Robert G. Marx,Sean M. Wilson,Marc F. Swiontkowski

Orthopaedic surgeons, like all physicians, must make clinical decisions based on the best available evidence. This evidence comes from individual clinical experience and external sources. Although clinical experience is left to the physician, the medical and surgical literature provides the best external evidence. To facilitate the process of determining the best evidence to answer a clinical question, The Journal of Bone & Joint Surgery assigns level of evidence (LOE) ratings to all clinical articles.

Since 2003, The Journal has used a hierarchical rating system based on the recommendations of the Centre for Evidence-Based Medicine (CEBM) in Oxford, United Kingdom, to rank articles according to the study design used to answer the primary research question. In 2011, the CEBM updated its recommendations. After robust internal and external discussion, The Journal has decided to keep pace with the CEBM and has updated our LOE table.

The new LOE table emphasizes the clinical applications of research findings and encourages a more holistic assessment of study design and execution. Those familiar with the original table will notice that this update retains many features of its predecessor. Nonclinical articles (such as cadaveric and animal studies) are still excluded from the ranking system, studies are still divided by type (therapeutic, prognostic, diagnostic, or economic analysis), and much of the ranking criteria remains the same.

Although the new table borrows from the original, it also represents an important departure. The most apparent change is structural. The rows and columns have been transposed, and there is an additional column for clinical questions. This new design reflects the order and the types of questions that arise in the process of clinical care.