Evidence Based Data In Hand Surgery And Therapy
Federation of European Societies for Surgery of the Hand Instructional Courses 2017
XXII. FESSH Congress & XII. EFSHT Congress 21-24 June 2017 | Budapest, Hungary
Editors Grey Giddins Gürsel Leblebicioğlu www.irisinteraktif.com [email protected] Phone : +90 (312) 236 28 79 Fax : +90 (312) 236 27 69
ISBN : 978-605-4711-07-9
Graphic Design Ayhan Sağlam Altan Kiraz
II Grey Giddins dedication: I dedicate this book to my family Jane, Imogen, Miranda and Hugo who have supported me through many long years of work and to my parents who have supported me for many decades.
Gürsel Leblebicioğlu dedication: To my wife Meral and to my son Can; this work has only been realised through the loss of precious time together.
III IV CONTENTS
1. GENERAL TOPICS 1.1 Basic Concepts 1 Gürsel LEBLEBİCİOĞLU, Egemen AYHAN
1.2 Hand Outcome Measurements 23 A Systematic Review of Performance-Based Outcome Measures and Patient-Reported Outcome Measures Çiğdem ÖKSÜZ, İlkem Ceren SIĞIRTMAÇ, Gürsel LEBLEBİCİOĞLU
2. CONGENITAL HAND PROBLEMS 2.1 Congenital Hand Surgery 87 Michael A. TONKIN, Jihyeung KIM, Goo Hyun BAEK, Anna WATSON, Konrad MENDE, David A. STEWART, Christianne Van NIEUWENHOVEN, Steven E.R. HOVIUS, Jose A. SUURMEIJER, Konrad MENDE, Pratik RASTOGI, Richard D. LAWSON, George R.F. MURPHY, Branavan SIVAKUMAR, Gill SMITH, Paul SMITH
3. BONE AND JOINT 3.1 Management of Common Hand Fractures: The Evidence 201 David SHEWRING, Robert SAVAGE, Dyfan EDWARDS, Grey GIDDINS, Ryan W. TRICKETT, Jeremy N RODRIGUES, Will COBB, Wing Yum MAN, Ryan W. TRICKETT, Daniel MG WINSON, Anca BREAHNA, Andy LOGAN
V Contents
3.2 Scaphoid Fractures- the Evidence 283 David WARWICK, Clare MILLER, Avishek DAS, Tim DAVIS, Joe DIAS, Mark BREWSTER, Richard PINDER, Lindsay MUIR, Shai LURIA, Lizzie PINDER
3.3 Tendon Reconstruction of the Unstable Scapholunate Dissociation. A Systematic Review 355 Marc GARCIA-ELIAS, Diana Marcela ORTEGA HERNÁNDEZ
3.4 Thumb TMC Joint Osteo-Arthritis 369 Massimo CERUSO, Giovanni MUNZ, Christian CARULLI, Gianni VIRGILI, Alessandro VIVIANI, Nadine HOLLEVOET, Grey GIDDINS
3.5 Systematic Review of the Management of Distal Radial Fractures 429 Charles PAILTHORPE, Nick JOHNSON, Joe Dias, Andrew DUCKWORTH, Shivkumar GOPAL, Lisa LEONARD, Adam WATTS, James WHITE, Adam BROOKS, Jamie BROSCH, Joelle CHALMER, Tim CHESSER, Zoe CLIFT, Clare GRANVILLE, Helen HEDLEY, Ian MCNAB, Alexia KARANTANA, Claire PULFORD, Pida RIPLEY
4. SOFT TISSUES 4.1 Systematic Review of Flexor Tendon Rehabilitation Protocols after Acute Flexor Tendon Repair in Zone 2 451 Thomas GIESEN, Maurizio CALCAGNI
4.2 Postoperative Care After Extensor Tendon Repair 459 Jin Bo TANG
4.2.1 Rehabilitation of Extensor Tendons in the Finger Zones I to V 459 Koji MORIYA, Takae YOSHIZU
4.2.2 Rehabilitation of Extensor Tendons in the Hand and Forearm Zones VI to IX and of Extensor Pollicis Longus Tendon 475 Adnan PRSIC, Jonathan L. BASS, Jin Bo TANG
VI 4.3 Comparison of Outcomes Following Nerve Transfers versus Nerve Grafting. 491 A Systematic Review of Individual Participant Data for Restoration of Elbow Flexion after Adult Brachial Plexus Injuries. Francisco SOLDADO, Egemen AYHAN, Cesar G. FONTECHA, Jayme A. BERTELLI, Gürsel LEBLEBİCİOĞLU
