Imagining that it will be possible at some time for us to have the solution to an orthopedic or traumatological problem based on a manual or a therapeutic information insert is a long-standing dream.
However, the classical protocols that are frequently used in oncology, for example, are still not accessible to our specialty and, in my opinion, never will be.
The diversity of variables involved in orthopedics and the even greater diversity in traumatology make it practically impossible for us to establish standards for our therapeutic management.
Evidence-based medicine, which is the dream of those who see medical practice as a cost or administrative problem, has been very fashionable. However, it is now considered that an acceptable level of evidence-based medicine is very difficult to apply to our specialty. At best, its suggestions for management may be taken into consideration.
There have been many examples of radical changes of direction in case management, aiming toward better results.
For many years, in knee surgery, anterior instability was initially not reconstructed because it was believed that "good muscle reinforcement" would be sufficient to bring stability. Practice demonstrated that demands in sports activities were leading to many episodes of insecurity of the knee, and thus, intra-articular reconstruction of the anterior cruciate ligament (ACL) emerged. The surgical results were not satisfactory, with significant joint limitation, and so intra-articular reconstruction was prescribed and the practice of tensioning the extra-articular ligament structures came to be the great indication.
The long-term results demonstrated that these techniques were insufficient for stability and for preventing knee arthrosis. With improvements in rehabilitation programs and in surgical techniques (with the advent of arthroscopy), techniques for reconstruction of the ACL alone resurged and this became the most cited topic in orthopedic publications for years. Today, with analysis on the evolution of patients who underwent ACL reconstruction, it is observed that although this technique brings satisfactory stability, it still does not prevent evolution to arthrosis. The current tendency is to reconstruct the ACL and provide extra-articular strengthening, probably using the anterolateral ligament, a ligament structure that was recently described in RBO 2013;48(4):368-79.
All these occurred over a 40-year period.
In traumatology, so as not to labor the point, let us simply recall the sequence: intramedullary nail > plates with absolute stability > locking nails > bridge plates.
The difference in surgical exposure from synthesis with absolute stability to a bridge plate or to a locking nail is enormous.
Were these approaches wrong at that time? It is obvious that they were not. We did what we believed would be best, based on studies and analyses that were done at that time. These provided reliable evidence.
Technological evolution, greater demands from patients and new means of diagnosis have brought new knowledge (even in the field of anatomy), have made therapeutic management faster and more dynamic and have not allowed a stagnant and definitive position to be reached within orthopedics.
Our assessments may be improved through expanding the follow-up periods, the number of individuals investigated and the number of studies taken into consideration. Information technology is a major ally in these evaluations and enables correlations that used to be practically impossible.
Meta-analysis is an interesting tool and, whenever possible, should be considered for evaluating approaches at a given time.
Today, consensus is in vogue. If a large number of specialists are brought together to answer the same questions on a given subject and establish a combined opinion that satisfies the majority of the participants, this is a consensus.
We have placed a consensus on infections in hip and knee prostheses on the RBO's website (www.rbo.org.br). This document - Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection - resulted from a meeting held in the United States with the presence of specialists, including some of our Brazilian colleagues. It was coordinated by Javad Parvizi and Thorsten Gehhrke and translated into Portuguese by Drs. Luiz Sérgio Marcelino Gomes, Marco Aurélio Telöken, Nelson Keiske Ono and Pedro Ivo de Carvalho, who kindly made the translation available for the Brazilian orthopedic community.
This consensus answers many questions on this serious problem within orthopedics and provides the current position regarding approaches to periprosthetic infections. We are sure that it will be very useful for our members.
Nonetheless, we believe that even with published data of this quality, there is nothing that can surpass doctors' greatest weapon: their common sense. This will help them to analyze which novelties deserve to be used and which of the old things should be preserved.
There is no consensus that surpasses common sense.
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Please cite this article as: Camanho GL. Não há consenso que supere o bom senso. Rev Bras Ortop. 2014;49:211-212.
Publication Dates
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Publication in this collection
May-June 2014
History
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Received
13 Apr 2014
