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Orthopedic
Traumatology
An Evidence-Based Approach
Second Edition

Manish K. Sethi
William T. Obremskey
A. Alex Jahangir
Editors

123
Orthopedic Traumatology
Manish K. Sethi • William T. Obremskey
A. Alex Jahangir
Editors
Thomas J. Iorio • Michelle S. Shen
Basem Attum
Associate Editors

Orthopedic
Traumatology
An Evidence-Based Approach

Second Edition
Editors
Manish K. Sethi, MD William T. Obremskey, MD, MPH, MMHC
Department of Orthopedics Department of Orthopedics
Vanderbilt University Medical Center Vanderbilt University Medical Center
Nashville, TN, USA Nashville, TN, USA
A. Alex Jahangir, MD, MMHC
Department of Orthopedics
Vanderbilt University Medical Center
Nashville, TN, USA

Associate Editors
Thomas J. Iorio, BS Michelle S. Shen, BA
Department of Orthopedic Surgery Department of Orthopedic Surgery
and Rehabilitation and Rehabilitation
Vanderbilt University Medical Center Vanderbilt University Medical Center
Nashville, TN, USA Nashville, TN, USA
Basem Attum, MD, MS
Department of Orthopedic Surgery
and Rehabilitation
Vanderbilt University Medical Center
Nashville, TN, USA

Section Editors
Mohit Bhandari, MD, PhD, FRCSC Mitchel B. Harris, MD, FACS
Division of Orthopedic Surgery Department of Orthopedic Surgery
McMaster University Brigham and Women’s Hospital
Hamilton, ON, Canada Harvard Medical School
Michael David McKee, MD, FRCS(C) Boston, MA, USA
Division of Orthopedics, Department of Surgery Cory A. Collinge, MD
St. Michael’s Hospital, University of Toronto Department of Orthopedic Surgery
Toronto, ON, Canada and Rehabilitation
Paul Tornetta III, MD Vanderbilt University Medical Center
Department of Orthopedic Surgery Nashville, TN, USA
Boston Medical Center Roy Sanders, MD
Boston, MA, USA University of South Florida
Andrew H. Schmidt, MD Department of Orthopedics
Department of Orthopedic Surgery Florida Orthopedic Institute
Hennepin County Medical Center Tampa General Hospital
Journal of Orthopedic Trauma
Department of Orthopedic Surgery Tampa, FL, USA
Unviersity of Minnesota
Minneapolis, MN, USA

ISBN 978-3-319-73391-3    ISBN 978-3-319-73392-0 (eBook)

https://doi.org/10.1007/978-3-319-73392-0
Library of Congress Control Number: 2018932331
© Springer International Publishing AG, part of Springer Nature 2013, 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
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publication does not imply, even in the absence of a specific statement, that such names are
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AG part of Springer Nature.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

When I wrote the foreword to the first edition of Orthopedic Traumatology:

An Evidence-Based Approach in late 2011, I emphasized the progress in the
orthopedic trauma community toward using, on a routine basis, the highest
levels of evidence on which to base treatment decisions. The first edition of
Orthopedic Traumatology has proven to fulfill that need as our community
moves away from expert opinion in the form of standard textbook writing and
toward aggregation of the highest levels of evidence. Not everything in ortho-
pedic trauma surgery is able to be studied with randomized trials, as many
injuries are of low incidence such that well-done cohort studies are going to
be the highest level of evidence available on which to base our treatment deci-
sions in the long run. However, the editors of the first edition – Drs. Sethi,
Jahangir, and Obremskey – and the chapter authors provided the roadmap of
level 1 and level 2 evidence for the most common conditions in orthopedic
traumatology. This approach has proven to be extremely useful, with over
17,000 downloads of this compilation.
In this second edition, the editors – now Drs. Sethi, Obremskey, and
Jahangir – decided to add chapters on four new conditions that are relatively
common. This includes chapters on elbow fracture dislocation, hip-pelvis-­
femoral neck fracture combination in younger patients, mid-foot fractures,
and acute infection. These chapters all represent useful additions to the com-
pendium. All chapter authors have performed extensive and broad-reaching
literature reviews to identify any high-level evidence that has been published
since the first edition.
The result is a book which is very useful for teaching and, more impor-
tantly, for making individual treatment decisions and for developing proto-
cols for use in trauma centers. These highly committed and compulsive
editors and authors have done a yeoman’s work in providing these collections
of the highest level of evidence. I recommend this second edition with great
enthusiasm, as it is the continued fulfillment of our migration toward
evidence-­based orthopedic trauma surgery for patient care.

Minneapolis, MN, USA Marc Swiontkowski

v
Preface

As medicine makes a transition from volume to value, the need for evidence-­
based practice is of even greater importance. We undertook the process of
creating this book to help residents, fellows, and practicing orthopedic sur-
geons understand the principles on which medical decisions are made and to
provide them with a reference that explains the data and thought processes of
leaders in orthopedic trauma patient care. Many “HOW” books are available
on surgical technique. This book was designed and intended to be a “WHY”
book that would help clinicians understand and make evidence-based deci-
sions on patient care.
We thank our many chapter authors – who are thought leaders and excel-
lent clinicians – for their astute evaluation of the literature and clear commu-
nication of treatment options.
The response and distribution of the first edition of this evidence-based
book were so great that we felt compelled to provide a second edition. We
hope this second edition continues the work started by the first edition to
improve the knowledge depth of clinicians and the quality of care for patients.

Nashville, TN, USA Manish K. Sethi, MD

 William T. Obremskey, MD, MMHC, MPH
 A. Alex Jahangir, MD, MMHC

vii
Contents

Part I Evidence-Based Medicine in Orthopedic Trauma Surgery

Mohit Bhandari

1 Introduction to Evidence-Based Medicine����������������������������������    3

Clary J. Foote, Mark Phillips, and Mohit Bhandari

Part II Spine Trauma

Mitchel B. Harris

2 Cervical Spine Clearance��������������������������������������������������������������   21

Daniel G. Tobert and Mitchel B. Harris
3 Cervical Spine Fracture-­Dislocation��������������������������������������������   31
Kevin R. O’Neill, Michelle S. Shen, Jesse E. Bible,
and Clinton J. Devin
4 Lumbar Burst Fractures ��������������������������������������������������������������   43
Daniel G. Tobert and Mitchel B. Harris

Part III Upper Extremity Trauma

Michael David McKee

5 Scapula Fractures��������������������������������������������������������������������������   57

Peter A. Cole and Lisa K. Schroder
6 Clavicle Fractures��������������������������������������������������������������������������   71
Brian L. Seeto and Michael David McKee
7 Proximal Humerus Fractures ������������������������������������������������������   83
Erik A. Lund and Paul S. Whiting
8 Humeral Shaft Fractures�������������������������������������������������������������� 109
Basem Attum, Diana G. Douleh, William T. Obremskey, Bill
Ristevski, and Jeremy A. Hall
9 Distal Humerus Fractures ������������������������������������������������������������ 119
Lee M. Reichel, Andrew Jawa, and David Ring

ix
x Contents

10 Elbow Fracture Dislocation���������������������������������������������������������� 127

Chad M. Corrigan, Clay A. Spitler, and Basem Attum
11 Distal Radius Fractures ���������������������������������������������������������������� 139
Cameron T. Atkinson, Michelle S. Shen, Samuel A. Trenner,
Philipp N. Streubel, and Jeffry T. Watson

Part IV Acetabular, Hip, and Pelvic Trauma

Cory A. Collinge

12 Acetabular Fractures in the Elderly�������������������������������������������� 155

John C. Weinlein, Edward A. Perez, Matthew I. Rudloff,
and James L. Guyton
13 Pelvic Ring Injury I����������������������������������������������������������������������� 171
Rita E. Baumgartner, Damien G. Billow, and Steven A. Olson
14 Pelvic Ring Injury II���������������������������������������������������������������������� 181
Matthew D. Karam, Adam Keith Lee, and David C.
Templeman
15 Femoral Neck Fractures in the Elderly���������������������������������������� 191
David Polga and Robert T. Trousdale
16 Intertrochanteric Femur Fractures���������������������������������������������� 201
Hassan R. Mir
17 Femoral Neck Fractures in the Young Patient���������������������������� 211
Cory A. Collinge

Part V Lower Extremity Trauma

Paul Tornetta III

18 Diaphyseal Femur Fractures�������������������������������������������������������� 223

Paul S. Whiting, Obioma V. Amajoyi, and Manish K. Sethi
19 Distal Femur Fractures����������������������������������������������������������������� 237
William M. Ricci, A. Alex Jahangir, and Christopher D. Parks
20 Knee Dislocations �������������������������������������������������������������������������� 249
Mahesh Kumar Yarlagadda, Frank R. Avilucea,
Samuel Neil Crosby Jr, Manish K. Sethi,
and William T. Obremskey
21 Tibial Plateau Fractures���������������������������������������������������������������� 263
Jodi Siegel and Paul Tornetta III
22 Closed Diaphyseal Tibia Fractures���������������������������������������������� 275
Michel A. Taylor, Marlis T. Sabo, and David W. Sanders
23 Open Diaphyseal Tibia Fractures������������������������������������������������ 287
Scott P. Ryan, Christina L. Boulton, and Robert V. O’Toole
Contents xi

Part VI Foot and Ankle Trauma

Roy Sanders

24 Pilon Fractures ������������������������������������������������������������������������������ 305

Basem Attum, Vamshi Gajari, David P. Barei,
and A. Alex Jahangir
25 Trimalleolar Ankle Fractures ������������������������������������������������������ 323
Conor Kleweno and Edward K. Rodriguez
26 Calcaneus Fractures���������������������������������������������������������������������� 335
Richard Buckley and Theodoros H. Tosounidis
27 Talus Fractures������������������������������������������������������������������������������ 345
Hassan R. Mir and Roy Sanders
28 Lisfranc Injuries���������������������������������������������������������������������������� 355
Basem Attum, Moses Adebayo, and A. Alex Jahangir

Part VII Polytrauma, Infection, and Perioperative Management

of the Orthopedic Trauma Patient
Andrew H. Schmidt

29 Timing of Treatment in the Multiply Injured Patient���������������� 367

Kevin D. Phelps, Laurence B. Kempton, and Michael J. Bosse
30 DVT Prophylaxis in Orthopedic Trauma������������������������������������ 385
Keith D. Baldwin, Surena Namdari, Jeffrey Zhao,
and Samir Mehta
31 The Infected Tibial Nail���������������������������������������������������������������� 395
Megan A. Brady, Seth A. Cooper, and Brendan M. Patterson
32 Perioperative Optimization in Orthopedic Trauma ������������������ 405
Jesse M. Ehrenfeld and Michael C. Lubrano
33 Management of Acute Postoperative Infection �������������������������� 419
Frank R. Avilucea

Index�������������������������������������������������������������������������������������������������������� 429
Contributors

