than either of these—it was a commission from his conscience.
“Very slowly he retraced his steps until he stood outside the glassenclosed cage where twelve of the hardest-worked clerks in London bent over their ledgers and invoicing. With his forefinger—a fat, pudgy forefinger—he tapped upon a pane of glass, and an anxious errand boy bolted through the doorway.
“‘Tell Mr. Reader to step this way,’ his employer ordered.
“Mr. Reader heard the message and came hurrying out. He was an undersized man, with somewhat prominent eyes concealed by gold-rimmed spectacles. He was possessed of extraordinary zest for the details of the business, and was withal an expert and careful adviser. Hence his hold upon the confidence of his employer.
“The latter addressed him with a curious and altogether unusual hesitation in his manner.
“‘Mr Reader,’ he began, ‘there is a matter—a little matter—upon which I—er—wish to consult you.’
“‘Those American serial rights——’
“‘Nothing to do with business at all,’ Mr. Oppenheim interrupted, ruthlessly. ‘A little private matter.’
“‘Indeed, sir?’”
Now as I say, at this point I went back and found to my bewilderment at first, but perfect satisfaction afterward, that Mr. Oppenheim seemed to be Mr. Weatherley, a worthy provisioner; the title, an umbrella; the Plot, a copy of the London Times; and the alarming commission from Mr. Oppenheim’s conscience, a possibly no less embarrassing commission from Mr. Weatherley’s wife. Thereupon everything went smoothly and excitingly through thirtyseven chapters. But afterward it occurred to me that perhaps, after all, my blunder, visual or mental, was not an unnatural one. Who has not had in his mind’s eye a picture of Mr. Oppenheim with a Plot, or Plots, bulging from his pockets, and with as many titles in his mental wardrobe as most men have neckties? And what one of his readers has not felt himself, time and again, personally summoned by the author to the consideration of a matter—a little matter—a quite private matter just then upon the author’s conscience....
ii
It is the secret of Mr. Oppenheim’s success, not detected as such by his readers, very probably not a trifle of which he himself is consciously aware. This engaging gift of confiding something, this easy air, this informality of his beginnings, disarms us and interests us as could no elaborately staged effort to arrest our attention and intrigue our minds. Even when he commences his story dramatically with such a confrontation as that which opens his The Wrath to Come, the air of naturalness is upon the scene. And the source of
this effect? It comes from the fact that Mr Oppenheim is imparting to you all that he himself knows at the given moment. Yes, literally. For our notion of him as a man with plots distending his pockets is entirely a mistaken notion. He has no plots; at least, he has no ready-made plots; he does not, so to say, plot his plots. “Just the first chapter, and an inkling of something to follow,” was his answer to some one who asked him how much of his leading character he saw when he began a novel.[47] What other method, when you stop to reflect upon it, would be possible for the author of eighty-six published novels? Certainly no one could map out his tales, even in essentials, and then write them to that number, not if he were to do the plots one by one, as occasion arose. He would be a slave, and the book, as written, would soon come to be lifeless. Nor, by such a method, would thirty-eight years afford time. In thirty-eight years the pace would be lost. Only spontaneity is capable of guaranteeing such a record as stands to Mr. Oppenheim’s credit. “Two or three people in a crowded restaurant may arouse my interest, and the atmosphere is compelling. I start weaving a story around them—the circumstances and the people gradually develop as I go on dictating to my secretary the casual thoughts about them that arose in me while I was looking at them and their surroundings. First of all I must have a congenial atmosphere—then the rest is easy.”[48] And again:
“Writing for the movies is a ghastly business. I speak from experience. I shall never do it again. The picture people came to me and said, ‘Next time you have a novel in your head, why not, instead of writing 80,000 words, write a 5,000-word synopsis and let us have it? Then write your novel from the synopsis.’
“Well, they paid well and I did it. I wrote the synopsis first and then set to work on the novel. I have never had a harder job in my life. Some writers, no doubt, do sketch out their plots beforehand, but I never work that way. When I start a story I never know just how it is going to end. All I have to start with is an idea. As I go along the idea grows and develops. So do the characters. I sort of live with them through the story and work out their salvation as it goes along. It is like a game.
