This 2009 JBJS symposium paper by Schemitsch and colleagues audits the quality of orthopedic evidence. It asks whether RCTs, observational studies, and expert opinion each adequately support clinical decision-making. The answer: orthopedic literature is dominated by low-level evidence, and even its RCTs are frequently underpowered and poorly reported.
When you read an orthopedic RCT that reports "no significant difference," ask whether it was powered to detect one. With 91% of fracture care RCTs underpowered, a negative result almost never constitutes proof of equivalence.
When a multi-outcome study reports a statistically significant finding, count how many outcomes were tested. Testing 16 outcomes gives a 55% chance of a spurious p < 0.05 by chance alone — the more outcomes reported, the less each individual positive result should be trusted without correction.
When a new implant or technique generates exciting single-center retrospective data, treat it as hypothesis-generating only. The unreamed femoral nail became standard practice on retrospective data, then failed in a powered RCT with a 4.5-fold higher nonunion rate. The pattern repeats.
Level of evidence is not the same as study quality. Level-I and Level-II RCTs in this review did not differ significantly in Cochrane quality scores (15.2 vs 11.7 points, p = 0.08). A Level-I label warrants scrutiny, not automatic trust.
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Treatment of Deep Cartilage Defects in the Knee with Autologous Chondrocyte Transplantation.
Interrater Reliability of a Modified Ashworth Scale of Muscle Spasticity
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Comparison of Upper Gastrointestinal Toxicity of Rofecoxib and Naproxen in Patients with Rheumatoid Arthritis. Vigor Study Group.
Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration.
Novel Regulators of Bone Formation: Molecular Clones and Activities.
The Diagnosis of Osteoporosis.
"modes of Failure" of Cemented Stem-Type Femoral Components: a Radiographic Analysis of Loosening.
Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: a Prospective Study.
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Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones: Retrospective and Prospective Analyses.
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A System for the Functional Evaluation of Reconstructive Procedures after Surgical Treatment of Tumors of the Musculoskeletal System.
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Porosity of 3D Biomaterial Scaffolds and Osteogenesis.
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Clinician's Guide to Prevention and Treatment of Osteoporosis.
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Epidemiology of Adult Fractures: a Review.
Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.
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A Joint Coordinate System for the Clinical Description of Three-Dimensional Motions: Application to the Knee.
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Oarsi Guidelines for the Non-Surgical Management of Knee Osteoarthritis.
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Osteoporosis: Now and the Future.
Clinical Features of Metastatic Bone Disease and Risk of Skeletal Morbidity.
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Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America.
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Bone Quality--The Material and Structural Basis of Bone Strength and Fragility.
Prevalence of Muscular Dystrophies: a Systematic Literature Review.
Mechanisms of Bone Metastasis.
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Metastatic Bone Disease: Clinical Features, Pathophysiology and Treatment Strategies.
Diagnosis and Treatment of Hip and Knee Osteoarthritis
Denosumab for Prevention of Fractures in Postmenopausal Women with Osteoporosis.
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This 2009 JBJS symposium paper by Schemitsch and colleagues audits the quality of orthopedic evidence. It asks whether RCTs, observational studies, and expert opinion each adequately support clinical decision-making. The answer: orthopedic literature is dominated by low-level evidence, and even its RCTs are frequently underpowered and poorly reported.
When you read an orthopedic RCT that reports "no significant difference," ask whether it was powered to detect one. With 91% of fracture care RCTs underpowered, a negative result almost never constitutes proof of equivalence.
When a multi-outcome study reports a statistically significant finding, count how many outcomes were tested. Testing 16 outcomes gives a 55% chance of a spurious p < 0.05 by chance alone — the more outcomes reported, the less each individual positive result should be trusted without correction.
When a new implant or technique generates exciting single-center retrospective data, treat it as hypothesis-generating only. The unreamed femoral nail became standard practice on retrospective data, then failed in a powered RCT with a 4.5-fold higher nonunion rate. The pattern repeats.
Level of evidence is not the same as study quality. Level-I and Level-II RCTs in this review did not differ significantly in Cochrane quality scores (15.2 vs 11.7 points, p = 0.08). A Level-I label warrants scrutiny, not automatic trust.