Moses Adebayo, MD Department of Orthopedic Surgery, Howard

University, Washington, DC, USA
Obioma V. Amajoyi, MD Department of Orthopedics and Rehabilitation,
University of Wisconsin-Madison, University of Wisconsin Hospital and
Clinics, Madison, WI, USA
Cameron T. Atkinson, MD Arlington Orthopedic Associates, Arlington,
TX, USA
Basem Attum, MD, MS Department of Orthopedic Surgery, Vanderbilt
University Medical Center, Nashville, TN, USA
Frank R. Avilucea, MD Department of Orthopedic Surgery, Division of
Orthopedic Trauma, University of Cincinnati Medical Center, Cincinnati,
OH, USA
Keith D. Baldwin, MD Children’s Hospital of Philadelphia, Department of
Orthopedics, University of Pennsylvania, Philadelphia, PA, USA
David P. Barei, MD, FRCSC Harborview Medical Center, University of
Washington, Department of Orthopedics, Seattle, WA, USA
Rita E. Baumgartner, MD Department of Orthopaedic Surgery, Duke
University Medical Center, Durham, NC, USA
Mohit Bhandari, MD, PhD, FRCSC Division of Orthopedic Surgery,
McMaster University, Hamilton, ON, Canada
Jesse E. Bible, MD, MHS Department of Orthopedics, Penn State Milton
S. Hershey Medical Center, Hershey, PA, USA
Damien G. Billow, MD Department of Orthopedics, Cleveland Clinic,
Cleveland, OH, USA
Michael J. Bosse, MD Department of Orthopedic Surgery, Carolinas
Medical Center, Charlotte, NC, USA
Christina L. Boulton, MD Department of Orthopedic Surgery, University
of Arizona – Banner University Medical Center, Tucson, AZ, USA
Megan A. Brady, MD Iowa Methodist Medical Center, Des Moines
Orthopedic Surgeons, West Des Moines, IA, USA

xiii
xiv Contributors

Richard Buckley, MD, FRCS Department of Surgery, Foothill Medical

Center, University of Calgary, Calgary, AB, Canada
Peter A. Cole, MD Department of Orthopaedic Surgery, Regions Hospital,
St. Paul, MN, USA
Department of Orthopaedic Surgery, University of Minnesota, Minneapolis,
MN, USA
Cory A. Collinge, MD Department of Orthopedic Surgery and Rehabilitation,
Vanderbilt University Medical Center, Nashville, TN, USA
Seth A. Cooper, MD Florida Medical Clinic, Department of Orthopedic
Surgery, Tampa, FL, USA
Chad M. Corrigan, MD Wesley Medical Center, University of Kansas –
Wichita School of Medicine, Wichita, KS, USA
Samuel Neil Crosby Jr., MD Elite Sports Medicine and Orthopedic Center,
Nashville, TN, USA
Clinton J. Devin, MD Department of Orthopedic Surgery and Rehabilitation,
Vanderbilt University Medical Center, Nashville, TN, USA
Diana G. Douleh, MD Department of Orthopedic Surgery, University of
Colorado Hospital, University of Colorado, Aurora, CO, USA
Jesse M. Ehrenfeld, MD, MPH Department of Anesthesiology, Surgery,
Biomedical Informatics and Health Policy, Vanderbilt University School of
Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
Clary J. Foote, MD Division of Orthopedic Surgery, McMaster University,
Hamilton, ON, Canada
Vamshi Gajari, MBBS Department of Orthopedic Surgery, Vanderbilt
University Medical Center, Nashville, TN, USA
James L. Guyton, MD Regional One Health, University of Tennessee –
Campbell Clinic, Memphis, TN, USA
Jeremy A. Hall, MD, FRCSC, MEd Division of Orthopedics, St. Michael’s
Hospital, Department of Surgery, University of Toronto, Toronto, ON, Canada
Mitchel B. Harris, MD, FACS Department of Orthopaedic Surgery, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
A. Alex Jahangir, MD Department of Orthopedic Surgery, Vanderbilt
University Medical Center, Nashville, TN, USA
Andrew Jawa, MD New England Baptist Hospital, Tufts University Medical
School, Boston, MA, USA
Matthew D. Karam, MD Department of Orthopedics and Rehabilitation,
University of Iowa Hospitals and Clinics, Department of Orthopedics and
Rehabilitation, University of Iowa, Iowa City, IA, USA
Contributors xv

Laurence B. Kempton, MD Indiana University School of Medicine,

Department of Orthopedic Surgery, IU Health Methodist Hospital,
Indianapolis, IN, USA
Conor Kleweno, MD Harborview Medical Center, Department of Orthopedic
Surgery, Seattle, WA, USA
University of Washington, Department of Orthopedics and Sports Medicine,
Seattle, WA, USA
Adam Keith Lee, MD Department of Orthopedic Surgery, Keck School of
Medicine of University of Southern California, Los Angeles, CA, USA
Michael C. Lubrano, MD, MPH Department of Anesthesia and
Perioperative Care, UCSF School of Medicine, San Francisco, CA, USA
Erik A. Lund, MD Department of Orthopedics and Rehabilitation,
University of Wisconsin–Madison, University of Wisconsin Hospital and
Clinics, Madison, WI, USA
Michael David McKee, MD, FRCS(C) Department of Orthopaedic Surgery,
University of Arizona College of Medicine–Phoenix, Phoenix, AZ, USA
Samir Mehta, MD Penn Presbyterian Medical Center, University of
Pennsylvania, Department of Orthopedic Surgery, Philadelphia, PA, USA
Hassan R. Mir, MD, MBA, FACS Florida Orthopedic Institute, University of
South Florida, Tampa, FL, USA
Surena Namdari, MD, MSc Rothman Institute and Department of
Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
Kevin R. O’Neill, MD, MS OrthoIndy, Inc., Indianapolis, IN, USA
Robert V. O’Toole, MD R. Adams Cowley Shock Trauma Center, University
of Maryland School of Medicine Department of Orthopedics, Baltimore,
MD, USA
William T. Obremskey, MD, MPH, MMHC Department of Orthopedic
Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
Steven A. Olson, MD, FACS Department of Orthopaedic Surgery, Duke
University Medical Center, Durham, NC, USA
Christopher D. Parks, MD Department of Orthopedics, New Hanover
Regional Medical Center, Wilmington, NC, USA
Brendan M. Patterson, MD, MBA Cleveland Clinic Main Campus, Case
Western Reserve University School of Medicine, Department of Orthopedic
Surgery, Cleveland, OH, USA
Edward A. Perez, MD Regional One Health, University of Tennessee –
Campbell Clinic, Memphis, TN, USA
Kevin D. Phelps, MD Department of Orthopedic Surgery, Carolinas Medical
Center, Charlotte, NC, USA
xvi Contributors

Mark Phillips, MSc(c) Division of Orthopedic Surgery, McMaster

University, Hamilton, ON, Canada
David Polga, MD Department of Orthopedic Surgery, Marshfield Clinic,
Marshfield, WI, USA
Lee M. Reichel, MD Department of Surgery and Perioperative Care, Dell
Medical School at The University of Texas at Austin, Austin, TX, USA
William M. Ricci, MD Hospital for Special Surgery, Weill Cornell School
of Medicine, New York, NY, USA
David Ring, MD, PhD Department of Surgery and Perioperative Care, Dell
Medical School at The University of Texas at Austin, Austin, TX, USA
Bill Ristevski, MD, MSc, FRCS(c), BSc Division of Orthopedics, Hamilton
General Hospital, Department of Surgery, McMaster University, Hamilton,
ON, Canada
Edward K. Rodriguez, MD, PhD Beth Israel Deaconess Medical Center,
Department of Orthopedic Surgery, Boston, MA, USA
Harvard Medical School, Boston, MA, USA
Matthew I. Rudloff, MD Regional One Health, University of Tennessee –
Campbell Clinic, Memphis, TN, USA
Scott P. Ryan, MD Department of Orthopaedics, Tufts University School of
Medicine, Tufts Medical Center, Boston, MA, USA
Marlis T. Sabo, MD, MSc, FRCSC Department of Surgery, South Health
Campus, Cumming School of Medicine, Calgary, AB, Canada
David W. Sanders, MD, FRCSC Department of Surgery, Victoria Hospital–
LHSC, University of Western Ontario, London, ON, Canada
Roy Sanders, MD Florida Orthopedic Institute, University of South Florida,
Tampa, FL, USA
Lisa K. Schroder, BSME, MBA Department of Orthopaedic Surgery,
Regions Hospital, St. Paul, MN, USA
Department of Orthopaedic Surgery, University of Minnesota, Minneapolis,
MN, USA
Brian L. Seeto, MD, FRCSC The CORE Institute, Phoenix, AZ, USA
Manish K. Sethi, MD Department of Orthopedic Surgery and Rehabilitation,
Vanderbilt University Medical Center, Nashville, TN, USA
Michelle S. Shen, BA Department of Orthopedic Surgery and Rehabilitation,
Vanderbilt University Medical Center, Nashville, TN, USA
Jodi Siegel, MD Department of Orthopedics, University of Massachusetts
Memorial Medical Center, University of Massachusetts Medical School,
Worcester, MA, USA
Clay A. Spitler, MD Department of Orthopedic Surgery, University of
Mississippi Medical Center, Jackson, MS, USA
Contributors xvii

