Misconceptions about practicing evidence-based orthopedic surgery

A fundamental principle of EBM tells us that evidence from the orthopedic literature alone can never guide our clinical actions; we always require the inclusion of patients’ values or preferences (Sackett et al. 2000, Guyatt et al. 2002). Individual patient preferences may differ from the evidence available in the literature. A relatively new concept is “evidence-based patient choice” (Parker 2001, Salkeld and Solomon 2003). It describes two movements in western healthcare systems: (1) the increasing demand for evidence-based information, and (2) the centrality of individual patient choices and values in medical decision making (Parker 2001, Salkeld and Solomon 2003). Nowadays, surgeons are not the only ones overloaded with information. Patients also have an abundance of information from a variety of resources, most commonly the internet. An evidence-based approach to surgery limits patients’ options to choosing from “proven” therapies (Salkeld and Solomon 2003). Newer therapeutic options, the effectiveness of which is not backed up by evidence in the literature, might therefore not be presented to the patient. To help patients in making the “right” decision for them, surgeons must be able to both know and critically appraise the literature. As Haynes believes: “Evidence does not make decisions, people do.” (Haynes et al. 2002). For example, a recent metaanalysis on intracapsular hip fractures showed that there was a significant re-operation rate with internal fixation compared to arthroplasty (relative risk 0.23; 95% CI: 0.13–0.42) (Bhandari et al. 2003a). However, there was a trend (relative risk 1.3; 95% CI: 0.84–1.9) toward an increase in mortality with hemiarthroplasty. This trend has been disputed by a subsequent meta-analysis (Rogmark and Johnell 2006). While this evidence suggests that arthroplasty would be the preferred choice for treating patients with displaced femoral neck fractures because of a lowered re-operation rate, patients may have compelling personal reasons and values that favor internal fixation devices. For example, they may fear a potentially increased risk of mortality with arthroplasty (a patient-important outcome) or have had previous personal experience leading them to one decision or the other. A particular patient may not fit the profile of those studied in a meta-analysis. This illustrates the importance of patient values, clinical acumen, and best evidence (Bhandari and Tornetta 2004).