“But when you write for the movies you have to reverse the process. In my case, it is fatal. Novels, even the kind that I write— and they are solely for amusement—must have some soul, something that gives them a human quality. This the author puts into the story as he goes along. When, however, he writes a synopsis and then sits down to enlarge and expand it into a novel, the spell is broken. He has a cold and rigid plan to follow. It nearly killed me to novelize my first scenario.”[49]
He dictates his novels, revising the sheets as they come from the typewriter, sometimes re-dictating a passage or chapter. In summer he works outdoors; in winter he may pace up and down his study. “Many a time, earlier in life, when I used to write my stories with my own hand, I have found that my ideas would come so much faster than my fingers could work that I have prayed for some more speedy method of transmission. My present method is not only an immense relief to me, but it enables me to turn out far more work than would have been possible by any other means.”[50] Story-writing, he believes, is an original instinct, “just as it is an original instinct with a sporting dog to sniff about in every bush he passes for a rabbit. One writes stories because if one left them in the brain one would be subject to a sort of mental indigestion. As to plots, there are only about a score in the world, and when you have used them all, from A to Z”—which he pronounced “Zed,” for this was in an after-dinner speech—“you can turn around and use them from Z to A.”[51] A favorite illustration with him is taken from a day’s walk in London. “You can take the same walk every day in the year and you will meet a different crowd of people. These people contain the backgrounds of 365 stories a year.” One person a day will keep the typewriter in play, for “I create one more or less interesting personality, try to think of some dramatic situation in which he or she might be placed, and use that as the opening of a nebulous chain of events.”
What he said of himself at 55 is still, two years later, true without abatement. “Even if, like one of the heroes of fiction, I should make a million dollars out of a ten-cent piece in Wall Street, I should still continue to write stories so long as I can sit in an easy chair and my voice will carry as far as my secretary before a typewriter.” Which is
reminiscent of Hugh Walpole’s remark in conversation the same year, that he was perfectly sure if a beam fell on his head and made him imbecile, he would continue to write novels for the pleasure of writing them.
Mr. Oppenheim was born in 1866 and went from school into his father’s leather business at Leicester—but he had started writing stories before that. He began to write them at fifteen, and showed his first to the headmaster of the school, “who, instead of giving me the birching I deserved, wished me luck and encouraged me to persevere.” The leather business was successful and was bought up by Blumenthals, a large American and Paris leather firm, who appointed young Oppenheim their director at Leicester. “His experience in that trade,” asserts Mr A. St. John Adcock in his Gods of Modern Grub Street, [52] “has proved immensely useful to him. It has not only helped him to material for his tales, but it was through the American head of Blumenthals that he had his chief incentive to the writing of the type of story that has brought him such success as a novelist. This gentleman introduced him to the proprietor of the Café de Rat Mort, the once famous Montmartre haunt, for Oppenheim was frequently in Paris on the affairs of his leather company, and at the Café he acquired his taste for the mysteries of those international intriguings and rascalities that figure so largely in several of his books, for the proprietor used to tell him all manner of thrilling yarns about political and international adventurers, some of whom had been among his customers, and his listener formed a habit of weaving stories around the more striking personalities in the cosmopolitan crowd that he met in the Dead Rat.”
