Editorial Commentary: The Power of Interpretation: Utilizing the P Value as a Spectrum, in Addition to Effect Size, Will Lead to Accurate Presentation of ResultsStatistics have helped develop evidence-based medicine. Comparing groups and rejecting (or not) a null hypothesis is a main principle of the scientific method. Many studies have demonstrated that drawing conclusions based on the statistical result of a dichotomic P value instead of a spectrum can mislead us to conclude that there is “no difference” between two groups, or two treatments. In addition to the P value, the utilization of effect size (magnitude of difference between studied groups), may help us obtain a better global understanding of the statement “no effect”.
Authors Dichotomize Medical Research Findings as Significant Versus Not Significant, Creating a False Sense of Certainty, and Report Outcomes on Patients Whose Results Have Been Previously Reported Without Proper DisclosureStatistical significance dichotomizes research findings into significant versus not significant, creating a false sense of certainty. It is insufficient to mindlessly report results as significant versus not significant without providing a quantitative estimate of the uncertainty of the data. Authors could provide a confidence interval, draw a P value function graph, or run a Bayesian analysis. Authors could calculate and report a Surprise or S value. Most importantly, authors could thoughtfully consider how the uncertainty within their research data informs the results of their study.
‘No Effect’ Conclusions in Studies Reporting Nonsignificant Results Are Potentially IncorrectTo examine the spectrum of effect sizes in line with “no effect” claims in clinical studies published in high-impact orthopaedic journals.
Understanding Network Meta-analysis (NMA) Conclusions Requires Scrutiny of Methods and Results: Introduction to NMA and the Geometry of EvidenceSynthesis of medical literature to determine the best treatment for a given problem is challenging, particularly when multiple options exist. Network meta-analysis (NMA) allows the comparison of different treatment approaches in a single, systematic review including treatments that have never been compared head-to-head. A key to understanding NMA is to focus on the network geometry showing the number of included studies and their relationships: different treatment options are illustrated as nodes.
Nearly One-Third of Published Systematic Reviews and Meta-analyses Yield Inconclusive Conclusions: A Systematic ReviewTo perform a systematic review that determines the percentage of published orthopedic surgery and sports medicine systematic reviews and meta-analyses that have a conclusive conclusion.
Misinterpretation of P Values and Statistical Power Creates a False Sense of Certainty: Statistical Significance, Lack of Significance, and the Uncertainty ChallengeDespite great advances in our understanding of statistics, a focus on statistical significance and P values, or lack of significance and power, persists. Unfortunately, this dichotomizes research findings comparing differences between groups or treatments as either significant or not significant. This creates a false and incorrect sense of certainty. Statistics provide us a measure of the degree of uncertainty or random error in our data. To improve the way in which we communicate and understand our results, we must include in reporting a probability, or estimate, of our degree of certainty (or uncertainty).
Sports Performance and Injury Research: Methodologic Limitations and Recommendations for Future ImprovementsEvidence-based research has resulted in incredible advances in sports medicine and is an important component of minimizing injury risk. Such research is similarly important when applied to care delivery to athletes after injury. For research into injury reduction and treatment outcomes to be most impactful, however, the methods must be of sufficient rigor to generate high-quality evidence. Two recent trends in sports injury research have led to specific concerns about evidence quality: 1) use of athletic performance metrics as an injury or treatment outcome and 2) use of publicly available data for injury or treatment research.
Health Research Titles and Guidelines Improve Impact and Article Acceptance RatesThe peer-reviewed publication of Arthroscopy, Arthroscopy Techniques, and Arthroscopy, Sports Medicine, and Rehabilitation is the result of a team effort. Our assistant editors-in-chief are a notable part of this team who are specifically credited for, among other contributions, leadership in organizing, creating, and publishing a series of pearls, templates, and checklists for health research authors as well as reviewers, editors, and readers. These articles and tools are available under drop-down menus on the Arthroscopy journal home page.
Pain Management ResearchOver the past decade, increased awareness by the medical profession of the devastating consequences of opioid addiction has resulted in substantial efforts to limit the number of opioid prescriptions for both perioperative pain management and chronic pain. While these efforts have had some success, opioid misuse remains a crisis, which we in the orthopaedic community have a particular opportunity to address. It is the belief of the undersigned that progress depends on improved research methods and reporting to further the understanding of pain experience and response to management, with the end goal of identifying more effective, nonnarcotic pain control measures for our orthopaedic patients.
Strategies to Standardize Opioid Research and Improve Clinical Pain ManagementOpioid abuse results in poor pain control, poor outcomes, and addiction. Clinical recommendations to manage pain include identifying the problem, considering multimodal anesthesia, avoiding overprescribing, acknowledging that minimizing opioid use is not equivalent to undertreating pain, minimizing preoperative opioid use, managing patient expectations, and continuing to investigate outcomes of pain management while limiting opioid prescriptions or forgoing opioids altogether. Authors are directed to new Recommendations for Pain Management Research to highlight critical research parameters and standardize outcome reporting.
The Patient-Reported Outcomes Measurement Information System (PROMIS): Can We Finally Compare Apples to Oranges?Legacy patient-reported outcome mea`sures lack standardization, resulting in difficulty comparing the results of diverse clinical outcome studies: “You can’t compare apples to oranges.” To address this concern, the National Institutes of Health initiated the Patient-Reported Outcomes Measurement Information System (PROMIS) to assess common dimensions of a wide range of diseases. PROMIS uses computer adaptive testing: A fluid questionnaire chooses subsequent questions based on the responses to previous questions to efficiently characterize outcomes using only 4 to 6 questions.