4.4 Evidence in Compression Neuropathies 537
4.4.1 Evidence in Carpal Tunnel Syndrome 537 Alessandro POZZI, Loris PEGOLI, Giorgio PIVATO
4.4.2 Evidence-Based Approach to the Treatment of Cubital Tunnel Syndrome 547 Krzysztof A. TOMASZEWSKI, Michael Henry BRANDON, Patrick POPIELUSZKO, Przemysław A. PĘKALA, Mariusz BONCZAR
4.5 Injection Therapy in Hand Surgery 564 Balazs LENKEI
5. MISCELLANEOUS 5.1 Complex Regional Pain Syndrome (CRPS) Treatment. A Systematic Review. 573 Andrzej ŻYLUK
5.2 Future for Evidence Based Data in Hand Surgery 595 Miriam MARKS, Daniel B. HERREN
VII
EDITORS
Grey GIDDINS Professor Consultant Orthopaedic and Hand Surgeon Visiting Professor University of Bath Editor-in-Chief Journal of Hand Surgery (European) (2012 -2016) President of the British Society for Surgery of the Hand
The Hayes Newton St Loe Bath BA2 9BU 07828 149967
The Hand to Elbow Clinic 29a James St West Bath BA1 2BT 01225 316895 [email protected]
Gürsel LEBLEBİCİOĞLU Professor of Orthopaedic Surgery and Traumatology Council Member, Federation of European Society for Surgery of the Hand FESSH Member of the European Board of Hand Surgery Diploma Examination Committee Member of the Management Committee, Journal of Hand Surgery European
Willy Brandt Sokak ¾, Çankaya, Ankara, Turkey. 06680 [email protected]
IX Contributors
Egemen AYHAN Department of Orthopaedics and Traumatology, Division of Hand Surgery University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Şehit Ömer Halisdemir Cad., Altındağ, Ankara, Turkey. 06110 [email protected]
Goo Hyun BAEK Professor Department of Orthopedic Surgery Seoul National University Hospital Seoul National University College of Medicine 101 Daehak-ro, Jongno-gu Seoul 03080, Korea. [email protected]
Jonathan L. BASS Department of Plastic Surgery, Rhode Island Hospital, Providence RI, USA; Division of Plastic Surgery, The Alpert Medical School, Brown University, Providence RI, USA.
Mariusz BONCZAR Intermed Medical Center, Krakow, Poland. [email protected]
X Anca BREAHNA Locum Consultant Hand & Plastic Surgeon, Pulvertaft Hand Centre, Derby, UK. [email protected]
Mark BREWSTER Consultant Hand Surgeon, University Hospital of Birmingham NHS Foundation Trust, UK. [email protected]
Adam BROOKS Consultant Orthopaedic Surgeon, Great Western Hospital, Swindon, BOA Professional Practice Committee representative.
Jamie BROSCH General Practitioner; GPwSI Orthopaedics; Medical Director, Medvivo Group, Chippenham, Whiltshire, UK.
XI Contributors
Maurizio CALCAGNI Plastic Surgery and Hand Surgery Division University Hospital Zurich Raemistrasse 100 8091 Zurich, CH. [email protected]
Christian CARULLI Orthopaedic Clinic, Department of Surgery and Translational Medicine, AOUC, University of Florence, Florence, Italy.
Massimo CERUSO Direttore S.O.D.C. Chirurgia e Microchirurgia ricostruttiva della Mano Azienda Ospedaliero-Universitaria Careggi. Firenze C.T.O. Largo P.Palagi, 1. 50139 Firenze (I), Italy. [email protected]
Joelle CHALMER Therapies Department, St George’s Hospital, London, UK.
