As the name suggests, evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Several papers published in Plastic Surgery journals concerning EBM topics have touched on this subject.1–6 Specifically, previous papers have discussed the lack of higher level evidence in PRS and need to improve the evidence published in the journal. Before that can be accomplished, it is important to understand the history behind the levels and how they should be interpreted. This paper will focus on the origin of levels of evidence, their relevance to the EBM movement and the implications for the field of plastic surgery as well as the everyday practice of plastic surgery.

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Observational studies are an important category of study designs. To address some investigative questions in plastic surgery, randomized controlled trials are not always indicated or ethical to conduct. Instead, observational studies may be the next best method to address these types of questions. Well-designed observational studies have been shown to provide results similar to randomized controlled trials, challenging the belief that observational studies are second-rate. Cohort studies and case-control studies are two primary types of observational studies that aid in evaluating associations between diseases and exposures. In this review article, we describe these study designs, methodological issues, and provide examples from the plastic surgery literature.

Distal radius fractures are one of the most common types of fractures, accounting for around 25% of fractures in the pediatric population and up to 18% of all fractures in the elderly age group. Although the pediatric and elderly populations are at the greatest risk for this injury, distal radius fractures still have a significant impact on the health and well-being of young adults. Data from the past 40 years has documented a trend towards an overall increase in the prevalence of this injury. For the pediatric population, this increase can likely be attributed to a surge in sports related activities. The growth of the elderly population and a rise in the number of active elderly are directly responsible for the increase seen in this age group. Understanding the epidemiology of this fracture is an important step towards the improvement of the treatment strategies and preventative measures which target this debilitating injury.

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Background: Traditionally, distal radial fractures in the elderly have been treated nonoperatively with casting.

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Purpose As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients 60 and over with five common techniques: volar locking plate system (VLPS), non-bridging external fixation (non-BrEF), bridging external fixation (BrEF), percutaneous Kirschner-wire fixation (PKF), and cast immobilization (CI). Methods Articles retrieved from MEDLINE, Embase and CINAHL Plus that met predetermined inclusion and exclusion criteria were reviewed in two literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. The data were statistically analyzed using weighted means and proportions based on the sample size in each study. Results 2,039 papers were identified, and 21 papers fitting the inclusion criteria were selected in the primary review of articles with mean patient age of 60 and over. Statistically significant differences were detected for wrist arc of motion, grip strength, and DASH score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences amongst the groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas VLPS had significantly more major complications requiring additional surgical intervention. Conclusions This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different than surgically treated groups for patients 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods. Level of Evidence Therapeutic, Level III