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Grades of Recommendation

Wright, James G., MD, MPH, FRCSC; Associate Editor for Evidence-Based Orthopaedics; Einhorn, Thomas A., MD; Deputy Editor for Current Concepts Reviews; Heckman, James D., MD; Editor-in-Chief

doi: 10.2106/JBJS.8709.edit

Surgeons use the literature to determine the best treatment for their patients. Although practice can be changed by a single study, we often find multiple studies more convincing. The appropriate literature can be identified in many ways. First, we can search the literature ourselves. However, this takes a lot of time and the search may not be comprehensive. Second, we can identify meta-analyses or systematic overviews, which collect and combine studies together to assemble a larger sample size in order to provide greater precision around treatment effects. However, meta-analyses pose many methodologic challenges and are not always available. Finally, we can use review articles such as the Current Concepts Reviews published by The Journal as a source for treatment recommendations. The difficulty with review articles is uncertainty about the quality of the recommendations they contain.

In this issue, The Journal introduces the latest in a series of changes to help surgeons appraise the literature to make the best decisions with and for their patients. In June 2000, The Journal featured a new section called Evidence-Based Orthopaedics1. On a quarterly basis, structured abstracts derived from high-quality evidence from journals other than JBJS are published with a commentary from a clinical expert. This section provides the latest and highest-quality evidence for orthopaedic surgeons. In January 2003, The Journal began publishing a Levels of Evidence rating at the end of the abstract for every clinical article2. This system rates the quality of the evidence with use of five levels that are based on the study methods. Levels of Evidence ratings provide a measure of the quality of clinical articles published in JBJS.

With this issue, The Journal extends the evidence-based approach to selected Current Concepts Reviews by applying Grades of Recommendation to selected treatments discussed in the reviews. Authors writing Current Concepts Review articles are encouraged to provide definitive and explicit recommendations regarding the care of patients. Definitive recommendations are most appropriate either when there is minimal disagreement among clinicians or when the evidence is consistent and of high quality. If authors choose to make their recommendations explicit, they should be formatted in a standard way. Recommendations must be included in a separate table entitled “Recommendations for Care.” Authors should base their recommendations on a complete evaluation of the appropriate literature. Support for recommendations regarding treatment, diagnosis, or prognosis are based on JBJS Levels of Evidence (; last accessed February 9, 2005). Levels of Evidence ratings for multiple studies addressing a clinical care recommendation are to be summarized with use of Grades of Recommendation. A Grade of Recommendation is to be attached to each recommendation in the table entitled “Recommendations for Care.” Grade-A recommendations are based on consistent Level-I studies. Grade-B recommendations are based on consistent Level-II or III evidence. Grade-C recommendations represent either conflicting evidence or are based on Level-IV or V evidence. A grade of I indicates that there is insufficient evidence to make a treatment recommendation (Table I).

TABLE I - Grades of Recommendation for Summaries or Reviews of Orthopaedic Surgical Studies
Grade Description
A Good evidence (Level-I studies with consistent findings) for or against recommending intervention.
B Fair evidence (Level-II or III studies with consistent findings) for or against recommending intervention.
C Conflicting or poor-quality evidence (Level-IV or V studies) not allowing a recommendation for or against intervention.
I There is insufficient evidence to make a recommendation.

Grades of Recommendation have been used most commonly in the development of practice guidelines. In this process, organizations assemble all of the appropriate literature on a clinical question. The quality of the literature is appraised with use of Levels of Evidence. Finally, the overall quality of the literature is summarized together as a Grade of Recommendation. The JBJS Grades of Recommendation, modified from previously published Grades (; last accessed February 9, 2005), were developed by a consensus group that included representation from the American Academy of Orthopaedic Surgeons, The Journal of Bone and Joint Surgery (American and British editions), and Clinical Orthopaedics and Related Research.

Using Grades of Recommendation will improve the review articles published by JBJS in two ways. First, the review articles will provide explicit treatment recommendations for surgeons. Second, Grades of Recommendation will guide surgeons as to whether they should definitely (Grade A) or probably (Grade B) change their practice. Finally, by using this system, we also will know those things that we do not know. In some clinical situations the surgeon will not have good evidence, or even any evidence at all, upon which to make an important decision, and in such cases the decision will have to be made with the surgeon relying heavily upon professional judgment alone.

We look forward to your feedback on this important initiative.

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1. Wright JG, Swiontkowski MF. Introducing a new journal section: evidence-based orthopaedics. J Bone Joint Surg Am. 2000;82: 759.
2. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85: 1-3.
Copyright © 2005 by The Journal of Bone and Joint Surgery, Incorporated