XII Tim CHESSER Consultant Trauma and Orthopaedic Surgeon, North Bristol NHS Trust, Chairman BOA Trauma Group, UK.
Zoe CLIFT Extended Scope Practitioner. The Pulvertaft Hand Unit, Royal Derby Teaching Hospitals, Derby, UK.
Will COBB Specialist Registrar in Plastic Surgery, Oxford University Hospitals, UK. [email protected]
Avishek DAS ST5 Trauma and Orthopaedics, East Midlands (Nottingham) Rotation, UK. [email protected]
XIII Contributors
Tim DAVIS Consultant Hand Surgeon, Queens Medical Centre Nottingham, UK. [email protected]
Joe DIAS Consultant Hand Surgeon, University of Leicester, UK. [email protected]
Andrew DUCKWORTH Specialty Registrar, Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Scotland.
Gray A.D. EDWARDS Specialist Registrar in Trauma & Orthopaedic Surgery, Gloucester Royal Hospital, Gloucester, UK. [email protected]
XIV César G. FONTECHA Vall d’Hebron Institute of Research (VHIR). Passeig de la Vall d’Hebron, 119-129. 08035 Barcelona, Spain. [email protected]
Marc GARCIA-ELIAS Institut Kaplan Passeig de la Bonanova, 9, 2-2 08022 Barcelona, Spain. [email protected]
Thomas GIESEN Plastic Surgery and Hand Surgery Division University Hospital Zurich Raemistrasse 100 8091 Zurich, CH. [email protected]
Shivkumar GOPAL Consultant Orthopaedic Surgeon Hull and East Yorkshire Hospitals NHS Trust, UK.
XV Contributors
Clare GRANVILLE Nurse. Plaster room representative.
Helen HEDLEY Consultant Hand and Wrist Surgeon University Hospitals Coventry and Warwickshire NHS Trust, UK.
Daniel HERREN Hand Surgery Department Schulthess Clinic Lengghalde 2 8008 Zurich, CH. [email protected]
Nadine HOLLEVOET Ghent University Hospital, Department of Orthopaedic Surgery and Traumatology since 1995. Associated Professor of Orthopaedic Surgery at the Ghent University. Ghent, Belgium. [email protected]
XVI Steven E.R. HOVIUS Professor (emer.) of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands and Xpert Clinic, The Netherlands. [email protected]
Nick JOHNSON Speciality Registrar, University Hospitals of Leicester, UK.
Alexia KARANTANA Speciality Registrar, University Hospitals of Leicester, UK.
Jihyeung KIM Department of Orthopaedic Surgery, Seoul National University, College of Medicine, Seoul, Korea. [email protected]
XVII Contributors
Richard D. LAWSON Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children’s Hospital at Westmead, University of Sydney, Sydney, Australia. [email protected]
Balazs LENKEI B-A-Z County Hospital Traumatology Departement Street: 72-76 Szentpeteri kapu ZIP: 3526 City: Miskolc, Hungary. [email protected]
Andy LOGAN Consultant Hand Surgeon, Cardiff, UK. [email protected]
Shai LURIA Department of Orthopaedic Surgery, Hadassah-Hebrew University Medical Centre, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel. [email protected]
XVIII Wing Yum MAN Specialist Registrar in Trauma & Orthopaedic Surgery, Cardiff, UK. [email protected]
Miriam MARKS Department of Teaching, Research and Development. Schulthess Clinic Lengghalde 2 8008 Zurich, Switzerland. [email protected]
Ian McNAB Consultant Hand Surgeon, Nuffield Orthopaedic Centre, Oxford, UK.
Konrad MENDE Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children’s Hospital at Westmead, University of Sydney, Sydney, Australia. [email protected]
XIX Contributors
Brandon MICHAEL HENRY Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. International Evidence-Based Anatomy Working Group, Krakow, Poland. [email protected]
Clare MILLER Consultant Hand Surgeon, Aberdeen Royal Infirmary, Scotland. [email protected]
Koji MORIYA Niigata Hand Surgery Foundation, Suwayama 997, Seiro-machi, Niigata 957-0117, Japan. [email protected]
Lindsay MUIR Consultant Hand Surgeon, Salford Royal NHS Foundation Trust, UK. [email protected]
XX Giovanni MUNZ Hand Surgery, Department of Surgery and Translational Medicine, AOUC, University of Florence, Florence, Italy.