Research Pearls: Checklists and Flowcharts to Improve Research QualityTo instill quality in published clinical research, reporting guidelines, consisting of checklists and flowcharts, were developed to protect against reporting poorly designed research, and researchers should be aware of the available instruments and their appropriate use. With the popularity of synthetic reviews, meta-analyses, and systematic reviews, there is a greater need to assess risk of bias and study quality. This review highlights the most frequently used guidelines and checklists, risk-of-bias scales, and quality rating scales that can assist researchers with improving their research and its eventual publication.
Do Some Patients Count More Than Others? Reporting Outcomes of the Same Patient in More Than One Study Requires DisclosureClinical databases allow researchers to test multiple hypotheses. This could result in including outcomes on the same patient or patients in more than 1 study. When this occurs, it is vital for authors to clarify multiple reporting in their study methods to avoid having patients counted more than once in future systematic reviews or meta-analyses. As a caveat, primary authors should consider whether publication of multiple studies is important or whether they are simply generating “least publishable units” (LPUs, also known as salami slicing).
Journal Article Titles Impact Their Citation RatesA journal article’s title gives authors one chance to make a first impression and communicate succinctly the findings from their important research. The goal of a research article rests in disseminating information. Both authors and academic journals benefit from increasing the number of times an investigation is cited. A scientific manuscript title accurately summarizes the research using key words that can be identified with search engines. This review aims to condense evidence-based research to improve a scientific manuscript title for both clarity and impact.
Medical Research Publication: An Insider’s GuideMost original scientific articles submitted to high-impact medical journals are not accepted for publication. Reasons for rejection are diverse, and tips and pearls to improve chances for acceptance are manifold. Four essential points could maximize the chance that submission of a scientific article will result in acceptance and publication. First, before initiation of a study, it is valuable to state a hypothesis detailing what one expects the study to show. Second, the conclusion should be based exclusively on, and not overreach, the results.
Editorial Commentary: Defining Improvement After Arthroscopic Meniscal Surgery—How Much of a Difference Does a Difference Make?Patient-centered metrics including the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state have been proposed to determine the clinical significance of patient-reported outcome scores. These values allow clinically meaningfully interpretation of changes in scores such that the degree of improvement (minimal clinically important difference and substantial clinical benefit) and satisfaction (patient acceptable symptom state) can be determined.
Methods to Improve Arthroscopic and Orthopaedic Biomechanical Investigations: A Few of Our Favorite ThingsControlled biomechanical studies, generally in vitro (and often ex vivo), may represent a first step in evaluation of a new arthroscopic or orthopedic implant or technique. The purpose and methods of biomechanical studies must be thoughtfully considered to achieve results translatable to a clinically relevant conclusion. A limitation is that with the exception of animal studies or rare human investigations, most biomechanical studies actually only investigate mechanics and do not study biological healing.
Editorial Commentary: Network Geometry of Nonoperative Management of Patellar Tendinopathy—Can the Shape of the Evidence Inform Practice?Recent research has examined the comparative effectiveness of nonoperative treatments for patellar tendinopathy using a network meta-analysis method. This method allows analysis of a network of clinical trials individually studying different treatment options in comparison to an eccentric exercise control; however, most treatments have not been compared head to head. Although leukocyte-rich platelet-rich plasma is statistically ranked as the treatment with the highest improvements in pain and function, concerns over the assumption of transitivity (on which network meta-analysis is based) and the lack of connection or comparisons among treatments suggest that future studies comparing treatments head to head are needed.
Our Measure of Medical Research Should Be Appreciable Benefit to the PatientThe clinical relevance of research is much more important than statistical significance. Patient-reported outcome measures (PROM) are the strongest determinants of satisfaction as the result of an intervention or treatment. Outcomes can be measured in terms of the minimal clinically important difference (MCID) detectable by a patient, bearing in mind that “detectable” includes worsening as well as improvement. Patient-acceptable symptomatic state (PASS) and substantial clinical benefit (SCB) ultimately correlate with whether patients are happy or willing to undergo an intervention again.
Research Pearls: How Do We Establish the Level of Evidence?Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used.
Research Pearls: Expert Consensus Based Evidence Using the Delphi MethodThe evolution of a systematic approach to assessing pertinent investigations is known as evidence-based medicine (EBM). EBM is defined as the conscientious and judicious use of current best evidence from clinical care research and integration of clinical expertise in the management of individual patients. There is no doubt that EBM is important but may not give clinically meaningful guidance on topics with clinical equipoise for individual patient care. When EBM has been insufficiently developed for a specific topic, a consensus opinion of experts can be valuable.
Reviews Pooling Heterogeneous, Low-Evidence, High-Bias Data Result in Incorrect Conclusions: But Heterogeneity is an Opportunity to ExploreSystematic Review submissions to our journal commonly pool heterogeneous studies of low levels of evidence and a high risk of bias. Pooling, or quantitative synthesis, of such study data regularly results in incorrect conclusions. We reject these submissions without peer-review (desk rejection), and typically invite authors to submit a new, subjective synthesis without pooling and to report ranges of the results of included studies rather than pooled values. Generally, quantitative synthesis, or meta-analysis, should restrict included studies to randomized controlled trials.
Tools to Improve Scientific ResearchThe mission of Arthroscopy is to provide authoritative, current, peer-reviewed clinical and basic science information regarding arthroscopic and related surgery. In addition, with a goal of improving the quality of the scientific research published in our journal and others, we develop and publish research pearls, statistical guides, article checklists and templates, and related tools. In sum, this effort allows our cadre of editors, reviewers, authors, and readers to strive to improve in our ability to create and critically analyze medical literature of the greatest merit.
Invention Versus Gold Standard: A Hands-On Research Pearl on Study Design and Statistical ConcernsThis article points out what is important to consider when planning to perform and analyze a commonly seen study involving a comparison of an innovation with something established. A hands-on guide on how to perform this type of research trial and how to choose proper statistical methods is given.