Philipp N. Streubel, MD Department of Orthopedic Surgery and

Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
Michel A. Taylor, MD, FRCSC Department of Surgery, Victoria Hospital—
LHSC, University of Western Ontario, London, ON, Canada
David C. Templeman, MD University of Minnesota, Hennepin County
Medical Center, Minneapolis, MN, USA
Daniel G. Tobert, MD Department of Orthopaedic Surgery, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
Paul Tornetta III, MD Department of Orthopedic Surgery, Boston Medical
Center, Boston, MA, USA
Theodoros H. Tosounidis, MD, PhD Major Trauma Centre, Leeds General
Infirmary, Academic Department of Trauma and Orthopedic Surgery,
University of Leeds, NIHR Leeds Biomedical Research Unit, Chapel Allerton
Hospital, Leeds, UK
Samuel A. Trenner, DPM Department of Orthopedic Surgery and
Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
Robert T. Trousdale, MD Department of Orthopedic Surgery, Mayo Clinic,
Rochester, MN, USA
Jeffry T. Watson, MD Colorado Springs Orthopedic Group, Colorado
Springs, CO, USA
John C. Weinlein, MD Regional One Health, University of Tennessee –
Campbell Clinic, Memphis, TN, USA
Paul S. Whiting, MD Department of Orthopedics and Rehabilitation,
University of Wisconsin–Madison, University of Wisconsin Hospital and
Clinics, Madison, WI, USA
Mahesh Kumar Yarlagadda, BS, MSPH Department of Orthopedic
Trauma, Vanderbilt University Medical Center, Meharry Medical College,
Nashville, TN, USA
Jeffrey Zhao, BA Northwestern Medicine, Northwestern University Feinberg
School of Medicine, Chicago, IL, USA
 Part I
Evidence-Based Medicine in Orthopedic
Trauma Surgery
 Introduction to Evidence-Based
Medicine
Clary J. Foote, Mark Phillips, and Mohit Bhandari
Introduction
The science of addressing problems that confront
orthopedic surgeons every day requires a rigor-
ous methodology to guide investigation and pro-
vide valid answers. The term “evidence-based
medicine” (EBM), first coined by Dr. Gordon
Guyatt at McMaster University, has become the
standard for clinical investigation and critical
appraisal. EBM has been defined as the conscien-
tious and judicious use of current best available
evidence as the basis for surgical decisions [1–3].
Application of the evidence does not occur in iso-
lation but rather with integration of surgical
expertise and clinical circumstances, as well as
with societal and patient values [4, 5] (Fig. 1.1).
In addition, identifying and applying best avail-
able evidence require a comprehensive search of
the literature, a critical appraisal of the validity
and quality of available studies, astute consider-
ation of the clinical situation and factors that may
influence applicability, and a balanced applica-
tion of valid results to the clinical problem [6].
In 2000, Marc Swiontkowski introduced the
evidence-based orthopedics (EBO) section of the
C. J. Foote · M. Phillips · M. Bhandari (*)
Division of Orthopedics, McMaster University,
Hamilton, ON, Canada
e-mail: bhandam@mcmaster.ca
© Springer International Publishing AG, part of Springer Nature 2018
M. K. Sethi et al. (eds.), Orthopedic Traumatology, https://doi.org/10.1007/978-3-319-73392-0_1
1
Journal of Bone and Joint Surgery (JBJS) with a
focus on higher levels of evidence such as
randomized controlled trials (RCTs), which rec-
ognized the deficiency of controlled studies in
the orthopedic literature [7]. In 2003, the JBJS
adopted EBM and the hierarchy of evidence for
grading all clinical papers. Also during that year,
Dr. Bhandari initiated the evidence-based
orthopedic trauma section in the Journal of
Orthopaedic Trauma (JOT) [8]. Since then, the
EBO initiative has grown into a global initiative
and has become the common language at interna-
tional orthopedic meetings. The American
Orthopedic Society has recognized and incorpo-
rated EBO for utilization into clinical guidelines
[9]. Clinical practice guidelines developed by
organizations such as the American Academy of
Orthopaedic Surgeons (AAOS) have become a
prominent driver of EBO dissemination, as these
groups have adopted an evidence-based approach
for providing clinical recommendations to ortho-
pedic surgeons.
Paramount to the understanding of “best avail-
able evidence” are the concepts of hierarchy of
evidence, meta-analyses, study design, and preci-
sion of results. A familiarity with these concepts
will aid the orthopedic surgeon in identifying,
understanding, and incorporating best evidence
into their practice. We begin here with an over-
view of the hierarchy of surgical evidence with
attention paid to study design and methodologi-
cal quality. Some of the common instruments to
3
4 C. J. Foote et al.
Fig. 1.1 The triumvirate of evidence-based orthopedics
(EBO) to improve best practice in orthopedics (Used from Ref.
[5]: with permission of John Wiley and Sons Tilburt et al.)
measure study quality are described, and we
direct our readership to adjunctive educational
resources. Finally, we conclude by clarifying
misconceptions of EBO to reinforce its underpin-
ning principles that help the reader interpret the
surgical evidence presented in this text.
Hierarchy of Research Studies
To understand the concept of best evidence, a sur-
geon must first be knowledgeable about the hier-
archy of surgical evidence. The hierarchy can be
thought of as a classification system to provide a
common language for communication and a
basis for review of available evidence. Research
studies range from very high quality to low qual-
ity, which are largely based on the study design
and methodological quality [10]. In general,
high-quality studies minimize bias and thus
increase our confidence in the validity of results.
Bias can be defined as systematic error in a
research study that impacts outcome such that it
differs from the truth [11]. There are several
available systems to formulate the level of evi-
dence of a given study. The Oxford Centre for
Evidence-Based Medicine has published hierar-
chies for therapeutic, prognostic, harm, preva-
lence, and economic analyses [12]. For each of
aforementioned subcategories, there is a hierar-
chy of evidence with unique clinical significance
[13, 14]. JBJS has incorporated the Oxford
System in order to develop a hierarchy for ortho-
pedic studies (Table 1.1). For the purposes of this
text, when we refer to the “hierarchy” or “level of
evidence,” we will be referring to this table.
In orthopedic traumatology, therapeutic stud-
ies are of central importance. For instance, they
may tell us the revision surgery rates of dynamic
hip screws versus cancellous screws for the treat-
ment of femoral neck fractures [15]. When evalu-
ating a study of a surgical or therapeutic
intervention, one must identify the study design
as an initial step to identify best evidence [16].
The highest level of evidence lies in RCTs and
systematic reviews or meta-analyses of high-­
quality RCTs [17, 18]. These are referred to as
level I trials [2]. The process of randomization is
the best research tool to minimize bias by distrib-
uting known and unknown prognostic variables
uniformly between treatment groups [19, 20].
Available evidence suggests that non-­randomized
studies tend to overestimate [21] or underesti-
mate [22] treatment effects. Systematic reviews
of RCTs use rigorous methodology to improve
sample size and precision of study results and are
therefore considered the highest level of evidence
when reviewed studies are of sufficient method-
ological quality [12, 23]. Reviews may statisti-
cally combine results (meta-analyses) when trial
reporting allows or provide a qualitative over-
view of the results of included studies (system-
atic reviews) [24]. Additionally, reviews may
indirectly compare pooled results (network meta-­
analyses) across multiple interventions that have
not been directly compared within an RCT. For
example, if there are two RCTs, one comparing
treatment A to placebo and one comparing treat-
ment B to placebo, an indirect comparison can be
made between treatment A and treatment B [25].
Non-randomized prospective studies such as
cohort studies (also known as prospective com-
parative studies) provide weaker empirical
­evidence, as they are prone to several biases [22].
For instance, treatment allocation is uncontrolled,
and therefore treatment cohorts may differ in
prognosis from the outset due to selection bias
 1
Table 1.1 Levels of evidence for primary research questiona,b
Study type Question Level I Level II Level III Level IV Level V
Diagnostic – Is this (early Randomized controlled trial Prospectivec cohortd study Retrospectivee cohortd study Case series Mechanism-based
investigating a detection) test Case–controlf study reasoning
diagnostic test worthwhile?
Is this Testing of previously Development of diagnostic Nonconsecutive patients Poor or nonindependent Mechanism-based
diagnostic or developed diagnostic criteria (consecutive No consistently applied reference standard reasoning
monitoring criteria (consecutive patients with consistently reference standard
test accurate? patients with consistently applied reference standard
applied reference standard and blinding)
and blinding)
Prognostic – What is the Inceptionc cohort study (all Prospectivec cohortd study Retrospectivee cohortd study Case series Mechanism-based
investigating the natural history patients enrolled at an early,(patients enrolled at Case–controlf study reasoning
effect of a patient of the uniform point in the course different points in their
characteristic on condition? of their disease) disease)
Introduction to Evidence-Based Medicine

the outcome of a Control arm of randomized

disease trial
Therapeutic – Does this Randomized controlled trial Prospectivec cohortd study Retrospectivee cohortd study Case series Mechanism-based
investigating the treatment Observational study with Case–controlf study Historically controlled reasoning
results of a help? dramatic effect study
treatment What are the
harms?g
Economic Does the Computer simulation model Computer simulation Computer simulation model Decision tree over the Decision tree over
intervention (Monte Carlo simulation, model (Monte Carlo (Markov model) with inputs short time horizon with the short time
offer good Markov model) with inputs simulation, Markov model) derived from level II input data from original horizon with input
value for derived from level I studies, with inputs derived from studies, relevant time level II and III studies data informed by
dollars spent? lifetime time duration, level II studies, lifetime horizon, less than lifetime, and uncertainty is prior economic
outcomes expressed in time duration, outcomes outcomes expressed in examined by univariate evaluation and
dollars per quality-adjusted expressed in dollars per dollars per QALYs, and sensitivity analyses uncertainty is
life years (QALYs), and QALYs, and uncertainty stochastic multilevel examined by
uncertainty examined using examined using sensitivity analyses univariate sensitivity
probabilistic sensitivity probabilistic sensitivity analyses
analyses analyses
Used from Ref. [71]: with permission of Wolters Kluwer Health Inc. from Marx et al.

(continued)
5
 6
Table 1.1 (continued)
a
This chart was adapted from OCEBM Levels of Evidence Working Group, “The Oxford 2011 Levels of Evidence,” Oxford Centre for Evidence-Based Medicine, http://www.
cebm.net/index.aspx?o=5653. OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl
Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson. A glossary of terms can be found here: http://www.cebm.
net/glossary/
b
Level I through IV studies may be graded downward on the basis of study quality, imprecision, indirectness, or inconsistency between studies or because the effect size is very
small; these studies may be graded upward if there is a dramatic effect size. For example, a high-quality randomized controlled trial (RCT) should have ≥80% follow-up, blind-
ing, and proper randomization. The level of evidence assigned to systematic reviews reflects the ranking of studies included in the review (i.e., a systematic review of level II
studies is level II). A complete assessment of the quality of individual studies requires critical appraisal of all aspects of study design
c
Investigators formulated the study question before the first patient was enrolled
d
In these studies, “cohort” refers to a nonrandomized comparative study. For therapeutic studies, patients treated one way (e.g., cemented hip prosthesis) are compared with those
treated differently (e.g., cementless hip prosthesis)
e
Investigators formulated the study question after the first patient was enrolled
f
Patients identified for the study on the basis of their outcome (e.g., failed total hip arthroplasty), called “cases,” are compared with those who did not have the outcome (e.g.,
successful total hip arthroplasty), called “controls”
g
Sufficient numbers are required to rule out a common harm (affects >20% of participants). For long-term harms, follow-up duration must be sufficient
C. J. Foote et al.
1 Introduction to Evidence-Based Medicine
Table 1.2 Definitions of bias types in therapeutic
studies
Types of
biases Definition
Selection Treatment groups differ in measured and
bias unmeasured characteristics and therefore
have differential prognosis due to
systematic error in creating intervention
groups [33]
Recall bias Patients who experience an adverse
outcome are more likely to recall
exposure than patients who do not
sustain an adverse outcome [28, 72]
Detection Biased assessment of outcome. May be
bias influenced by such things as prior
knowledge of treatment allocation or
lack of independent affiliation within a
trial [26]
Performance Systematic differences in the care
bias provided to cohorts are independent of
the intervention being evaluated [26, 73]
Attrition bias Occurs when those that drop out of a
study are systematically different from
those that remain. Thus, final cohorts
may not be representative of original
group assignments [2, 74]
Expertise Occurs when a surgeon involved in a
bias trial has differential expertise (and/or
convictions) with regard to procedures
in a trial where trial outcomes may be
impacted by surgeon competency and/or
beliefs rather than interventional
efficacy [75]
(Table 1.2) [26]. Retrospective case–control stud-
ies assess past characteristics and exposures in
cases as compared with controls. These studies
are subject to several types of bias including
selection and recall bias (Table 1.2). Matching
treatment and control groups for known prognos-
tic variables (e.g., age, gender, functional level)
may partially control for confounding variables
but rarely sufficiently negates them. One can also
“overmatch” groups such that the groups are so
closely matched that the exposure rates between
cohorts are analogous [27]. In addition, the retro-
spective structure can lead to imprecise data col-
lection and differential patient follow-up [28]. At
the bottom of the evidence hierarchy are case
reports and series and expert opinion. Case series
are uncontrolled, unsystematic studies with a role
mainly in hypothesis generation for future
7
i­nvestigation and provide very little utility in
guiding care. These reports are usually single-
surgeon and single-center experiences which fur-
ther impair generalizability.
 tudy Quality and the Hierarchy
S
of Evidence
When placing a study into the surgical hierarchy,
one must also consider study quality. In general,
studies drop one level if they contain method-
ological problems (Table 1.1) [12, 29]. RCTs are
only considered level I evidence when they have
proper institution of safeguards against bias
(Table 1.3), high precision (narrow confidence
intervals), and high levels of patient follow-up;
lesser-quality RCTs are assigned to level II evi-
dence. Several instruments have been validated
to assess the quality of RCTs which include the
Cochrane risk of bias assessment tool (1–3),
Jadad scale (range 0–5), Delphi list (range 0–9),
and numeric rating scale (NRS; range 1–10). The
Cochrane risk of bias assessment tool contains
seven questions assessing six different bias
domains that are rated as either a high, unclear, or
low risk of bias within the trial [30]. These
domains are selection bias, performance bias,
detection bias, attrition bias, reporting bias, and
other potential forms of bias. The seven questions
within the tool provide a means for determining
the risk of bias within the study (Table 1.4). The
Jadad scale is another instrument to assess meth-
odological quality of clinical trials, which con-
tains three main areas of assessment:
randomization, blinding, and loss to follow-­up
[31]. In addition, quality scoring systems exist
for observational studies (i.e., cohort and case–
control) such as the Newcastle–Ottawa scale for
cohort studies [32]. For cohort studies, this tool
assesses the rigor of cohort selection and compa-
rability, ascertainment of exposure, outcome
assessment (e.g., blinded assessment), and fol-
low-up. From this, we have summarized crucial
methodological elements of quality studies in
Table 1.3. Although the actual validated instru-
ments need not be used rigorously in everyday
orthopedics, these quality criteria should be of
8 C. J. Foote et al.