George R.F. MURPHY Department of Plastic Surgery, Great Ormond St Hospital for Children, London, United Kingdom; The Portland Hospital for Women & Children, London, UK. [email protected]
Diana Marcela ORTEGA HERNÁNDEZ Centro Médico Teknon, Barcelona, Spain. [email protected]
Çiğdem ÖKSÜZ Hacettepe Üniversitesi, Sağlık Bilimleri Fakültesi, Ergoterapi Bölümü 06100 Samanpazarı/Ankara, Turkey. [email protected]
XXI Contributors
Charles PAILTHROPE Consultant Orthopaedic Surgeon, Royal Berkshire Hospital, Reading, UK. [email protected]
Loris PEGOLI ISSPORTH Secretary General Hand and Microsurgery Unit San Pio X Clinic - Milan, Italy Via Francesco Nava 20159, Milan, Italy. [email protected]
Przemysław A. PĘKALA Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. International Evidence-Based Anatomy Working Group, Krakow Poland. [email protected]
Lizzie PINDER Consultant Orthopaedic and Hand Surgeon, Ipswich, UK. [email protected]
XXII Richard PINDER Consultant Plastic and Hand Surgeon, Hull & East Yorkshire Hospitals NHS Trust, UK. [email protected]
Giorgio PIVATO Chief of Hand and Microsurgery Unit San Pio X Clinic - Milan, Italy. Via Francesco Nava 20159, Milan, Italy. [email protected]
Patrick POPIELUSZKO Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. International Evidence-Based Anatomy Working Group, Krakow. Poland. [email protected]
Alessandro POZZI Hand and Microsurgery Unit San Pio X Clinic - Milan, Italy Via Francesco Nava 20159, Milan, Italy. [email protected]
XXIII Contributors
Adnan PRSIC Department of Plastic Surgery, Rhode Island Hospital, Providence RI, USA; Division of Plastic Surgery, The Alpert Medical School, Brown University, Providence RI, USA. [email protected]
Pratik RASTOGI Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children’s Hospital at Westmead, University of Sydney, Sydney, Australia. [email protected]
Jeremy N. RODRIGUES NIHR Academic Clinical Fellow in Plastic Surgery, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK. [email protected]
Robert SAVAGE Consultant Orthopaedic and Hand Surgeon, Newport, UK. [email protected]
XXIV David SHEWRING Consultant Hand Surgeon, Cardiff, UK. [email protected]
İlkem Ceren SIĞIRTMAÇ Hacettepe Üniversitesi, Sağlık Bilimleri Fakültesi, Ergoterapi Bölümü 06100 Samanpazarı/Ankara, Turkey. [email protected]
Branavan SIVAKUMAR Department of Plastic Surgery, Great Ormond St Hospital for Children, London, United Kingdom; The Portland Hospital for Women & Children, London, UK. [email protected]
Gill SMITH Department of Plastic Surgery, Great Ormond St Hospital for Children, London, United Kingdom; The Portland Hospital for Women & Children, London, UK. [email protected]
XXV Contributors
Paul SMITH Department of Plastic Surgery, Great Ormond St Hospital for Children, London, United Kingdom; The Portland Hospital for Women & Children, London, UK. Bishops Wood Hospital, Rickmansworth Road Northwood, Middlesex, UK. HA6 2JW [email protected]
Francisco SOLDADO Hospital Sant Joan de Deu. Passeig Sant Joan de Deu, 2. 08950 Esplugues de Llobregat, Barcelona, Spain. [email protected]
David A. STEWARD Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children’s Hospital at Westmead, University of Sydney, Sydney, Australia. Sydney Hand Surgery Associates Suite 1, Level 4 North Shore Private Hospital Westbourne Street St Leonards NSW 2061, Australia. [email protected]
Jose A. SUURMEIJER Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children’s Hospital at Westmead, University of Sydney, Sydney, Australia Acute Services Building, Clinical Admin 3E Royal North Shore Hospital St Leonards NSW 2065, Sydney, Australia. [email protected]
XXVI Jin Bo TANG The Department of Hand Surgery, Hand Surgery Research Center, Nantong University, Nantong, Jiangsu, China. [email protected]
Krzysztof A. TOMASZEWSKI Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. International Evidence-Based Anatomy Working Group, Krakow, Poland. [email protected]
Michael A. TONKIN My postal address is: PO Box 632 Milsons Point 1565 Australia. [email protected]
Ryan TRICKETT Consultant Hand Surgeon, Cardiff, UK. [email protected]
XXVII Contributors
Christianne Van NIEUWENHOVEN Department of Plastic and Reconstructive Surgery, and Hand Surgery Erasmus MC Rotterdam. Postbox 2060 3000 CB Rotterdam, The Netherlands. [email protected]
Gianni VIRGILI Department of Translational Surgery and Medicine, University of Florence, AOUC, Florence, Italy.
