Are large clinical trials in orthopaedic trauma justified?

Journal Article (Journal Article)

BACKGROUND: The objective of this analysis is to evaluate the necessity of large clinical trials using FLOW trial data. METHODS: The FLOW pilot study and definitive trial were factorial trials evaluating the effect of different irrigation solutions and pressures on re-operation. To explore treatment effects over time, we analyzed data from the pilot and definitive trial in increments of 250 patients until the final sample size of 2447 patients was reached. At each increment we calculated the relative risk (RR) and associated 95% confidence interval (CI) for the treatment effect, and compared the results that would have been reported at the smaller enrolments with those seen in the final, adequately powered study. RESULTS: The pilot study analysis of 89 patients and initial incremental enrolments in the FLOW definitive trial favored low pressure compared to high pressure (RR: 1.50, 95% CI: 0.75-3.04; RR: 1.39, 95% CI: 0.60-3.23, respectively), which is in contradiction to the final enrolment, which found no difference between high and low pressure (RR: 1.04, 95% CI: 0.81-1.33). In the soap versus saline comparison, the FLOW pilot study suggested that re-operation rate was similar in both the soap and saline groups (RR: 0.98, 95% CI: 0.50-1.92), whereas the FLOW definitive trial found that the re-operation rate was higher in the soap treatment arm (RR: 1.28, 95% CI: 1.04-1.57). CONCLUSIONS: Our findings suggest that studies with smaller sample sizes would have led to erroneous conclusions in the management of open fracture wounds. TRIAL REGISTRATION: NCT01069315 (FLOW Pilot Study) Date of Registration: February 17, 2010, NCT00788398 (FLOW Definitive Trial) Date of Registration: November 10, 2008.

Full Text

Duke Authors

Cited Authors

  • Sprague, S; Tornetta, P; Slobogean, GP; O'Hara, NN; McKay, P; Petrisor, B; Jeray, KJ; Schemitsch, EH; Sanders, D; Bhandari, M; FLOW Investigators,

Published Date

  • April 20, 2018

Published In

Volume / Issue

  • 19 / 1

Start / End Page

  • 124 -

PubMed ID

  • 29678204

Pubmed Central ID

  • PMC5909275

Electronic International Standard Serial Number (EISSN)

  • 1471-2474

Digital Object Identifier (DOI)

  • 10.1186/s12891-018-2029-3


  • eng

Conference Location

  • England