Table 1.3 Some essential methodological components Table 1.3 (continued)

of high-quality studies
Item Study design Description
Item Study design Description Blinding RCT and Surgeon blinding may
A priori defined RCT and A protocol is critical to observational not be possible, but
study protocol observational establish a priori blinding patients,
primary and secondary outcome assessors,
outcomes which will data analysts, authors
require specific of the results section,
considerations, and outcomes’
resources, and sample adjudicators is
size. A priori outcomes imperative to protect
maximize the benefits of against detection and
cohort assignment (e.g., performance biases
randomization) and Randomization RCT Safeguard against
limit overanalyzing trial selection bias by
data that leads to a ensuring equal
higher rate of identifying distribution of
significant differences prognostic
by chance alone characteristics
Prospective RCT and Studies started before between cohorts
observational the first patient Concealment RCT Investigators must be
enrolled to improve blinded to treatment
cohort assignments, allocation of patients
blinding, precision of to protect against
data collection, undue influence on
completeness of treatment allocation
follow-up, and study (i.e., selection bias)
directness Complete RCT and Complete follow-up
Power analysis RCT or Determination of the follow-up observational of all patients should
observational appropriate sample size always be sought [74].
to detect a prespecified Appreciable risk of
difference of clinical attrition bias exists
significance between when follow-up is less
cohorts. Based on than 80% [76]
standard deviation Expert-based RCT A surgeon with
measurements from design expertise in one of the
previous reputable procedures being
studies. Ensures that a evaluated in a trial is
study has sufficient paired with a surgeon
power to detect a with expertise in the
clinically significant other procedure.
difference Subjects are then
Exclusion and RCT and Defining the study randomized to a
inclusion observational population of interest surgeon, who
criteria and limiting patient performs only one of
factors which may the interventions (i.e.,
confound outcomes the procedure that he/
greatly improve the she has expertise and/
generalizability of or a belief that it is the
study results superior procedure)
Clinically RCT and The efficacy of an [50]. A safeguard for
relevant and observational intervention should be expertise bias
validated based on outcomes
outcome that are important to
measures patients using
instruments validated
in capturing this
clinical information
(continued)
1 Introduction to Evidence-Based Medicine 9

Table 1.4 Cochrane risk of bias assessment tool

Review authors’ judgment
(assess as low, unclear, or high
Bias domain Source of bias Support for judgment risk of bias)
Selection Random Describe the method used to generate the Selection bias (biased
bias sequence allocation sequence in sufficient detail to allow allocation to interventions) due
generation an assessment of whether it should produce to inadequate generation of a
comparable groups randomized sequence
Allocation Describe the method used to conceal the Selection bias (biased
concealment allocation sequence in sufficient detail to allocation to interventions) due
determine whether intervention allocations could to inadequate concealment of
have been foreseen before or during enrollment allocations before assignment
Performance Blinding of Describe all measures used, if any, to blind trial Performance bias due to
bias participants and participants and researchers from knowledge of knowledge of the allocated
personnela which intervention a participant received. interventions by participants
Provide any information relating to whether the and personnel during the study
intended blinding was effective
Detection Blinding of Describe all measures used, if any, to blind Detection bias due to
bias outcome outcome assessment from knowledge of which knowledge of the allocated
assessmenta intervention a participant received. Provide any interventions by outcome
information relating to whether the intended assessment
blinding was effective
Attrition bias Incomplete Describe the completeness of outcome data for Attrition bias due to amount,
outcome dataa each main outcome, including attrition and nature, or handling of
exclusions from the analysis. State whether incomplete outcome data
attrition and exclusions were reported, the
numbers in each intervention group (compared
with total randomized participants), reasons for
attrition or exclusions, and any reinclusions in
analyses for the review
Reporting Selective State how selective outcome reporting was Reporting bias due to selective
bias reporting examined and what was found outcome reporting
Other bias Anything else, State any important concerns about bias not Bias due to problems not
ideally covered in other domains in the tool covered elsewhere
prespecified
Adapted from Ref. [30] with permission of BMJ Publishing Group LTD from Higgins Julian et al. Assessing risk of
bias in included studies. In: Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions.
Wiley: 2008:187–241
a
Assessments should be made for each main outcome or class of outcomes

central concern to the orthopedic surgeon in
assessing the validity of results of published
studies.
Additionally, the Consolidated Standards of
Reporting Trials (CONSORT) Group published
updated guidelines on how to report RCTs [33].
A previous systematic review of the surgical
­literature has reported poor compliance of sur-
gical RCTs with its recommendations and
endorsed educational initiatives to improve
RCT reporting [34]. Although a thorough
review of this document is beyond the scope of
this chapter, it suffices to say that it serves as an
excellent overview to aid in planning, execut-
ing, and reporting RCTs.
Randomized Surgical Trials:
An Overview of Specific
Methodologies
RCTs are considered the optimal study design to
assess the efficacy of surgical interventions [29].
RCTs in the orthopedic literature have been
described as explanatory (also called mechanis-
tic) or pragmatic [35]. The explanatory trial is a
10
r­ igorous study design that involves patients who
are most likely to benefit from the intervention
and asks the question of whether the intervention
works in this patient population who receive
treatment. Pragmatic trials include a more hetero-
geneous population, usually involve a less rigor-
ous protocol and question whether the
intervention works to whom it was offered [36].
The explanatory trial measures the efficacy of the
intervention under ideal conditions, whereas the
pragmatic trial measures the effectiveness of the
intervention in circumstances resembling daily
surgical practice. For that reason pragmatic trials
have been said to be more generalizable, but this
comes at the cost of reduced study power due to
patient heterogeneity, as well as the potential for
poor patient compliance with applicable treat-
ments, which results in a larger range of treat-
ment effects (increased noise). Explanatory and
pragmatic approaches should be thought of as a
continuum, and any particular trial may have
aspects of each. The optimal trial design depends
on the research question, the complexity of the
intervention, and the anticipated benefit of the
new intervention to the patient. Randomized tri-
als are best suited to assess interventions with
small-to-medium treatment effects. The smaller
the anticipated effect, the more an investigator
should consider optimizing the participant pool
and intervention to provide clean results (explan-
atory trial) [36, 37].
Orthopedic surgery trials pose many method-
ological challenges to researchers. These include
difficulties with recruitment of an adequate num-
ber of patients, blinding, differential cointerven-
tion, and outcome assessment. These difficulties
are reflected in the quality of the current orthope-
dic literature. A previous review of orthopedic
RCTs showed that a high percentage failed to
report concealment of allocation, blinding, and
reasons for excluding patients [38–40]. The
results of these RCTs may be misleading to read-
ers, and there is a growing consensus that larger
trials are required [41]. A recent RCT has shown
that many of these problems can be circumvented
with multicenter surgical RCTs that include strict
guidelines for cointervention and contain a
C. J. Foote et al.
blinded adjudication committee to determine out-
comes [42].
The orthopedic community generally agrees
that RCTs are the future of orthopedic research,
but there have been many arguments against
them. These include ethical assertions about
patient harm which include (1) surgeons per-
forming different operations at random where
they may be forced to perform a procedure at
which they are less skilled and comfortable per-
forming, (2) conducting RCTs which involve
withholding care such as in a placebo-controlled
trial, and (3) inability to blind surgeons and the
difficulty in blinding patients unless a sham RCT
is conducted [25]. Although sham RCTs that
facilitate patient blinding have been published,
many ethics committees continue to deny its use
on the basis of potential harm to patients who
receive sham treatment [43, 44]. To help answer
the question of surgical RCTs containing a pla-
cebo arm, a systematic review has highlighted
the main obstacles and considerations with con-
ducting a sham surgical trial [45]. This review
describes the key feasibility issue with a placebo
surgical trial is a slow recruitment rate due to a
lack of eligible patients; however, sham surgical
trials remain feasible, especially for procedures
that are minimally invasive [45].
Others believe that discrepancies between
RCTs and types of studies are overexaggerated.
Concato and coworkers searched MEDLINE for
meta-analyses of randomized controlled trials
and meta-analyses of cohort or case–control
studies in five clinical areas. They found “remark-
able” similarities and concluded that these
­observational studies did not systematically over-
estimate the magnitude of the treatment effects.
They ended with the statement that “the popular
belief that only randomized, controlled trials pro-
duce trustworthy results and that all observational
studies are misleading does a disservice to patient
care, clinical investigation, and the education of
health care professionals” [46]. Benson and col-
leagues looked at 136 reports on 19 diverse treat-
ments. In most cases the estimates of treatment
effects from observational studies and random-
ized controlled trials were similar. In only 2/19
1 Introduction to Evidence-Based Medicine
treatment effects did the combined effect in the
observational studies lie outside the 95% confi-
dence interval for the combined magnitude in the
RCTs [47]. Ioannidis and colleagues found that
25/45 (56%) topics in non-randomized studies
showed larger treatment effect. 14/45 (31%)
RCTs showed larger treatment effect, and in 7/45
(16%), the magnitude of the differences would
not be expected by chance alone [48]. MacLehose
and coworkers systematically reviewing the com-
parisons of effect size from randomized and non-
randomized studies found that effect size
discrepancies between RCTs and observational
studies were lower in high-quality studies. These
studies lend to the argument that the quality of
the study might be more important than the
research design [49].
The Expertise-Based Design
In surgical trials, an ethical dilemma can arise if the
surgeon believes one intervention is superior or has
more expertise with one procedure but is forced to
perform the other procedure due to random patient
allocation. In such a circumstance, it is unethical
for the surgeon to be involved in the trial. To
address this problem, Dr. P.J. Devereaux has pub-
lished extensively on the expertise-based design
where the patient is randomized to one of the two
groups of surgeons and not to the procedure itself
[50]. This is in contrast to the parallel RCT where
surgeons perform both procedures in random order.
This avoids the aforementioned ethical dilemma
and also minimizes performance bias where the
results of the trial may be heavily impacted by sur-
geon experience or comfort. The downside of
expertise-based design is that in some research
areas, such as trauma surgery, both surgeon groups
need to be available at all times to perform their
designated intervention. This may limit feasibility
in small centers with scarce resources.
Parallel Trial Design
The most commonly utilized and simplest design
is the parallel randomized trial. Participants are
assigned to one of two or more treatment groups
11
in a random order. The most basic of these
involves two treatment groups – a treatment and
control arm. Trials can have more than two
arms to facilitate multiple comparisons, but this
requires larger sample sizes and increases the
complexity of analysis.
Factorial Design
The factorial trial enables two or more interventions
to be evaluated both individually and in combina-
tion with one another. This trial design is thought to
be economical in some settings because more than
one hypothesis (and treatment) can be tested within
a single study. For example, Petrisor and colleagues
[51, 52] conducted a multicenter, blinded random-
ized 2 × 3 factorial trial looking at the effect of
irrigation solution (castile soap or normal saline)
and pressure (high versus low versus very low pres-
sure lavage) on outcomes in open fracture wounds.
The corresponding 2 × 3 table is shown in Table 1.5.
From this table the investigator wound compare the
1140 patients receiving soap with the 1140 who
received saline solution. Concurrently, comparison
can be made between each of the pressure catego-
ries with 760 participants.
With factorial designs there may be interaction
between the interventions. That is, when treat-
ments share a similar mechanism of action, the
effect of one treatment may be influenced by the
presence of the other. If the treatments are com-
monly co-administered in surgical practice (such
Table 1.5 A 2 × 3 factorial trial table from the fluid
lavage in open fracture wounds (FLOW) randomized trial
Gravity flow Low High
pressure pressure pressure Total
Soap 380 380 380 1140
solution
Saline 380 380 380 1140
Total 760 760 760 2280
Source: Ref. [77]: Flow Investigators. Open Access
Article
This study had a target sample size of 2280 participants
and was designed to assess the impact of irrigation solu-
tion (soap or saline = 2 categories) and lavage pressure
(gravity flow, low, and high pressure = 3 categories) in
open fracture wounds
12
as the aforementioned lavage study), then this trial
design is ideal, as it allows for assessment of the
interaction to identify the optimal treatment com-
bination. Treatment interactions may be negative
(antagonistic) or positive (synergistic), which
reduce or increase the study power, respectively.
This consequently affects sample size, and there-
fore potential interactions should be considered in
the design phase of the study.
Other Randomized Designs
In surgical trials the unit of randomization is
often the patient or the limb of interest [15, 51].
In other words, when we randomize to one treat-
ment versus another, we are usually talking about
randomizing patients. In some circumstances,
however, randomizing patients may not be feasi-
ble or warranted. When the intervention is at an
institutional or departmental level, such as with
implementation of a new process, guideline, or
screening program, patient randomization is dif-
ficult and often impossible. This is for several
reasons: (1) surgeons or health-care practitioners
are unlikely to use a new guideline for one patient
and not the other; (2) patients randomized to dif-
ferent interventions will often educate each other
(a process called contamination); and (3)
department-­wide programs are often expensive
and challenging to implement, so running multi-
ple programs is not practical or economical. In
these circumstances, it is best to randomize insti-
tutions, departments, or geographical areas. This
process is called cluster randomization. For
instance, if one were to implement a chewing
tobacco cessation program among major league
baseball players, it would make more sense to
randomize teams to the cessation program rather
than individual players. Two important aspects of
cluster trials are as follows: (1) participants
within clusters are more similar with regard to
prognostic factors than between clusters, and (2)
a sufficient number of clusters must be available
to provide prognostic balance and sufficient
power. In general, because patients within clus-
ters are similar, there is a reduced power and an
increased required sample size of cluster trials. In
the analysis, one can compare the outcomes of
C. J. Foote et al.
entire clusters or individuals. Individual patient
analysis requires an estimate of patient similarity
(called an intraclass correlation coefficient). The
more similar the participants are within clusters,
the higher the intraclass correlation coefficient,
and the required sample size is consequently
greater to reach significance.
Another trial design is the crossover trial
where patients are randomized to a treatment and
then receive the other treatment after a desig-
nated period of time. Each participant serves as
their own control when a within-patient analysis
is conducted. These studies have significant
power but are rarely conducted in orthopedic sur-
gery because they require chronic diseases with
treatments that are quickly reversible once
stopped. For example, Pagani and colleagues
[53] conducted a crossover trial assessing the gait
correction of 4-valgus and neutral knee bracing
in patients with knee OA. All patients performed
gait and stair climbing assessments without an
orthosis and then were randomized to one of the
two bracing arms for 2 weeks followed by cross-
over to the other bracing arm for 2 weeks.
Because of the power of this analysis, they
­demonstrated a statistically significant improve-
ment in gait mechanics with 4-valgus bracing
with only 11 patients.
 pecial Considerations Within the
S
Hierarchy
In addition to reviews of level II studies [54],
reviews of high-quality RCTs with inconsistent
results [55] are also regarded as level II evidence
(Table 1.1). For instance, Hopley and associates
performed a meta-analysis comparing total hip
arthroplasty (THA) to hemiarthroplasty (unipolar
and bipolar) which included seven RCTs, three
quasi-randomized, and eight retrospective cohort
studies. This review reported reduced reopera-
tion rates and better functional improvements
after THA than hemiarthroplasty. However, from
review of this study’s forest plot of randomized
studies, one can see that there is a wide range in
point estimates leading to imprecision within
their pooled effect size (Fig. 1.2). This analysis
encountered methodological issues such as lack
1 Introduction to Evidence-Based Medicine 13

