The Journal of Bone and Joint Surgery (American). 2009;91:2-9.
doi:10.2106/JBJS.H.01571
© 2009 The Journal of Bone and Joint Surgery, Inc.
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Hierarchy of Evidence: Where Observational Studies Fit in and Why We Need Them

Daniel J. Hoppe, MD1, Emil H. Schemitsch, MD, FRCSC2, Saam Morshed, MD, MPH3, Paul Tornetta, III, MD4 and Mohit Bhandari, MD, MSc, FRCSC1

1 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 2X2, Canada. E-mail address for M. Bhandari: bhandam{at}mcmaster.ca
2 Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada
3 Department of Orthopaedic Surgery, University of California San Francisco, Orthopaedic Trauma Institute at San Francisco General Hospital, 1001 Potrero Avenue, Room 3A-36, San Francisco, CA 94110
4 Department of Orthopaedic Surgery, Boston University, 818 Harrison Avenue, Dowling 2 North, Boston, MA 02118

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Although randomized controlled designs are considered the so-called gold standard in medical trials and sit atop the hierarchy of evidence in evidence-based medicine, there are situations in which they are impractical or unethical to undertake, especially in surgical trials. Then, observational studies often provide the best source of information. In this paper, we use examples from the literature to explain the importance of observational studies in furthering the boundaries of orthopaedic surgery and knowledge of musculoskeletal disorders.


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