Page 17 - Athletic Health Handbook
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with an arthroscopic approach. The without combining the patients or Should the clinician use open or
patient’s desires must also be balanced outcomes. In addition to this hierarchy arthroscopic Bankart reconstructions
in the clinical equation. This article of medical evidence, many journals, for shoulder instability? A systematic
will demonstrate EBM can be used including AJSM, have adopted level review of three prospective appropri-
to determine clinical approaches, of evidence designations for published ately randomized level 1 trials demon-
change clinical practice, or design studies. Typically meta-analyses and strated no significant difference in the
future research. systematic reviews of level 1 or 2 clinical outcomes of the two methods,
studies represent level 1 or 2 evidence. including recurrent dislocation rates.
Evidence-based medicine relies Depending on the quality of the RCT, Thus, based upon this well done
upon the fundamental hierarchy these typically represent level 1 or 2 systematic review the clinician can
of medical evidence. This hierarchy evidence. Prospective clinical trials and make the decision to transition to
is as follows: longitudinal cohort or comparative arthroscopic reconstructions or
studies are typically level 2 evidence. continue to use open methods.
Meta-analysis/Systematic Review Case-control studies represent level 3
(if level 1 or 2 studies) evidence. Level 4 evidence is typically EBM can be used to challenge
Randomized Clinical Trials a case series. Expert opinion is deemed commonly held beliefs regarding
Clinical Trials level 5 evidence. clinical decision making. The decision
Cohort of which autograft tissue (hamstring
Case-control Clinical Use or bone-patellar tendon-bone) to use
Case Series in primary ACL reconstruction takes
Expert Opinion An example of how to use EBM to on nearly biblical implications for
Meta-analysis is statistical analysis decide about changes to a clinical many clinicians. Based upon several
of the combined results of clinical practice was recently demonstrated in systematic reviews of this topic
studies. These rely upon homogeneous an American Orthopaedic Association recently summarized in JBJS there
patient populations and outcome (AOA) Symposium and published in may exist minimal clinical difference
measures to allow appropriate the Journal of Bone and Joint Surgery in the outcome of reconstruction using
conclusions. Systematic reviews rely Am (JBJS).2 The question was posed: either graft except in uncommon
upon analysis of a group of studies
EVIDENCE-BASED MEDICINE: A PRIMER
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