Since 2003, JBJS has assigned level-of-evidence (LOE) ratings to all clinical articles, based on a system developed by the UK’s Centre for Evidence-Based Medicine (CEBM). The CEBM updated its rating system in 2011, and The Journal has revised its LOE guidance in ways that largely but not entirely reflect the CEBM update.

In an editorial in the January 7, 2015 JBJS, Editor-in-Chief Dr. Marc Swiontkowski and Associate Editor for Evidence-Based Orthopaedics Dr. Robert Marx note that the revised JBJS LOE table still divides studies by type and that “much of the ranking criteria remain the same.” However, the rows and columns have been transposed and a column focused on specific clinical questions has been added. The clinical-question column—which poses queries such as “Does this treatment help?”—can guide busy clinicians quickly and efficiently to the best available evidence about their immediate situation.

In addition, guidance in the new table’s footnotes permits flexibility to grade studies upward if there is a dramatic effect size or downward on the basis of small effect size or study-quality issues such as imprecision. Overall, the revised table clarifies and makes more transparent The Journal’s LOE-assignment process.

Notably, The Journal has decided to depart from the CEBM update in two important ways. We will not follow the CEBM’s policy of reserving Level-I designation for systematic reviews, believing that certain high-quality original research also merits Level-I status. In addition, because economic and population-health decisions play an increasingly important role in orthopaedic surgery today, we have retained economic studies in our table, while the CEBM eliminated such research from its update.

Finally, the editorial reminds readers that “a higher LOE does not necessarily reflect the clinical importance of a given study.” Ultimately, each reader is responsible for deciding what constitutes the best external evidence for his or her specific clinical question.

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