Alessandro VIVIANI Statistics, Computer Science, Applications "G. Parenti" (DISIA), University of Florence, Florence, Italy.
David WARWICK Consultant Hand Surgeon, University Hospital Southampton, UK. [email protected]
XXVIII Anna WATSON Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children’s Hospital at Westmead, University of Sydney, Sydney, Australia 45/93 Elizabeth Bay Road, Elizabeth Bay, Sydney, NSW, Australia. [email protected]
Adam WATTS Consultant Upper Limb Surgeon, Wrightington Hospital. Visiting Professor, Department of Materials, University of Manchester, UK.
James WHITE Speciality Registrar, Northwest Thames Deanery, St Mary’s Hospital, Paddington, London, UK.
Daniel M.G. WINSON Specialist Registrar in Trauma & Orthopaedic Surgery, Cardiff, UK. [email protected]
XXIX Contributors
Takae YOSHIZU Niigata Hand Surgery Foundation, Suwayama 997, Seiro-machi, Niigata 957-0117, Japan. [email protected]
Andrzej ŻYLUK Department of General and Hand Surgery Pomeranian Medical University in Szczecin, Poland. 71-252 Szczecin, ul. Unii Lubelskiej, Poland. [email protected]
XXX FOREWORD
his FESSH instructional course book is unique amongst FESSH instructional books in concentrating on Evidence TBased Medicine through systematic reviews. It was con- ceived by Zsolt Szabo the Chairman of the 2017 FESSH organ- ising committee. We were asked to chair the instructional course and edit the instructional book. A systematic review of every topic in Hand Surgery was plainly impossible. We have commissioned a range of topics outlining Evidence Based Medicine and how it works, and a range of Elective and Trauma topics in Hand sur- gery. We have tried to cover a broad range of subjects. Not every- one who was approached could deliver their work in time so there are common conditions that we treat which we have not covered. This was inevitable given how much work there is in writing a systematic review especially in some parts of Hand Surgery where there is extensive published literature. In other sections there is very little published work making the chapters rather sparse. That reflects the work we as Hand Surgeons need to do, not the work of the authors. Editing the chapters has been very instructive. Some have con- firmed what we already know. Others have challenged our beliefs usually showing that what we believed we knew is not so clear-cut. For a few sub-topics we can be clear we have achieved a reasonably definitive position, e.g. endoscopic carpal tunnel release does not give better results than open surgery; in most we have highlighted how little we know. This may seem a disappointment and in some ways it is; many dedicated, often brilliant, surgeons, therapists and
XXXI Foreword
others have worked incredibly hard to advance our speciality, but what we know definitively is surprisingly small. Science moves on and what was good science 20 or more years ago is often (but not always) inadequate. It is important that we highlight this rather than perpetuating errors. That does not mean that what we are doing is wrong (although sometimes it will be), but that we cannot be sure enough that what we are doing is right. We hope this work, combined with other systematic reviews and Cochrane reviews will provide a basis from which to develop our speciality along more scientific lines to try to ensure what we do is right. Read these chapters, learn what we know and where you see what we do not know set out to answer those many questions. However young you are you will still have plenty of work left to complete by the end of your career. We want this work available to anyone working to advance the care of patients with hand problems. This electronic book will be given to everyone attending the FESSH meeting in Budapest and can be distributed widely from there to help all clinicians and scientists in interested in advancing Hand care through Evidence Based Medicine. We have been honoured to do this work for FESSH. We are tre- mendously grateful to the editors and authors of the chapters who have done an enormous amount of work to produce this book. We hope we have made a small contribution to the advancement of Hand Surgery by throwing some light on what we know and especially on what we do not know.