of concealment, heterogeneity of study inclusion Grades of Recommendation:

criteria, and type of hemiarthroplasty; all of these From the Bench
factors would negatively affect this meta-­ to the Operating Room
analysis’s rating within the hierarchy. In addi-
tion, the included review of retrospective cohort The quality of best available evidence and the
studies would be regarded as level III evidence magnitude of treatment effect reported play a
(Fig. 1.2; Table 1.1). central role in the strength of clinical practice

Fig. 1.2 Sample forest plot that shows the point estimates
and 95% confidence intervals of individual primary studies
and pooled effect sizes represented as a relative risk (dia-
mond). This meta-analysis provided separate pooled effect
sizes for each type of study design and an overall pooled
estimate shown at the bottom. Estimates to the left favor
total hip arthroplasty and to the right hemiarthroplasty
(References and reference numbers in figure refer to refer-
ence list in source article.) (Used from Ref. [55]: with per-
mission of BMJ Publishing Group LTD from Hopley et al.)
14 C. J. Foote et al.

Table 1.6 Modified GRADE quality assessment criteria [56]

Quality of
evidence Study design Lower ifa Higher ifa
High Randomized trial Study quality: Strong association:
–1 Serious limitations +1 Strong, no plausible confounders, consistent
–2 Very serious limitations and direct evidenceb
–1 Important inconsistency +2 Very strong, no major threats to validity
Directness: and direct evidencec
–1 Some uncertainty +1 Evidence of a dose–response gradient
–2 Major uncertainty +1 All plausible confounders would have
–1 Sparse data reduced the effect
–1 High probability of
Reporting bias
Moderate Quasi-randomized
trial
Low Observational
study
Very low Any other evidence
Source: Ref. [57]: Atkins et al. Open Access Publication
a
1 = move up or down one grade (e.g., from high to moderate). 2 = move up or down two grades (e.g., from high to low).
The highest possible score is high (4) and the lowest possible score is very low (1). Thus, for example, randomized trials
with a strong association would not move up a grade
b
A relative risk of >2 (<0.5), based on consistent evidence from two or more observational studies, with no plausible
confounders
c
Available studies provide direct comparisons between alternative treatments in similar participant populations

recommendations. A recommendation for or (items 1 and 4) or many (items 2 and 4) well-­

against an intervention is based on a comprehen-
sive systematic review of available evidence,
evaluation of the methodological quality of avail-
able studies, and focus group discussion of sub-
specialty experts to achieve consensus. In 2004,
the Grading of Recommendation Assessment,
Development, and Evaluation (GRADE)
Working Group developed a system for scoring
the quality of evidence (Table 1.6) [57]. This
scoring system places more weight on studies
with better design, higher methodological qual-
ity, and larger treatment effects, but also consid-
ers factors such as directness [57]. The GRADE
criteria are applied to all critical outcomes. Once
the evidence is “graded” and several factors such
as calculation of baseline risk in the target popu-
lation, feasibility of the proposed intervention,
and a benefit versus harm assessment are com-
pleted, a recommendation level is assigned which
includes one of the following: (1) do it, (2) prob-
ably do it, (3) toss up, (4) probably do not do it,
and (5) do not do it [36, 37]. These recommenda-
tions guide surgeons by suggesting that most
informed surgeons would make a particular deci-
sion, based on systematic review of the literature.
The GRADE approach provides a basic founda-
tion for translating evidence into practice and
serves as a useful communication tool for clini-
cians and review panels. However, even valued
input and consensus from expert panels do not
replace a sound understanding of the available
evidence (e.g., from a critical appraisal of a meta-­
analyses) and good clinical judgment. Hence, we
return to the essence of EBO which considers
best available evidence, clinical judgment,
patient values, and clinical circumstances when
making treatment decisions (Fig. 1.1).
Evidence-Based Orthopedics:
Advances and Misconceptions
EBM has been recognized as one of the top 15 medi-
cal discoveries of the last 160 years. In the past
decade, it revolutionized clinical research and care
by providing the basis for the development of clinical
1 Introduction to Evidence-Based Medicine
trials, systematic review, and validated outcomes.
International standards have been developed such as
the Oxford Centre for Evidence-Based Medicine,
the Cochrane Collaboration, and Britain’s Center for
Review, which are providing updated systematic
reviews of the effects of medical and surgical care
[58]. In orthopedics, JBJS has fully incorporated the
hierarchy of evidence into all published manu-
­ [55, 66, 67].
scripts, and this has been utilized in annual meetings
of the American Academy of Orthopedic Surgeons
(AAOS) [59]. As a consequence, the overall quality
of clinical trials and systematic reviews in orthope-
dics appears to be improving [23, 60].
Improving the validity of orthopedic studies is
only one facet of EBO in its pursuit to improving
standards in orthopedic practice. EBO also
requires a willingness of an orthopedic society,
for example, the AAOS in this case, to incorpo-
rate best evidence into practice [61]. Traditionally,
there has been a resistance to perform
­well-­designed studies in orthopedics and miscon-
ceptions about the practice of EBO [62, 63]. In
contrast, an international cross-sectional survey
among International Hip Fracture Research
Collaborative (IHFRC) surgeons revealed that
most surgeons are willing to change their prac-
tice based on large-scale clinical trial results [64].
Thus, it appears that orthopedists are recognizing
the need for higher standards to ensure best care
for patients with musculoskeletal conditions.
Despite the global movement of EBO, mis-
conceptions about it exist. There have been criti-
cisms that EBO only gives information about the
average patient and that simple application of
trial results is analogous to “cookbook” medicine
[16, 65]. The approach of EBO is actually exactly
the opposite. EBO utilizes a bottom-up approach
which begins with a surgical problem and incor-
porates best available evidence, surgical exper-
tise and experience, the clinical context, and
patient preferences. Surgical expertise and a
working understanding of EBO are essential to
appreciate if the available evidence applies well
to the individual patient and clinical circum-
stances, and if so, how it should be applied. For
example, if one were to encounter the 65-year-­
old marathon runner with a displaced femoral
neck fracture after a fall, one must consider the
15
available evidence of improved outcomes of
THA as compared to hemiarthroplasty and inter-
nal fixation, the current limitations of this litera-
ture, the patient’s functional status and
physiologic age, and patient preferences and
expectations with regard to the complication pro-
file and functional outcomes of these procedures
Some have equated EBO with only RCTs and
meta-analysis, as these are considered the high-
est quality of evidence. On the contrary, EBO
proposes to use the most appropriate study
design and methodology to answer the surgical
question with maximal validity. RCTs are more
effective when the condition is common rather
than when it is rare. For instance, many condi-
tions in orthopedic oncology are too scarce to
permit an RCT, but EBO advocates that studies
in this field institute as many safeguards as pos-
sible to limit bias, to focus on outcomes that are
important to patients, and to perform systematic
review when possible [68]. In addition, evalua-
tion of ­diagnostic efficacy is best answered by
cross-sectional studies rather than RCTs.
Questions regarding biomechanics and pros-
thetic wear properties are often best addressed
by studies in basic science. Despite this, ran-
domized trials have claimed much of the focus
of EBO because of their important role in pro-
viding valid outcomes for surgical interventions
(Table 1.1). Observational studies that are
designed well have their place. A well-­designed
observational study can limit bias and confound-
ing that is associated with nonrandomization.
Some questions answered by this type of study
can be the etiology, natural history, identification
of prognostic factors, and the possibility of
adverse treatments. From an ethical standpoint,
it would be unethical to randomize treatment
groups to management that may be harmful [69].
Thus, it is important to keep in mind that many
factors determine the ideal study design that best
answers the clinical problem. Such consider-
ations include the type of question being asked
(e.g., therapeutic efficacy, diagnosis), frequency
of the condition, ethics of intervention, the qual-
ity and uncertainties of available evidence, and
surgical equipoise.
16
Closing Comments
Ultimately, becoming an evidence-based ortho-
pedic surgeon is not a simple task. One must
understand the hierarchy of evidence, from meta-­
analysis of RCTs to clinical experience. In mak-
ing surgical decisions, a surgeon should know the
strength of best available evidence and the cor-
responding degree of uncertainty. The process of
exploration of evidence to answer specific ques-
tions is equally critical. The ability to search the
available literature, evaluate the methodological
quality of studies to identify best evidence, deter-
mine the applicability of this information to the
patient, and appropriately store this information
for further reference requires education and prac-
tice. For educational modules on these topics, we
direct you toward several additional resources to
this text including Clinical Research for Surgeons
[25], the Users’ Guides to the Medical Literature:
A Manual for Evidence-Based Clinical Practice
[2], the JBJS Users’ Guide to the Surgical
Literature: How to Use a Systematic Literature
Review and Meta-Analysis [70], and the Journal
of Orthopedic Trauma evidence-based orthope-
dic trauma summaries [8].
References
1. Hoppe DJ, Bhandari M. Evidence-based orthopae-
dics: a brief history. Indian J Orthop. 2008;42:104–10.
2. Guyatt DR G, editor. Users’ guide to the medial lit-
erature: a manual for evidence-based clinical practice.
Chicago, IL: American Medical Association Press;
2001.
3. Guyatt GH, Sackett DL, Cook DJ. Users’ guides to
the medical literature. II. How to use an article about
therapy or prevention. B. What were the results
and will they help me in caring for my patients?
Evidence-Based Medicine Working Group. JAMA.
1994;271:59–63.
4. Sackett DL. Evidence-based medicine. Semin
Perinatol. 1997;21:3–5.
5. Tilburt JC. Evidence-based medicine beyond the bed-
side: keeping an eye on context. J Eval Clin Pract.
2008;14:721–5.
6. Guyatt GH, Sackett DL, Sinclair JC, et al. Users’
guides to the medical literature. IX. A method for grad-
ing health care recommendations. Evidence-Based
Medicine Working Group. JAMA. 1995;274:1800–4.
C. J. Foote et al.
7. Swiontkowski MF, Wright JG. Introducing a new
journal section: evidence-based orthopaedics. J Bone
Joint Surg. 2000;82:759.
8. Bhandari M, Sanders RW. Where’s the evidence?
Evidence-based orthopaedic trauma: a new section in
the Journal. J Orthop Trauma. 2003;17:87.
9. Weber KL. The AAOS clinical practice guidelines.
J Am Acad Orthop Surg. 2009;17:335–6.
10. Phillips BBC, Sackett DL, Badenoch D, Straus S,
Haynes B, et al. Levels of evidence and grades of rec-
ommendation. Oxford: Oxford-Centre For Evidence
Based Medicine: GENERIC; 1998.
11. Schunemann HJ, Bone L. Evidence-based
orthopaedics: a primer. Clin Orthop Relat Res.
2003;213:117–32.
12. Group OLoEW. The Oxford 2011 levels of evidence.
Oxford: Oxford Centre for Evidence-Based Medicine;
2011.
13. Sackett DL, Rosenberg WM, Haynes RB. Evidence
based medicine: how to practice and teach
EBM. New York: Churchill Livingstone; 1997.
14. Sackett DL. Evidence-based medicine and treatment
choices. Lancet. 1997;349:570; author reply 572–3.
15. The FAITH Investigators. Fixation using alternative
implants for the treatment of hip fractures (FAITH):
design and rationale for a multi-centre randomized
trial comparing sliding hip screws and cancellous
screws on revision surgery rates and quality of life
in the treatment of femoral neck fractures. BMC
Musculoskelet Disord. 2014;15:219.
16. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence
based medicine: what it is and what it isn’t. BMJ.
1996;312:71–2.
17. Schulz KF, Grimes DA. Unequal group sizes in ran-
domised trials: guarding against guessing. Lancet.
2002;359:966–70.
18. Biedermann R, Martin A, Handle G, et al.
Extracorporeal shock waves in the treatment of non-
unions. J Trauma. 2003;54:936–42.
19. Thoma A, Farrokhyar F, Bhandari M, et al. Users’
guide to the surgical literature. How to assess a
randomized controlled trial in surgery. Can J Surg.
2004;47:200–8.
20. Urschel JD, Goldsmith CH, Tandan VR, et al. Users’
guide to evidence-based surgery: how to use an article
evaluating surgical interventions. Evidence-Based
Surgery Working Group. Can J Surg. 2001;44:95–100.
21. Miller JN, Colditz GA, Mosteller F. How study design
affects outcomes in comparisons of therapy. II surgi-
cal. Stat Med. 1989;8:455–66.
22. Bhandari M, Tornetta P III, Ellis T, et al. Hierarchy
of evidence: differences in results between non-­
randomized studies and randomized trials in patients
with femoral neck fractures. Arch Orthop Trauma
Surg. 2004;124:10–6.
23. Bhandari M, Morrow F, Kulkarni AV, et al. Meta-­
analyses in orthopaedic surgery. A systematic review
of their methodologies. J Bone Joint Surg Am.
2001;83-A:15–24.
Another random document with
no related content on Scribd:
 “The stay at home statesman,” she once said, “think that
Africans are all awful savages or silly children—people who
can only be dealt with on a reformatory, penitentiary line. This
view, you know, is not mine ... but it is the view of the
statesmen and the general public and the mission public in
African affairs.”