He was eighteen years old when his first short story was published, and only twenty when his first novel appeared. Before he was thirty he married Miss Elsie Hopkins, of Chelsea, Massachusetts. Mr. Oppenheim and his wife called their cottage in Sheringham, Norfolk, “Winnisimmet,” which was the Indian name of her Massachusetts home town. The house overlooked the North
Sea. Perhaps this detail, as much as another, led the author to the construction in the years before the world war of that series of stories in which, as an element of his plots, Mr. Oppenheim kept repeating Germany in the rôle of the villain. Legend has it that during the war itself his name was on the list of Britons to be shot if captured, although lists of that sort are usually myths. “There was one period,” he has commented since, “in the autumn of 1918, when a welldirected bomb upon the Ministry of Information might have cleared the way for the younger novelists at the expense of Arnold Bennett, John Buchan, Dion Calthrop, E. Temple Thurston, Hugh Walpole and myself.”[53] He visited America in 1911 and again in 1922, when Mrs. Oppenheim came with him. On the latter occasion he made by far the wittiest comment of any visitor in reply to the usual question: what he thought of prohibition. “My only fear,” with a smile, “is that it may make me a drunkard.”[54] Those who met the victim of this reasonable dread saw a sturdy, broad-shouldered figure developed by air and outdoor exercise; and those who played golf with him respected his handicap of seven strokes only. His large, florid face seemed to kindle into laughter from the constant humorous gleam in his blue eyes. Among his own titles he confessed to a fondness for A Maker of History, The Double Life of Mr. Alfred Burton, The Great Impersonation and—perhaps influenced a little by its then impending publication—The Great Prince Shan. At this time he was subjected to one of those sets of questions from the answers to which one may construct a totally wrong picture of the person. However, we may note that his idea of happiness was tied up with his work, and that he gave as his notion of unhappiness, “No ideas.” His particular aversion, he said, was fog.[55] Fog? Yet he has said: “I would be perfectly content to spend the rest of my days in London. Half a dozen thoroughfares and squares in London, a handful of restaurants, the people whom one meets in a single morning, are quite sufficient for the production of more and greater stories than I shall ever write.”[56] He describes himself as no great traveller; he has, though, been in most European countries, and he pretty regularly spends his winters at his villa in Cagnes on the Riviera. He
divides his time in England between the house in Norfolk and his rooms in London.
ivMr. Oppenheim does not take himself seriously in the rôle of prophet. “Large numbers of people have noted the fact that in certain of my earlier novels I prophesied wars and world events that actually did come to pass. In The Mysterious Mr. Sabin, I pictured the South African Boer war seven years before it occurred. In The Mischief Maker, The Great Secret, and A Maker of History I based plots upon the German menace and the great war that did actually occur. The romance of secret diplomacy has enthralled me for years. In writing my novels I have had no particular advance knowledge of world affairs. I have reasoned to myself, ‘This nation is aiming toward this,’ and ‘That nation is aiming toward that’; then I have invented my puppets representing these conflicting ambitions and set them in action. It was the story first of all that appealed to me, and not any burning desire to express political convictions and lay bare great conspiracies.”[57]
He takes himself seriously only in the rôle of entertainer, of storyteller. “If you tell him you like his books,” says Gerald Cumberland, in Written in Friendship, “he is frankly pleased; but if you pay him high-flown compliments he will begin to yawn.” There need be no paying of compliments in a consideration of Mr. Oppenheim’s work, but no analysis of his method could fairly withhold considerable praise. We have spoken of his confidential, easy manner with the reader as a secret of his toward establishing plausibility for the things he is about to tell. But there is more to be noted. Like the best writers of his sort among his countrymen—and like far too few Americans in the same field—he is unhurried. He is never afraid to pause for the amplification of sentiment, the communication of the moment’s feeling, a bit of characterization or a passage of pure description. And these are the matters which give an effect of rondure, and not infrequently touches of charm, to a story of whatever sort. At the moment I can think of only one
American—Hulbert Footner—who has had the wisdom, or perhaps the temperament, to follow British practice in this by no means negligible affair of workmanship; and it is significant that Mr. Footner, an American, has so far had a better reception in England than in his own country. Apparently we value this certain leisureliness when it comes to us from abroad, for Mr. Footner, re-exported to us, is making distinct headway. What the American writer generally does is to accelerate his action to the pitch of implausibility (if he only knew it). This does very well, and may be indispensable, for all I know, with the readers of a certain type of American magazines; unfortunately the habitual buyers and readers of books demand something more careful.
The other interesting point of excellence in Oppenheim’s work derives from his method of spontaneity. He once said: “The lure of creation never loses its hold. Personally I cannot account for the fact. Perhaps it springs from the inextinguishable hope that one day there will be born the most wonderful idea that has ever found its way into the brain of a writer of fiction.”[58] For the creator, the superlative never arrives; but certainly for the reader Mr. Oppenheim has materialized more than one wonderful idea. The Great Impersonation, deservedly one of his most successful books, is a fairly recent illustration. But I would like to call particularly to attention an earlier story, both for what seems to me to be its astonishing merit and for its interesting light on the method of spontaneity which is Oppenheim’s special technique. This is The Way of These Women, now ten years old. That it still sells is evidence that its merit is recognized; that one never hears mention of it in any offhand mention of its author’s work shows that the recognition is by no means wide enough.
