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Correspondence

Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends


To the Editor: As members of the American Academy of Orthopaedic Surgeons (AAOS) Council on Research and Quality, we read with great interest the correspondence between Dr. Rickert1 and Drs. Hosalkar, Pandya, and Namdari2 concerning the article Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends.3 When it comes to discussing evidence-based practice, unintentional misuse of language can misinform the reader; thus, we feel obliged to comment. Dr. Rickerts criticism that Dr. Hosalkar and his colleagues present no evidence whatsoever might more appropriately be stated as presenting evidence comprised only of individual studies. It does not appear that the authors either systematically evaluated the literature or based their position on multiple evidence data points akin to treatment recommendations found in evidence-based clinical practice guidelines. Dr. Hosalkars claim that [f]rom the perspective of AAOS guidelines, [level III and IV studies] do not meet the criteria to be included in any evidence-based recommendation as even modest evidence clearly misstates the process used by the AAOS in developing evidence-based clinical practice guidelines. As recommended by seminal guideline developers in medicine,4 the AAOS uses the best available evidence to determine the strength of a recommendation (as Strong, Moderate, or Limited) in a guideline and does indeed use level III studies to formulate recommendations when these provide the best evidence available. Although pointing out that no level I or II studies have been published on the subject of nonsurgical management of clavicle fractures may be true, Dr. Hosalkar and coauthors imply that level I and II studies are the only studies that the AAOS uses to generate clinical practice guidelines recommendations. Inaccurate statements such as this can lead to misperceptions about AAOS guidelines and ultimately undermine their value to the end user. The AAOS should be proud of the work done by its many volunteers and staff to develop and improve the process for creating evidence-based CPGs. We invite Dr. Rickert, Dr. Holsakar and his coauthors, and other readers of the Journal of the American Academy of Orthopaedic Surgeons to learn more about AAOS Clinical Practice Guidelines by logging on to http:// www.aaos.org/guidelines. Michael J. Goldberg, MD Rosemont, Illinois David Jevsevar, MD, MBA St. George, Utah Kevin J. Bozic, MD, MBA San Francisco, California

Dr. Goldberg or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons. Dr. Jevsevar or an immediate family member is a member of a speakers bureau or has made paid presentations on behalf of Medacta USA; has stock or stock options held in OMNIlife science; and has received research or institutional support from Medacta USA. Dr. Bozic or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Association of Hip and Knee Surgeons, American Joint Replacement Registry, the American Orthopaedic Association, California Joint Replacement Registry Project, the California Orthopaedic Association, Harvard Business School, and the Orthopaedic Research and Education Foundation. http://dx.doi.org/10.5435/ JAAOS-21-04-199 April 2013, Vol 21, No 4

References
1. Rickert JB: Displaced clavicle fractures in adolescents: Facts, controversies, and current trends. J Am Acad Orthop Surg 2013;21(1):1-2.

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2.

Hosalkar H, Pandya N, Namdari S: Facts, controversies, and current trends. J Am Acad Orthop Surg 2013;21(1):1-2.

3.

Pandya NK, Namdari S, Hosalkar HS: Displaced clavicle fractures in adolescents: Facts, controversies, and current trends. J Am Acad Orthop Surg 2012;20(8):498-505.

4.

Cook DJ, Mulrow CD, Haynes RB: Systematic reviews: Synthesis of best evidence for clinical decisions. Ann Intern Med 1997;126(5):376-380.

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Journal of the American Academy of Orthopaedic Surgeons