And again:—

“The African you have got in your mind up here, that you
are legislating for and spending millions in trying to improve,
doesn’t exist; your African is a fancy African.... You keep your
fancy African and I wish you joy of him, but I grieve more than
I can say for the real African that does exist and suffers for all
the mistakes you make in dealing with him through a dream
thing, the fiend-child African of your imagination. Above all, I
grieve for the true negro people whose home is in the West
Coast....”

No, you cannot excite public interest in these matters. But mention
the liquor trade, describe the Nigerian as an infant in brain, incapable
of self-control, down whose throat wicked merchants are forcibly
pouring body and soul destroying drink which a wicked
Administration taxes in order to raise revenue. Public sentiment
responds with alacrity. It becomes at once a popular cry, and the
most inconceivable distortions of native character and native life
pass muster. Oppose that view and it will be a miracle if you emerge
with any shred of reputation you may once have possessed. Stones
from episcopal catapults will whistle round your ears. Scribes, utterly
ignorant of the country whose inhabitants they portray in an absurdly
false light, and who make their living by going shuddering around in
professional temperance circles, will hint darkly that somewhere in
the dim back of beyond your attitude is dictated by personal interest.
A certain type of missionary will denounce you from the housetops,
ransack the Bible for quotations to describe the extent of your fall
from grace, and end up by praying the Almighty for the salvation of
your soul. You will be described as a man who cynically ministers to
the degradation of the negro. People who believed in you will ponder
sadly over your moral declension. You may consider yourself lucky if
your best friend does not cut you in the street. To disparage the
Administration, to describe the English gentlemen who serve it in
Nigeria as callous onlookers while a people sinks down before them
in ruin and decay; to paint the sober Nigerian as a drunken brute—all
this is permissible. But the deafening clamour which arises, the
protesting and outraged indignation which obtains if a humble voice
is heard to deny the accuracy, and to resent, in the public interest,
these sweeping charges against White and Black alike, beggars
description. You find yourself denounced to the whole world as a
cruel libeller of godly men, and much else besides. It would be
humorous if it were not pathetic, because amidst all this froth and
fury the vital problems arising out of European contact with West
Africa are obscured, and a force which, instructed and directed in the
right way, might be of untold benefit is wasted on a sterile issue.
The onslaught upon Southern Nigeria in the matter of the liquor
traffic carried on by that sincere, but tactless, misinformed and
pugnacious cleric, Bishop Tugwell, and the bulk of his assistants in
West Africa, aided by the Native Races and Liquor Traffic United
Committee at home, is a typical example of the harm which lack of
perspective and muddle-headedness can do to a good cause. The
liquor traffic is common to the whole of West Africa and requires
constant and vigilant attention. For more than a century, long before
the bulk of the coast line was occupied by the Powers in a political
sense, spirits had been exported to West Africa from Europe
together with cotton goods, woollen goods, beads, ironware,
hardware, haberdashery, perfumery, salt, tobacco and a host of other
articles. At first the trade was untaxed. As European political
influence extended, the various Administrations found it necessary to
control the traffic by placing an import duty upon spirits at the port of
entry. In this policy Great Britain has always led; the other Powers
have always lagged. When interior penetration from the coast began
and the scramble for Western Africa was well on its way, Great
Britain’s influence was responsible for the proposal that the import
should be prohibited beyond a certain geographical limit
interiorwards. Thus Northern Nigeria was excluded from the
accessible zone of European spirit import. By general consent the
trade has been looked upon as a potential danger, if unregulated,
and nowhere has the determination to prevent it from becoming an
active evil been so clearly recognized as in Southern Nigeria; by
successive increases of duty, and, as I shall show, by so adjusting
taxation as virtually to penalize spirits of high potency in favour of
spirits of weak strength. The Governor-General of French West
Africa, M. Ponty, told me only last autumn at Dakar, how he desired
to bring the French duties up to the British level, and what difficulties
he was experiencing in doing so. Now the existence of a permanent,
outside influence, whatever its origin, directed at encouraging the
Administration in this course could only be to the good. While
differences of opinion must exist as to the relative importance of the
matter compared with other problems of administration, I have met
no one who would not regard a policy of letting in spirits free, as
wrong. I have met no one who is not convinced that it is right to tax
the trade just as high as it can be taxed, up to the point, that is, when
people will still buy and not be driven to illicit distilling, which in the
West African forest could not be suppressed. If Bishop Tugwell and
his friends had concentrated upon the potentiality of the danger, and
had given every help and assistance to the Administration to cope
with it, supplying the Administration with such information as they
might possess of a specific, controllable, accurate character, it would
have been difficult to over-estimate their usefulness from this
particular point of view.
But the course they have been pursuing for the last few years has
been quite different. It has been so illogical, so lacking in judgment
and sobriety, and so pronouncedly foolish and unjust, as to disgust
every fair-minded man who has looked into the facts for himself.
Instead of common-sense and reasonable debate, there has been
violent and senseless denunciation accompanied by the grossest
misstatements. The Administration, urged perpetually to increase the
tax, has been cursed with bell, book and candle for the automatic
result in swelling the proceeds of revenue derived from these
increases. What was demanded as a moral duty has, in its inevitable
result, been stigmatized as a crime, and the very men who
clamoured for more taxes, have denounced the effect of them. A
trade forming from time immemorial, as already stated, part of the
general barter trade of the West Coast has become identified in the
public mind with a particular British dependency, the very one where
official vigilance has been specially exercised. A difficult and
complicated economic and fiscal problem has been handled in so
unintelligent a manner that it has degenerated into systematic and
silly abuse of British officials, who have no more to do with the
existence of the traffic than has the Duke of Westminster who
presides over the Native Races and Liquor Traffic United Committee.
These officials of ours, some of whose difficulties I have attempted to
portray, have actually been accused—nay, are still being—of
encouraging the trade in every possible way, of forcing it upon the
people, of thriving on the drinking habits of the native. Fanaticism
has even gone the length of stating that they are “financially
interested” in the traffic, as though they received a percentage from
Government on the revenue derived from taxing the article! The very
Commission which Lord Crewe sent out to investigate the charges
persistently brought, has been assailed with unmeasured
vituperation for the crime of having rendered a truthful report on the
evidence produced, and the public at home has been asked to
believe that these Commissioners, the Political and Judicial Staff of
the Protectorate, the Medical Staff, the Roman Catholic
missionaries[15]—the most numerous in the Protectorate—together
with prominent natives and independent outside witnesses as well,
are either deliberate perjurers or incompetent observers; although
the accusers’ testimony was hopelessly, even pitifully, inadequate
when brought to the test of public examination and inquiry. In an
official pamphlet issued by the Native Races Committee the
statements of Sir Mackenzie Chalmers, the Chairman of the
Commission, as recorded in the minutes of evidence, have been
reproduced in mutilated form, presumably in order to carry conviction
of his bias with the public. Those who can stoop to such methods do
irreparable injury to a good cause. What in its origin was
undoubtedly a movement of a genuine philanthropic character, has
been converted into an agitation which has so incensed authorized
Native opinion, that Mr. Sapara Williams, the leading Native member
of the Legislative Council of Southern Nigeria and a fearless critic of
the Government, found it necessary to voice the feelings of the
community in the following vigorous language uttered in the
Legislative Council itself:—

“I must say that I believe every unofficial member and every

member of the community of these countries feel bound to
say that the majority of the statements made by Bishop
Tugwell are untrue. It is a slander on the Administration, a
slander on the gentlemen who sit here, and a slander on the
general public; and for a man in Bishop Tugwell’s position as
the head of the Church here—namely, a Church which always
makes it a boast amongst the native communities of its
connection as being in communion with the great Church of
England—to go before the British public and endeavour, by
means of gross misrepresentations and statements which are
absolutely incorrect and palpably false on the face of them, to
enlist their sympathy and induce them to support a noble
cause, is not only detrimental to the good cause itself, but
also to the progress of Christianity and missionary work in
these countries.... If Bishop Tugwell will talk of something
else, instead of this persistent indulging in calumny and
malignity simply to promote the movement against the Liquor
Traffic it would, perhaps, be better for the interest of this
Colony and Protectorate, and the welfare of the Church, and
of the mission work in Western Equatorial Africa under him. I
say that, to my thinking, these misstatements are made
deliberately with a view to influence subscriptions towards the
various branches of his many diocesan funds, a course
clearly opposed to the true principles of Christianity,
inconsistent with the high purpose and professions of his
calling and the dignity of his office.”

