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Letter to the Editor
Reply to: Risk factors for infection in total knee arthroplasty, including previously unreported intraoperative fracture and deep venous thrombosis
Réplica a: Factores de riesgo para la infección en prótesis de rodilla, incluyendo la fractura intraoperatoria y la trombosis venosa profunda, no descritos previamente
M.S. de Dios-Péreza,
Corresponding author
marisol_dedios@yahoo.es

Corresponding author.
, J. Cordero-Ampuerob
a Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
b Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Princesa, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We share the interest of Dr&#46; Arriaza and Dr&#46; Saavedra in understanding the risk of infection in knee arthroplasty&#44; and we will try to answer the statistical questions they have asked about the paper&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The paper does indeed state that intraoperative fracture is a risk with statistical significance per se&#44; even though only one case of this occurred&#46; We did not forget at any time that this was a single case&#44; and even in the original paper we warned and explained at all times that as it was a single case it had to be considered with the appropriate precaution&#44; and that statistical significance is based on a unique event in a series of cases of infection&#46; Once again in the discussion we stated that &#8220;we know of no previous description of an intraoperative fracture as a risk factor for knee arthroplasty&#44; and in our comparison it was significantly more frequent among infected patients&#44; although it has to be said that statistical significance is attained with a single infected case with no uninfected control&#8221;&#46; I&#46;e&#46;&#44; we tried to make it absolutely clear that this is a new result which has to be approached with due caution&#44; and that more research is required&#44; although the results indicate that it may be relevant to take intraoperative fractures into account as a risk factor&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As to whether the prolonged duration of surgery associated with an intraoperative fracture could be the risk factor in itself&#44; and not the fracture&#44; we would like to clarify that it no case did this study aim to investigate the interactions between variables &#40;in this case&#44; between the intraoperative fracture and the duration of the surgical operation&#41;&#46; As we explained in the methodology&#44; the sample is small&#44; so that it would be too risky &#40;and imprudent&#41; to statistically analyse the interaction of risk factors&#46; Moreover&#44; as you yourselves state&#44; there is a single case of intraoperative fracture&#44; so that seeking a relationship between this fracture and the duration of the operation would be&#44; at the very least&#44; imprudent&#46; This is a very new study which explores many factors simultaneously&#59; the fundamental contribution of the study is based on analysing possible risk factors&#46; Study of the interactions between them will be the object of analysis in subsequent studies that would be impossible to undertake without this previous research&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand your suggestion that the duration of the surgical operation may be the risk factor in itself&#44; and not the fracture &#40;the specific cause why the operation was prolonged&#41; is erroneous from a methodological and statistical viewpoint&#46; Both events &#40;the fracture and the time&#41; arose at the same time&#44; so that it is impossible to establish a causal relationship with one of them &#40;as they state that time would be the risk factor in itself&#41; while negating the causal relationship with the other one &#40;the fracture&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> When 2 events occur at the same time it is not possible to establish any type of causal relationship whatsoever for one of them&#44; given that the effect of one cannot be separated from the effect of the other&#46; Both aspects &#40;time and fracture&#41; could perfectly well be independent risk factors for the development of an infection&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding their remark on the validity of the Chi-squared analysis when the value is less than 5 &#40;as is the case with the intraoperative fracture&#41; it has to be pointed out that the criterion for carrying out this statistical analysis is not based on the frequency that is observed&#44; but rather on the frequency that is expected&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> It is true that 50&#37; of the boxes do not fulfil the observed frequency of 5&#59; nevertheless&#44; authors such as Carrasco<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> state that a previous condition for the Chi-squared test is that the theoretical boxes &#40;i&#46;e&#46;&#44; the expected frequency&#44; and not the observed frequency&#44; as you state in this reply&#41; contain at least 5 individuals&#46; Our contingency tables therefore fulfil the basic requisite to be able to be interpreted in terms of significance&#46; Additionally&#44; we wish to point out that the relationship of the variables and their clinical relevance has been quantified with the OR&#46; Lastly&#44; as we pointed out&#44; due to the low frequency observed these results have to be analysed cautiously&#44; as we do in the article&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Respecting the doubts that arose for you about the &#8220;low weight&#8221; factor &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#41; and the similarity of results that you believe should exist with those of the fracture&#44; as well as the supposition that at least one of the 2 values is incorrect&#44; we would like to clarify that no variable at all is incorrect&#46; Obviously&#44; we understand this remark to be due once again to a lack of statistical comprehension&#46; Any analysis of this type is based on a 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 table&#44; which is the one that makes it possible to find Chi-squared&#44; given that there are 2 variables&#58; fracture &#40;yes&#47;no&#41; and group &#40;infection&#47;no infection&#41;&#46; The 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 table is obtained by crossing these two variables&#46; As is obvious&#44; in Table 2 of our study it makes no sense to show the value of the 4 boxes and only the most relevant information is shown&#44; on the cases with a fracture in both groups&#46; The fact that there is a single case in a Chi-squared box does not imply at all that they will have the same level of significance&#44; given that the result of statistical analysis depends on the distribution of the cases and the expected frequencies in the cross of both variables&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#8211;4</span></a> To make such a simplification and think this is a statistical error&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We agree with you that type of previous surgery performed and its associated factors &#40;anatomical distortion&#44; multiple incisions&#44; osteosynthesis material to be extracted&#44; etc&#46;&#41; is important&#46; Nevertheless&#44; and as was pointed out above&#44; the interactions between the variables studied are not covered by this paper&#46; It is necessary to first carry out a descriptive study of all of the variables before going on to analyse interactions such as the one considered here &#40;previous surgery &#8211; duration of the surgical operation&#41;&#46; We understand surgery in the past as a risk factor for infection is a datum with intrinsic value&#44; regardless of the type of operation&#46; On the other hand&#44; once again it would be risky to try to draw conclusions based on the type of surgery performed in this relatively small sample&#44; if proceeding with scientific rigour&#46; We wish once again to underline that the fundamental aim of the paper is based on the analysis of risk factors&#59; study of the interactions between them or increased specificity within each one of these factors will be the object of subsequent studies with larger samples&#44; taking this descriptive study as the basis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We would like to thank the authors for their input and hope to be able to complement these data with ongoing studies of the interactions between the factors analysed here&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Level of evidence</span><p id="par0045" class="elsevierStylePara elsevierViewall">Level of evidence III&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Ethical disclosures</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Protection of human and animal subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed conform to the ethical norms of the responsible human experimentation committee and the World Medical Association and the Helsinki Declaration&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they followed the protocols of their work centre on the publication of patient data&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients or subjects mentioned in the paper&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financing</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they received no financing for the preparation of this work&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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Article information
ISSN: 19888856
Original language: English
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