Grey Giddins, Bath, UK Gürsel Leblebicioğlu, Ankara, Turkey
XXXII CHAPTER1 GENERAL TOPICS 1. GENERAL TOPICS
2 1.1 Basic Concepts
Gürsel LEBLEBİCİOĞLU Egemen AYHAN
Corresponding Author Gürsel LEBLEBİCİOĞLU Professor of Orthopaedic Surgery and Traumatology Willy Brandt Sokak ¾, Çankaya, Ankara, Turkey. 06680 [email protected]
Introduction Why do we read? Any of us will answer this question similarly: I am curious, I am looking for answers, or I am working on a re- search project. But, how much do you read per patient? Seconds, or minutes? What do you read? Textbooks, or journals? Traditionally, if our clinical experience is sufficient to solve the problem of the patient, we used to rely on that only. If we are not sufficiently experienced, acting upon the well-known motto -med- ical teaching is a kind of master and apprentice model-, our next step may be to consult an expert. Finally, we read textbooks and medical journals. However, these are conflicted: as we grow older, our experience expands but our up-to-date knowledge weakens; the research evidence behind our (or the expert’s) treatment weak- ens; and it is not possible to keep up with all the published knowl- edge even in hand surgery. We all need an easily available source of valid, up-to-date information in a short time. This has led to emergence of “evidence-based medicine” (EBM) leading to a paradigm shift in medicine, trivializing the expert opinion and case studies and emphasizing randomized clinical tri- als and systemic researches (Hoppe and Bhandari, 2008).
3 1. GENERAL TOPICS
SUBTOPICS History and Evolution of Evidence-Based Medicine Practice of EBM • Asking a Focused Question • Finding the Best Evidence • Critical Appraisal of the Evidence • Integration of the best evidence with clinical expertise and pa- tient values • Self-evaluation (of the previous steps) PRISMA Methodology Industrial Considerations History and Evolution of Evidence-Based Medicine In the early 1980s, as the seeds of the paradigm shift, Dr. David Sackett used the term “critical appraisal” to describe the system- atic examination of the medical literature to extract best evidence at McMaster University (Hoppe and Bhandari, 2008; Sackett et al., 2000). In 1992 the term Evidence Based Medicine (EBM) was used to describe a new approach to medical practice, by a group led by Gordon Guyatt (Guyatt et al., 1992). The Oxford Centre for Evidence-Based Medicine (CEBM) was established in 1995 by the efforts of Dr. Muir Gray, who invited Dr. David Sackett to be director of CEBM. The CEBM is now an internationally renowned not-for-profit organization for practice, teaching and dissemina- tion of high quality evidence based medicine to improve healthcare in everyday clinical practice. In 1996, Sackett et al., (1996) de- fined EBM:“Evidence based medicine is the conscientious, explic- it, and judicious use of current best evidence in making decisions about the care of individual patients.” The same year, Haynes et al (1996) described the “conscientious use” phrase as the evidence is applied consistently to each patient for whom it is relevant. They described the “judicious use” phrase as the clinical application to the patient’s unique clinical circumstances and preferences. These concepts were schematized (Figure 1).
4 Figure 1
Clinical e pertise
Research atient e idence preferences
In 2000, Sackett et al., refined their definition: “EBM is the in- tegration of current best research evidence with clinical expertise and patient values.” Based on this revised definition, Haynes et al., (2002) offered an advanced diagram for evidence-based decisions (Fig 2). As an alternative definition of EBM, Trisha Greenhalgh and Anna Donald pointed to the use of mathematics for an evi- dence-based approach (Greenhalgh, 2014): “Evidence based med- icine is the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.”
Figure 2 Clinical state and circumstances
Clinical states and circ mstances
Clinical e pertise