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 Table of Contents  
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 35-36

Evidence-based orthopedic: The contemporary challenges

1 Department of Orthopaedics, ESIC Medical College and Hospital Joka, Kolkata, West Bengal
2 Department of Orthopaedics, Jagannath Gupta Institute of Medical Sciences, Budge-Budge, Kolkata, West Bengal, India

Date of Submission07-Dec-2021
Date of Acceptance07-Dec-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Sanjay Keshkar
Department of Orthopaedics, ESIC Medical College & Hospital Joka, Kolkata 700104, West Bengal.
West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijors.ijors_32_21

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We are talking about evidence-based medicine (EBM) for decades. Now each and every field of medicine has adapted evidence-based practices and the same is true for orthopedics also. There are thousands of reasons to support an evidence-based approach in the teaching and practice of orthopedics but hurdles and challenges are also there. So it’s time to revisit the challenges of EBM in orthopedic teaching and practice.

Keywords: Decision making, evidence-based medicine, evidence-based orthopedics, orthopedic practice

How to cite this article:
Keshkar S, Dey N. Evidence-based orthopedic: The contemporary challenges. Int J Orthop Surg 2021;29:35-6

How to cite this URL:
Keshkar S, Dey N. Evidence-based orthopedic: The contemporary challenges. Int J Orthop Surg [serial online] 2021 [cited 2023 Mar 25];29:35-6. Available from: https://www.ijos.in/text.asp?2021/29/2/35/332936

  Introduction Top

The word “evidence-based medicine (EBM)” came from McMasters University in Ontario, Canada in the 1980s when Dr. David Sackett and colleagues proposed EBM as a new way of teaching, learning, and practicing medicine.[1] They defined EBM as “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” In simple terms, EBM is an approach to medical practice that uses the results of patient care research and other available objective evidence as a part of decision-making/appraisal. For EBM practice, one has to follow four simple steps namely Ask (formulation of clinical question), Access (searching available evidence), Appraisal (appraising the evidence), and Apply (incorporation of evidence into decision making).[2] The same steps need to be followed in orthopedics also in its teaching and practice.

As far as orthopedics is concerned, new developments are taking place day by day, and therefore teaching/practicing evidence-based orthopedics (EBO) is not easy as compared to other branches of medicine.[3] Obstacles are there in each and every step of EBO and hence it is time to revisit the challenges.

  Challenges of Evidence-Based Orthopedic Practice Top

Out of four steps of EBO practice, the first step, that is, asking questions or formulation of clinical question is not much of a problem. The problems/challenges are mainly related to accessing, appraising, and applying the evidence into decision making. It is pertinent to highlight those challenges.

Challenges of accessing/searching available evidences

For getting answers to clinical/research questions, one has to search (e.g., Google Scholar) the evidence from level 1 to level 5 and by virtue of that there will be enumerable data in hand. So quantity of enumerable evidence is the first challenge.[3] The second challenge is the quality of evidence. High numbers of books and journals and published articles are available and it is difficult to get the best possible evidence for a given problem. In his landmark article, Ioannidis (by means of a rather complex argument) proposes that most published research findings may be false.[3],[4] As a busy practitioner, it is difficult to devote time for searching such data and not only that one has to read and interpret also. Overall it is a time-taking process and needs a lot of patience.

Challenges of appraising the available evidence

The third problem is the interpretation of available evidence.[4] Apprising or interpretation of available evidence is also an issue for an orthopedic surgeon. We are not sound in statistics and research methodology and hence face difficulty while interpretation. It is found that 28% of orthopedic randomized controlled trials with negative findings were underpowered leading to inappropriately failing to reject the null hypothesis.[5] In such a scenario, inadvertently one can choose the false evidence as to the best one. Overall it not only kills the time but sometimes creates confusion also.

Challenges of applying the available evidence in decision making

The fourth problem is the application of available evidence. Despite many refinements in the research and presentation of knowledge, many surgeons do not have the time to sift through even well-formulated articles and find it difficult to translate current research into better care for their patients.[6],[7] While conducting evidence-based practice we as orthopedic surgeons should be aware that “anatomical reduction” may be an unthinkably right choice but in some cases is not supported by the best available evidence and there lies the problem.[8] In fracture management; Conservative/surgical treatment and then Clinical/radiological outcome are some other issues.[8] In some displaced fractures even severe radiological malunion seems to be well-tolerated, at least in older adults.[9] Therefore one must consider the patient’s need and preferences as part of decision-making instead of focusing exclusively on radiographic appearance and surgical techniques.[8]

  Take Home Point! Top

It is not necessarily the EBO principle, that is important but the reliability of the data. So it is time to revisit the challenges of EBM in orthopedic teaching and practice. In spite of all the challenges, one must try to overcome and try to acquaint with EBO.

Contributions of authors

Sanjay Keshkar studied and prepared the manuscript for Editorial. Nirmal Dey reviewed the manuscript and helped in the final preparation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sackett DL. Evidence-based medicine and treatment choices. Lancet 1997;349:570.  Back to cited text no. 1
Masic I, Miokovic M, Muhamedagic B. Evidence based medicine - new approaches and challenges. Acta Inform Med 2008;16:219-25.  Back to cited text no. 2
Marais LC. The changing landscape of evidence-based orthopaedics. SA Orthopaedic Journal Autumn 2017;16:16-18.  Back to cited text no. 3
Ioannidis JP. Why most published research findings are false. Plos Med 2005;2:e124.  Back to cited text no. 4
Abdullah L, Davis DE, Fabricant PD, Baldwin K, Namdari S. Is there truly “no significant difference”? Underpowered randomized controlled trials in the orthopaedic literature. J Bone Joint Surg Am 2015;97:2068-73.  Back to cited text no. 5
Hurwitz SR, Slawson D, Shaughnessy A. Orthopaedic information mastery: Applying evidence-based information tools to improve patient outcomes while saving orthopaedists’ time. J Bone Joint Surg Am 2000;82:888-94.  Back to cited text no. 6
Hoppe DJ, Bhandari M. Evidence-based orthopaedics: A brief history. Indian J Orthop 2008;42:104-10.  Back to cited text no. 7
[PUBMED]  [Full text]  
Brorson S. Evidence-based orthopedics and the myth of restoring the anatomy. Acta Orthopaedica 2021;92:505-6.  Back to cited text no. 8
Mulders MAM, Detering R, Rikli DA, Rosenwasser MP, Goslings JC, Schep NWL. Association between radiological and patient-reported outcome in adults with a displaced distal radius fracture: A systematic review and meta-analysis. J Hand Surg Am 2018;43:710-19.e5.  Back to cited text no. 9


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