I am not concerned with Mr. Williams’ views, but nothing could be

more significant than this speech—and it is not the only Native
protest which has been made in the Southern Nigeria Legislative
Council—coming from a native in Mr. Williams’ position, a Christian
and a total abstainer. The Native Races Committee has been
singularly ill led. It has identified itself completely with extremists
whose looseness of statement, whose persistency in statistical and
other errors, and whose extraordinary lack of judgment were so
painfully apparent when they testified before the Commission of
Inquiry. It is matter for regret that divines of high position in this
country and Members of Parliament have plunged into the fray
without exercising sufficient caution before allying themselves to a
campaign conducted on lines inconsistent with accuracy and fair
play.
The literature on this subject is enormous, and several chapters
would be needed to follow it in any detail. I propose, however, to
summarize certain points.
First. The statements as to race demoralization and deterioration,
of decrease of energy for labour; of decrease in other branches of
trade; of an increase in crime and decrease of population as the
result of the spirit trade, have been totally disproved. They have,
indeed, been officially dropped by the Native Races Committee.
Secondly. The allegations as to the evil quality of the liquor imported
have also been disproved and dropped by the Committee. Thirdly.
By a system of sur-taxes upon the higher forms of alcohol initiated
by Sir Walter Egerton, the character of the Southern Nigerian spirit
trade has been revolutionized for good in the last six years. The
system inaugurated in 1905 imposed, over and above the general
duty, a sur-tax of ½d. for every degree or part of a degree in excess
of 12·4 under proof. This sur-tax was successively raised until it
reached its present figure of 2½d., with the result that while five
years ago nearly 60 per cent. of the total spirits imported varied in
strength from between 45 degrees and 55 degrees Tralles, to-day
something like 90 per cent. of the total spirits imported are just under
40 degrees Tralles, i.e. 28 per cent. under proof.
Fourthly. Not only is the general trade (i.e. the trade in cotton
goods, hardware, etc.) increasing at a far greater ratio than the spirit
trade, but the amount of alcohol imported into the Protectorate is
actually decreasing, notwithstanding the enormous development of
general trade and the steady opening up of the country to which the
former is largely due. Here are the figures. They are official and their
accuracy has been endorsed by the Secretary of State—
GALLONS OF ALCOHOL

Years Totals Annual average

1902-04 8,947,000 2,982,332

1905-07 8,746,000 2,915,333

1908-10 8,626,000 2,875,333

Fifthly. The population of Southern Nigeria, according to the 1911

census, is 7,750,000. It is believed to be, and probably is, much
greater. Thus on the basis of estimated population the consumption
of alcohol per head works out at a fraction over one quarter of a
gallon. It is, of course, not nearly so great, and this for several
reasons. The alcohol imported is not all drunk, to begin with. A great
deal of it is stored, sometimes for years, as banked wealth. A great
deal of it, in the Central Province and to some extent in the Eastern
Province, circulates continuously as a sort of barter currency. This
system, a purely native one (in certain regions cloth and tobacco are
also used as currency) will gradually fade away with the increased
circulation of silver coin. Then, again, a good deal of it is wasted,
poured out on the ground as libations to the gods; how much it is
impossible to say.
I will now conclude with a consideration of what other steps may
be possible to adopt with a view to further controlling the traffic. The
policy of the Native Races Committee and of Bishop Tugwell and his
friends has apparently changed. Up to the time of the Commission of
Inquiry they alternated between a demand for higher duties, and
prohibition. Some years ago a deputation waiting upon Mr.
Chamberlain put forward a request for a 4s. duty per Imperial gallon.
The duty to-day is 5s. per Imperial gallon, apart from the sur-taxes
already referred to. “Total prohibition” was officially demanded by the
Native Races Committee shortly before the Commission was
appointed. The Committee has now dropped the demand for total
prohibition, which does not prevent Bishop Tugwell’s friends and
coadjutors from continuing to denounce the Administration and
describe the ravages of the traffic in lurid terms up and down the
country. That the demand for prohibition has been abandoned is
significant. Coupled with a cessation of the abusive tactics it would
indicate the beginning of wisdom. That the latter continue suggests
the possibility that the demand for prohibition will be or may be
revived. The only concrete demands now put forward by the official
spokesmen of the Committee (vide the deputation to Mr. Harcourt in
July) are (1) an international conference; (2) what is described as a
system of local option. That is the somewhat feeble conclusion to the
raging, tearing propaganda of the last ten years.
How the Native Races Committee can reconcile it with the furious
attacks upon all and sundry in which they have indulged is not my
affair. At any rate, it is a confession of constructive impotence. And
for this reason. International conferences on this subject are held
regularly every few years, and much portentous talk is indulged in by
grave gentlemen sitting round a table. As a matter of fact, Britain, as
already stated, leads in the matter of high duties and adjustment of
duties to strike at spirits of higher potency. We have difficulty, which
is perennial, in getting the other Powers to agree to our level. At the
present moment the duty levied in the French territory of Dahomey,
which borders Southern Nigeria, is much lower than ours, and
smuggling is the result. Therefore, whatever good a Conference may
do, that good will affect foreign territory, not Southern Nigeria. As a
practical policy the international conference is, thus, devoid of import
so far as Southern Nigeria is concerned. “Local option” is largely a
catch word which appeals to the public—always influenced by the
subjective point of view. What is really meant by it is that a native
community should be given the option of not buying spirits. But it has
that option now! The native community of Ibadan and of Abeokuta
stopped buying spirits three years ago for several months on end,
because the people objected to a licensing duty, which naturally put
up the price of spirits and was an innovation entirely foreign to the
native mind. Any native community in Southern Nigeria is free, to-
day, to buy or not to buy spirits, or cotton goods or tobacco or
anything else. But a native community consists not of one Chief, but
of a Paramount Chief or King (when the native state form has
developed to that extent which, in the Eastern Province, for example,
is not yet the case), a number of ordinary Chiefs with their
councillors, and the people. It is one thing for a Native community to
make up its mind not to buy spirits. It is quite a different thing for a
Chief to impose his caprice, which may be purely temporary in its
action, upon his people. If, for example, we suppose a Chief
desirous to please the missionaries in his locality, or objecting to the
present high price of imported spirits and wishing to pull it down, or
for some other reason, forbidding his people to buy spirits; then the
Administration would be clearly in the wrong in supporting that Chief
if his views did not coincide with the views of his people. Such action
would amount to coercion and interference with the liberties of the
people themselves. The Chief so acting would be violating native law
and assuming the powers of a dictator, which in Southern Nigeria
under the native system of rule he does not possess. He could only
do so backed by the British Administration, and in backing him the
British Government would be making native rule impossible and
inciting to disturbance and turmoil.
The Native Races Committee’s suggestions carry us then no
further. The alternative line of action I suggest is the following:—

The liquor traffic in Southern Nigeria (as everywhere else in

Western Africa), must be carefully watched.
It is not now an active evil in Southern Nigeria. It need
never become one if certain things are done.
Those things are—
A. Frequent analyses of the imported article. Severe
punishment if bad stuff is going in.
B. Continuation of the legislation, consistently followed
since 1905, of taxing, over and above the general tax, higher
degrees of alcoholic strength pro rata. Perhaps pursuing that
still further by prohibiting altogether the importation of liquor
above a certain strength.
C. Keeping duties to the level of safety, raising them
whenever possible, but never so highly that the population will
altogether cease to buy, and take to distilling, which by the
pot-still process is the easiest thing in the world.
D. Not permitting the proportion which the spirit trade now
bears to the general trade to increase—that means watching,
and increasing the duty when possible. At every sign of the
present proportion being increased, another increase of duty
should be made.
E. Restricting, if possible, the present proportion, by
degrees either by the policy of successive increases of duty;
or by an arrangement with the merchants (very difficult to
bring about, owing to the advent of new firms; but not,
perhaps, impossible), whereby they would be precluded from
exceeding in the spirit branch of their trade a certain fixed
proportion to their general trade turn-over—the imports of
each firm being calculated on a basis which would establish a
decrease in the total volume of the spirit trade. This
arrangement, if it were possible, would have, really, the same
effect as judicious increases of duty, by making the imported
article dearer.
F. The creation of a sitting committee in Lagos—sitting and
permanent—the members of which would be gazetted and
paid a small salary: with two branches, one in the Central and
one in the Eastern Province, and (if necessary) with
corresponding members in several of the more important
centres—with the object of creating in each province a sort of
bureau of information on the spirit trade to which every one
would feel free to communicate.
G. Standing instructions to every medical officer to give
attention to the subject from the physiological point of view,
within his area and to furnish a half-yearly report to the
Principal Medical Officer. These reports would be annotated
 by the P. M. O., who, reviewing the whole evidence, would
give his report. Specific instances raised by any medical
officer, might if necessary be referred to the permanent
committee above mentioned.
H. A yearly report to be furnished by the Chairman of the
permanent committee, and by the P. M. O. respectively, to the
local Government, and published in the Official Gazette.
I. Maintenance of the prohibitory line under amalgamation;
and its deflection southwards in the Eastern Province in order
to keep from the influence of the trade, the northern portions
of the Eastern Province where the trade has, up to now, not,
or barely, penetrated.
J. Gradual, very gradual, introduction of direct taxation in
the Central and Eastern Provinces, working upwards from the
coast line—preceded by full explanations, and the calling
together of District Chiefs and Heads of Houses for purposes
of discussion. In the Western Province, where direct taxation
by the British Government would be a violation of Native law
and of Treaties and Arrangements, a policy (sketched in Part
II.) of re-constituting according to native law, the old Yoruba
Kingdom, and reviving through the Alafin, the tribute which in
native law is due to him, and eventually controlling the
expenditure of the proceeds through the Alafin and the heads
of the various Yoruba States. These respective proceedings
being taken with the object of gradually making us
independent, or virtually independent, of taxation on spirits as
a source of revenue.

