Levels of Evidence for Primary Research Question
Grades of Recommendation for Summaries or Reviews of Orthopaedic Surgical Studies

The field of evidence-based medicine faces challenges in its future implementation. It is well known that most current studies available to support clinical care in orthopaedic surgery are low-level studies. This limits the number of Grade A and even Grade B treatment recommendations that can be generated. One solution seems to be a multi-centered approach, and this appears to be a growing trend. These trials take substantial financial and organizational efforts to be successful, however.

With an abundance of Level IV and V evidence currently in the orthopaedic literature, there is a need for the reconciliation of this low level evidence. The basis of this reconciliation may arise from the current evidence available on a clinical condition.

For example, if a well-studied clinical condition has ample high-level studies available to provide a Grade A recommendation, then the value of a Level V study is very low. However, if a new clinical condition or treatment is identified with no studies at all, then the value of a Level V study for this new clinical condition/treatment may be very high. Thus, the future may hold a new scale that depicts the current “rarity” of available studies on a particular clinical condition/treatment to assist with designating the importance of lower Level of Evidence studies that may be all that are currently available.

Despite some challenges, the implementation of evidence-based medicine in orthopaedics has been a significant advancement in patient care and is currently becoming more widespread in orthopaedic literature. Thus, it is very likely that evidence-based medicine is here to stay. If you are not practicing evidence-based medicine, you will likely be left behind.

Reprinted with permission from the Fall 2010 issue of COA Bulletin