The Wright Group | Changing Orthopaedic Practice
Our group is interested in the development of implementation strategies for embedding evidence-based clinical practice in orthopaedic surgery.
Previous research suggests that clinicians are resistant to changing practice1,2. In fact, prior efforts to align best practice with the body of evidence throughout all branches of medicine have reported only modest average improvements of 5-12%3.
There are many reasons that these programmes have not been more successful. For example, failing to attain sufficient stakeholder buy-in, or underestimating the impact of key factors on the process such as the individual characteristics of patients and of the health system itself.
To that end, we aim to completely rethink the process of effecting change in physicians’ behaviour in order to achieve more successful embedding of evidence-based practice and therefore improved clinical outcomes for patients.
We are developing a research programme that seeks to investigate how surgical practice may be changed at a national level in response to clinical evidence. It will engage a variety of stakeholders, including patients, members of the public, policy makers and orthopaedic clinicians in the complete process of change management – from choosing criteria to select the target procedure, to evaluating and refining the implementation strategy.
We have designed a multi-faceted approach to enlist the help of different stakeholder groups to develop the process (known as co-creation). The use of social media will be an integral part of this process, providing an open platform for discussion and sharing of ideas.
Based at the Botnar Research Centre, our group is led by Paediatric Orthopaedic Surgeon Professor James Wright. The team draws on expertise from around the globe which spans a wide range of disciplines, including;
- Orthopaedic surgery
- Health economics
- Medical sociology
- Behavioural economics
- Clinical trial design
SBoCK (Simple Bone Cysts in Kids)
Simple bone cysts (also known as unicameral bone cysts), are benign, fluid-filled lesions found most commonly in the long bones of growing children. Their cause is unknown, but can cause pain and/or fracture in patients, frequently affecting quality of life. Simple bone cysts can also potentially lead to growth arrest and/or deformity, so effective treatment is important to allow children to retain normal function as quickly as possible.
Currently, there are a number of ways to treat simple bone cysts, but little evidence to recommend one treatment over another. Around a decade ago, Professor Wright led the first (and only) clinical trial to date to compare the effectiveness of steroid injections compared to bone marrow injections4,5. While the data suggested the former led to better patient outcomes (and led to a change in clinical practice), new interventions have since been devised, making a new trial necessary in order to continue to advance treatment.
In collaboration with co-principal investigator Dr. Sevan Hopyan from The Hospital for Sick Children (SickKids) in Toronto, Professor Wright is conducting a multi-centre, randomised clinical trial to evaluate the effectiveness of two contemporary surgical procedures – curettage with puncture followed by injection with Vitoss synthetic bone graft morsels, versus curettage with puncture alone. This trial is funded by a grant from the Canadian Institutes of Health Research (CIHR).
Infrastructure for Musculoskeletal Paediatric Acute Care Clinical Trials (IMPACCT)
Professor Wright is one of the founding members of the IMPACCT consortium – a group comprising surgeons, clinicians and researchers seeking to facilitate the development of robust clinical evidence in paediatric orthopaedics. Other key members include Dr. Jay Janicki (Lurie Children’s Hospital, Chicago), Dr. Andrew Howard (The Hospital for Sick Children, Toronto) and Jamie Burgess (Lurie Children’s Hospital).
The group’s primary goals include developing the infrastructure necessary to perform world-class studies in the field and so elevating the profile of paediatric orthopaedics as an evidence-based field.
By bringing together an international network of experts from across Europe and North America, IMPACCT aims to deliver a transferable toolkit of resources to support trial design and delivery, thus allowing important clinical questions to be answered more effectively.
Examples of how this might be achieved include:
- Promoting standardisation of randomised trial design
- Developing explicit criteria to evaluate trial feasibility and fundability
- Sharing research methodology
- Providing rigorous scrutiny of study data
- Delivering training for investigators in clinical trials
IMPACCT has benefited from support provided by the Pediatric Orthopaedic Society of North America (POSNA) via its 2016 Clinical Trials Planning Grant.
1) Carr A, Arthroscopic surgery for degenerative knee. BMJ. 2015;350:h2983.
(2) Hawker G, Guan J, Judge A, Dieppe P. Knee arthroscopy in England and Ontario: patterns of use, changes over time, and relationship to total knee replacement. The Journal of bone and joint surgery American volume. 2008;90(11):2337-45.
(3) Grol R. Improving patient care: the implementation of change in health care. 2nd ed. Chichester, UK; Hoboken, NJ, USA: Wiley Blackwell, BMJ/Books; 2013. xvii, 374 p.p.
(4) Canavese F, Wright JG, Cole WG, Hopyan S. Unicameral bone cysts: comparison of percutaneous curettage, steroid, and autologous bone marrow injections. J Pediatr Orthop. 2011 Jan-Feb;31(1):50-5.
(5) Donaldson S, Chundamala J, Yandow S, Wright JG. Treatment for unicameral bone cysts in long bones: an evidence based review. Orthop Rev (Pavia). 2010 Mar 20;2(1):e13.