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August 5, 2020

Evidence-Based Orthopedic Surgery—From Synthesis to Practice

Author Affiliations
  • 1Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
JAMA Surg. 2020;155(11):1009-1010. doi:10.1001/jamasurg.2020.1521

The adoption of evidence-based surgery (EBS) initiated a paradigm shift from the emphasis on expert opinion to a more objective and reproducible algorithm based on the best available evidence. This Viewpoint provides a case example illustrating the lag in applying EBS in practice in addition to discussing hurdles and potential solutions for the synthesis and practice of EBS in orthopedics.

Several studies have indicated satisfactory short- and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in elderly patients.1 These findings challenge the need for open reduction with internal fixation given the equivalence of functional outcomes between nonoperative and operative management without the risk of surgical complications associated with the latter. Duckworth et al2 conducted a randomized clinical trial (RCT) attempting to provide further evidence by comparing operative treatment vs nonoperative treatment for displaced olecranon fractures in the elderly population. The authors reported its premature termination because of an unacceptably high complication rate within the operative cohort (81.8%).2 Nevertheless, open reduction with internal fixation continues to be the most frequently used intervention in treating displaced olecranon fractures in elderly individuals. Another ongoing RCT is currently testing for the superiority of operative vs nonoperative treatment for displaced olecranon fractures in elderly individuals by comparing pain and function in the affected limb up to 1 year after the injury.3 Altogether, the challenge regarding how to guide surgical indication and the application of EBS remains.

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