Sir Jermyn Annerley, a young man of fine taste and high honor, though certainly inclined toward priggishness, is a playwright of the intellectual type. Sybil Cluley, the actress who has aroused London by her performance in Jermyn’s drama, comes to Annerley Court as his weekend guest. They are to discuss his new play in which Sybil is to appear. Aynesworth, Marquis of Lakenham and Jermyn’s second cousin, chances to pay a visit at the same time. Another
distant cousin of Jermyn’s, Lucille, who has divorced a French nobleman, is Jermyn’s hostess. Lucille is in love with Jermyn. During the visit Jermyn surrenders to his love for Sybil; they announce their engagement to the others. Sybil is obviously afraid of Lakenham to a degree not to be accounted for by his reputation for excesses, and after some time Lakenham confirms and shares with Lucille his knowledge of a discreditable episode in Sybil’s career before her success on the stage.
Lakenham is murdered at Annerley Court. Suspicion points directly to Sybil, but Lucille has aided Sybil and Jermyn in the removal of very incriminating evidence. As the price for protecting Sybil, Lucille requires Jermyn to marry her within two months.
The story is developed with admirable intervals and suspense. The point of the first quarter of the book is Lakenham’s knowledge of something in Sybil’s past, and Lucille’s determination to fight Sybil for Jermyn. Then Lakenham is killed. Almost half the book lies between the murder and its solution. It is evident that as he wrote Mr. Oppenheim saw (what he may not have grasped at the beginning) that Lucille was his most striking character As the novel proceeded he became absorbed in the possibilities Lucille offered; if, as may well be the case, he vaguely contemplated solving the murder and bringing Sybil and Jermyn happily together for a quick “curtain,” he deliberately abandoned so conventional and easy an ending. Jermyn and Lucille are married under the hateful terms Lucille has imposed as the price of Sybil’s safety.
It is this that lifts The Way of These Women out of the run of Mr. Oppenheim’s work. Did Sybil kill Lakenham? If she did not, who did she think killed him? If Lucille used fraud with Jermyn, why not annul the marriage for fraud and bring down the curtain? (And in putting these questions I decline responsibility for your wrong inferences as to the answers.) In any case, the solution of the murder would seem to end the story. But something larger and more fateful, something of very near universal significance, had by this time lodged in Mr. Oppenheim’s mind. The “wonderful idea” had come. The last quarter of The Way of These Women is the material, intrinsically, for a very great novel. And Mr. Oppenheim handles it with touches of
greatness. He could, of course, by slashing off most he had already written, by adopting some such technical device as W. B. Maxwell used in The Devil’s Garden, have made it a masterpiece, for his knowledge of his theme and his appreciation of its character are plain to be seen. I do not know whether this novel has ever been dramatized, but it is incredible that it should not have been dramatized; the possibilities of Lucille are greater than those of Camille, for they are less artificial and they are not either sentimental or cheap. Why did Mr. Oppenheim not rework it; why did he let it go as the book is, a mixture? Of several possible extenuations, I think the best is that by leaving it alone he probably was able to take the reader who sought merely to be entertained into a very high place whither that reader could not have been lured directly. And it is an elevation to which the writer of ready-made plots never leads.
BOOKS BY E. PHILLIPS OPPENHEIM
N : The reader is referred to the bibliography by Mr. Hulings C. Brown appearing in the Boston Evening Transcript for 5 May 1923. Mr. Brown’s arrangement of the titles is alphabetical (including both English and American titles). His list includes Mr. Oppenheim’s five serials of book length, not given below because not published in book form. Mr. Brown also gives the publisher (except in a few cases where no record exists). In the list below books that have been published in America are starred; those that have been published in America and were recorded by Mr. Brown as in print are doublestarred. Books written under the pseudonym “Anthony Partridge” are so indicated.
1887 Expiation
1894 A Monk of Cruta
1895 **A Daughter of the Marionis. First title in America was To Win the Love He Sought.
1895 The Peer and the Woman
1896 False Evidence
1896 A Modern Prometheus
1896 *The Mystery of Mr. Bernard Brown
1896 The Wooing of Fortune
1897 The Amazing Judgment
1898 *As a Man Lives. First title in America was The Yellow House.
