Page 18 - Athletic Health Handbook
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special circumstances.3 While each Purcell et al of the outcome of elbow decrease the bias inherent in an
of the systematic reviews has some ulnar collateral ligament reconstruc- expert opinion narrative review.
flaws, as is pointed out by the authors, tions.4 At the time the systematic
these did not result in dramatically review was performed there existed Conclusion
different conclusions. Many of the five level 3 retrospective cohort studies
studies reviewed by the systematic that demonstrated the general high EBM has been criticized as esoteric
reviews were randomized trials of level of return to athletics in this and impractical. As demonstrated
less than 100 patients. Thus, EBM overhead throwing population. While by the previous clinical examples
illustrates that future research of this many athletes return to their previous it can be used by the practicing
topic utilizing small randomized level of function this is not always orthopaedic sports medicine specialist
trials may not be indicated and may the case. A higher level of evidence is to address fundamental basic questions
not add to our current clinical necessary to identify the predictors of frequently seen in an individual’s
knowledge. This demonstrates the a worse outcome. A RCT of operative practice. Orthopaedics has lagged
role that meta-analyses or systematic versus nonoperative management of behind other medical specialties,
reviews hold in determining future these injuries would not be feasible especially internal medicine, in
research areas. Appropriately in this patient population. However, adopting these techniques. In addition,
performed meta-analyses or system- given the basic understanding of these insurance companies and third party
atic reviews utilizing homogeneous injuries and outcomes identified by payers will probably adopt some of
studies with similar outcome deter- the previous retrospective series, a these techniques to determine the
minants may increase the statistical larger or multi-center prospective appropriateness of treatment delivered.
power over any one individual study longitudinal cohort study is realistic By demystifying the concept of EBM
and thus preclude the initiation of and should be the expected standard through these real-world examples
additional prohibitively expensive for future research in this area. it is hoped we will be encouraged
and difficult RCTs. to implement them in our clinical
Current Concepts and Reviews decision-making process.
EBM can be used when only
low levels of evidence exist. In the The traditional invited review or
previously mentioned AOA Sympo- current concepts articles highlighted
sium the question of prognosis at the end of many orthopaedic
and best treatment for syndesmotic journals could frequently benefit
ankle sprains was addressed.2 Only from adopting an EBM approach.
level 4 case series exist in the literature These usually consist of narrative
regarding this question. These injuries reviews summarizing expert opinion
frequently result in significant time and personal beliefs following a
lost from sports activities, but some literature search with inclusion
athletes only miss a few days. Thus and exclusion criteria not identified
our prognostic ability based upon by the author. Given the rise in
current diagnostic measures is poor. popularity of systematic reviews
Currently, most of these injuries are these can be adopted as the standard
treated by conservative measures for current concepts articles. A
but some of the severe injuries systematic review consists of a
might benefit from more aggressive search of the world’s literature using
management. When and what treat- prospectively identified inclusion
ment should be rendered for these and exclusion criteria described in
more severe injuries is unknown. the article. Conclusions are reached
Thus, EBM through a systematic by the authors based upon levels of
review indicates the need for higher evidence and quality of the studies,
levels of research such as a prospec- including biases, but the process is
tive multi-center trial, to address transparent enough that the reader
these questions. evaluates the data and reaches similar
or sometimes slightly dissimilar
An additional illustration of conclusions. Adopting this process
the use of EBM is demonstrated for our journals would significantly
by a systematic review performed by

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