That is, broadly, the constructive policy I venture to recommend. It

might have to be modified here and there. But in its main lines I
believe it to be sound.
On the main issue I would say this. The Southern Nigeria
Administration stands for high ideals and good government, sound
native policy, preservation of native authority and land tenure. In my
belief the untruthful and malignant charges brought against it are
weakening that for which the Administration stands. This is a grave
danger, and one’s sense of justice revolts at allegations made
against an Administration the bulk of whose officials are doing good
work under many difficulties. It is bad for the Empire and for the
forces making for just native government within the Empire, that
public opinion should be led to believe that Southern Nigeria is a
thing to be ashamed of rather than to be proud of—which ought
legitimately, on the facts, to be the case.
It is bad for public policy and the integrity of public life that a
Commission of Inquiry should be dragged in the mud when it has
recorded the truth.
It is Imperially foolish, and essentially unjust in itself, that the
natives of Nigeria should be represented as degraded and
demoralized, helpless creatures, when they are nothing of the kind.
They resent it, and it is untrue. The propagation of continuous
untruths about a native race will sooner or later lead that native race
to be held in such low estimation, that it will be persecuted and
unjustly dealt by. This picture drawn of this race, strengthens, in
public opinion, the various forces which are bent upon perpetuating
the legend of the African half-child and half-devil, which is so great
an obstacle to sane public views at home, and, therefore, in the
ultimate resort to sane policy in Africa.
If the Colonial Office is driven to prohibition or any violent step of
that sort, direct taxation must immediately follow in order to raise
revenue, and that will mean the massacre of thousands of innocent
people. It will also lead to the destruction of palm trees, which will
impoverish the country and lower trade; to the stoppage of all export
in cereals, the surplus crop being used to produce fermented liquors,
and thus, again, to the impoverishment of the country and possibly to
the shortage of crops, with the resultant scarcity of food supply; to
the creation of illicit stills and the production of a crude liquor full of
impurities, and, consequently, very harmful in effects. The Nigerian
population of the south must have liquor of some sort. It requires it,
like every race does, that is not naturally a teetotal race, which the
Nigerian race has never been. To stop drinking is impossible—nor,
perhaps, is it desirable if it were possible, especially in the forest
zone which is more or less under water for six months in the year.
Anyway, it cannot be done. The Nigerians do not over-drink. They
are much more sober than we are—that is incontestable. They
occasionally drink more than is good for them at weddings, etc. (just
as many people do in this country), and at their religious feasts. But
they did that (since feasting and drinking has always been part and
parcel of the religious stage of humanity the Nigerians are now in—
part of the cult of the fertilizing spirit of nature) long before we knew
they existed.
The danger of increasing over-indulgence in drink by “educated”
natives is a very real one. But “trade spirits” have nothing to do with
this. The secret of this tendency is to be found in the false ideal of
Christianity which is propagated by many of the missionaries and the
denationalizing tendencies which appear to be inseparable, on the
present system, from our religious and educationary influences.
The establishment of the European licensing system away from
the chief towns of the coast is, I consider, impossible for at least a
generation—and undesirable if it were possible.
As an antidote to any dangers of over-indulgence in drink among
the mass of the people which may exist, the spread of the
Mohammedan religion is automatically the most effective, from the
purely social standpoint; and this, not because of any special virtue
attaching to Islam, but because Islam in West Africa has become an
African religion which does not denationalize, and does not produce
the social unhappiness which denationalization brings in its train.[16]
 FOOTNOTES
[1] With the exception of the articles on Cotton, which appeared
in the Manchester Guardian.
[2] Lord Scarborough, I am glad to know, is instituting a
movement designed to put up a monument to Richard Lander and
Mungo Park at Forcados, one of the mouths of the Niger. The
suggestion that a monument should be erected to the memory of
Richard Lander at the mouth of the Niger was made last year in
the Times by the writer, who had the honour of reporting to Lord
Scarborough upon various sites examined in the course of this
year, and recommending Forcados as the most appropriate.
[3] The total value of the nett commercial trade of Southern
Nigeria amounted to £9,288,000 in 1910, viz. imports £4,320,000,
exports £4,968,000. Among the imports, cotton goods amounted
to £1,306,812. Ten years ago the total import of the latter was
only £605,146. The whole commercial movement has grown
enormously in the last few years, the total nett turnover in 1907
amounting only to £6,974,000.
[4] Vide Part IV.
[5] In this connection Mr. Dennett’s paper in the September
issue of the journal of the Colonial Institute is very valuable.
[6] Vide Part IV.
[7] February, 1911.
[8] “Affairs of West Africa.” Heinemann, 1902.
[9] The subject is discussed at greater length in Part IV.
[10] In the case of some of these companies, such as the West
African Mines, Ltd., the Anglo-Continental Mines Company, Ltd.,
etc., only a part of their capital is invested in the tin mines.
[11] Perhaps the above remarks are a little too sweeping. It has
been brought to my knowledge that in one such case where
permission was sought by an experienced ex-Government official
and granted by the authorities, the former’s action was, as a
matter of fact, twice instrumental in preventing a fraudulent
concern from being unloaded upon the public; and no doubt there
is something to be said in favour of the practice from that point of
view, arguing from an isolated case. But I must adhere to the
opinion that, speaking generally, the practice is objectionable, and
lends itself to incidents which are calculated to impair the very
high standard of public service of which Great Britain rightly
makes a boast.
[12] Whose administration offers no problems comparable with
the task of governing a Hausa province.
[13] Now the capital of the Niger province.
[14] It is only fair to state that Mr. W. H. Himbury, of the British
Cotton Growing Association, has since pointed out, in regard to
the prices fetched by indigenous Southern Nigerian cotton (p.
227), that the prices here given only refer to small samples and
cannot be taken as indicative of the general selling value of
Southern Nigerian cotton. The official report of the Commercial
Intelligence officer of Southern Nigeria, from which the figures
here given are quoted, is thus somewhat misleading. But the
correction does not appreciably affect my general line of
suggestion. Referring to the cotton grown in the Bassa and
Nassarawa provinces of Northern Nigeria, Professor Wyndham
Dunstan in his recent report states that in making a comparison of
the lint for the Liverpool market the standard employed is
“Moderately rough Peruvian, which is a grade of higher price than
Middling American.”
[15] And some of the Wesleyans—notably the Superintendent
of the Wesleyan Missions in Southern Nigeria, the Rev. Oliver
Griffen.
[16] It may, perhaps, be well to emphasize, in view of the
printed statements describing the writer as the “champion of the
liquor traffic” and so forth, which are so freely made in certain
quarters, that the above remarks are concerned solely with the
liquor traffic in Southern Nigeria—not in West Africa as a whole.
They deal with specific facts affecting a specific area of West
Africa and with specific circumstances surrounding those facts
which have formed the subject of public controversy.
 INDEX

Abeokuta, city of, 78, 79, 80, 84, 224

Alake of, 79
Alkalis, their functions, 149
Amalgamation of the Protectorates, 46, 187, 209.
(See under British policy.)
Anthropological research, British indifference to, 185.
(See under British policy.)
Ants, white, 29
Arab traders in Kano, 166

Baikie, Dr., 46
Baro, 91, 195, 203
Barth, Dr., 123, 152
Bassa, 117, 202, 231
Bauchi, people, plateau and Province of, 4, 19, 127, 138, 171,
177, 179-186, 192, 202
a unique ethnological field, 185
(See also under Mining and Tin.)
Beecroft, John, 45
Bees, 29, 114
Beit-el-Mals, the, 147, 148, 149
Bell, Sir Henry Hesketh, Preface, 136, 172, 241
Bello, Emir, 99, 100
Benin, country and people of, 65, 68-70, 140, 203
Benue, river and region of the, 94, 170, 171, 180, 183, 202-203
Bida, city of, 29, 31, 110, 119, 128
Blyden, Dr. E. Wilmot, Preface, Introduction
Borgu, 118, 138, 177, 202, 203
Bornu, 99, 101, 126, 127, 138, 170, 177, 202, 232
British Cotton Growing Association, 222, etc.
(See under Cotton.)
British policy, its ultimate effects, 6-7, 102-105, 171
danger of interference with social life, 20, 151-154
in Nupe, 29-30
a tour de force, 41
absence of constructive views from home, 46, 189-190
towards Mohammedanism, 47, 111, 112, 133-135, 152-153,
164
lack of home interest in, 48
as to forest development, 58-61
towards domestic “slavery,” 62-63
in the Central and Eastern Provinces of Southern Nigeria,
64, 65
in Benin, 68-69
in Yorubaland, 76-80, 82-88
neglect of the Niger river, 93-94
towards land tenure, 117
towards European trade in the Hausa towns, 133, 135
of indirect rule, its character and objects in Northern
Nigeria; its enemies; arguments for its retention, 136-
139, 145-150
consequences of direct rule, 139-140, 154
in connection with native law and custom, 140-144
in connection with the preservation of national life, 151-154,
159
towards Christian Missions in Northern Nigeria, 153
towards the national weaving industry of Kano, 152, 240-
241
 towards education, 160-165, 188
towards European trade, 172-174
towards mining enterprises, 180-183
towards ethnological research, 185
in Southern and Northern Nigeria compared, 188-189
position of a West African Governor, 189-190
position of officials, 190-193
in connection with officials’ wives, 192
opposing views regarding, Preface
(See also under Amalgamation, Christianity, Islam,
Railways, Education, etc., etc.)
Bukuru, 179, 183
Butterflies, 32, 33, 56

Carrier, the, 14-17, 23

Cattle, 12, 108.
(See under Nigerian.)
Cerebro-spinal meningitis, 9
Chad, Lake, 124, 179
Chalmers, Sir Mackenzie Dalzell, 252
Chamberlain, Right Hon. Joseph, 256
Chirol, Mr. Valentine, 160, 165
Christianity, character of mission work, 26-28
in Yorubaland, 77
an untouched field, 96
and indirect rule, 138
in the Mohammedan provinces, 153
in Kano, 133-135
and Islam in Southern Nigeria, 213-221.
(See under Islam, and British policy.)
Civilization, failure side of, 245
Clapperton, Commander, 100, 123
Clegg, Mr., 224
Cocoa, export of, 57, 224
Cotton, cultivation, manufacture and export of, 57, 114, 115,
119, 127, 152, 168-169, 222, 224.
(See under Hausas, Nigerian, Kano.)
Crewe, Earl of, 252
Cross, river, 51

Delimi, river, 119, 180

Dennett, Mr. R. E., 61
Dress, question of, 219-220
Drum, the Nigerian, 32

Eaglesome, Mr., Preface, 194

Educational policy, 72-76, 154, 158-159, 160-165, 188.
(See under Nassarawa, British policy.)
Egba, district of, 224.
(See under Yorubas.)
Egerton, Sir Walter, Preface, 11, 74, 254
Emigration, Fulani, 170

Finances of Northern Nigeria, 207-208.

(See under Amalgamation and British policy.)
Fireflies, 34
Firmin, Mr., Preface
Food supplies, 58, 142, 171, 179, 182, 191, 243
Forcados, port and river of, 45, 49, 73, 91, 93, 202
Forest belt in Southern Nigeria, 56-61, 224, 251
 forestry resources in Northern Nigeria, 170
Forestry Department in Southern Nigeria, 58-61, 69, 84
need of one in Northern Nigeria, 170
Foulkes, Captain, 185
Fulani, women, 19, 21, 119
as rulers, 23, 30, 47, 98, 118, 137, 140-142
as herdsmen, 29, 118, 119, 169-170
place in West African history, 98-99
conquest of Hausa, 99, 101, 124
as a spiritual force, 155-159
in Bauchi, 186
(See under Othman, Bello, British policy, Nigerian.)

Girouard, Sir Percy, 94, 137, 142, 143, 198

Gober, country of, 124, 157
Goldie, Sir George, 45, 166
Gombe, Emirate of, 184
Gummel, Emirate of, 130
Gwarris, the, 116

Hadeija, division of, 236

Harcourt, Hon. Lewis, 256
Harmattan, the, 8, 9, 11
Hausas, the, and their country, 19, 21, 45-47, 98-101, 108, 156,
169, 217, 231, 232, 237.
(See under Kano, Nigerian, British policy.)
Henna, 30
Himbury, Mr., Preface, 231
Holt, Mr. John, Preface
John & Co., Ltd., Preface, 166