Abstract
This is a visual representation of the abstract.
In this editorial, we are proud to present the levels of evidence for the Video Journal of Sports Medicine.
We have no relevant disclosures, and full disclosures for each author can be found on the AAOS website.
Levels of evidence exist in modern science as a hierarchy to rank scientific literature. In medicine, they allow clinicians to assess the relative strength of evidence quickly and efficiently. It is important to note that they do not necessarily provide conclusive judgement about the quality of the literature, nor do they provide definitive clinical recommendations.
Levels of evidence are a mechanism to standardize the way evidence is judged based on design and results. However, in video and multimedia journals, such as VJSM, no standard scale is currently employed. The goal of this editorial is to ensure that a clinician watching a VJSM video appreciates and understands the level of evidence underlying a technique. In the following slides, we have defined our Video Journal Levels of Evidence. For each level, we have cited one or two examples from the VJSM literature. A brief video clip highlights the technique and the relevant outcomes research that support its designated level.
We define Level One evidence videos to include techniques based on systematic reviews of randomized controlled trials or a single Level 1 randomized controlled trial, with narrow confidence intervals and a clinically significant effect size.
Sivasundaram et al’s 9 video on Combined Margin Convergence Repair and Subacromial Balloon Spacer in the treatment of massive rotator cuff tears provides an excellent example of a Level 1 video publication.
The technique demonstrates a combined margin convergence repair and subacromial balloon spacer for massive cuff tears. A polymer balloon spacer acts as a barrier to subacromial impingement and restores more normal shoulder biomechanics. Highlighted portions of the technique are shown. A well-designed level 1 randomized controlled trial supporting this technique justifies its classification as a Level 1 Video Journal publication.
We define Level 2 evidence to include videos comparing interventions based on level 2 randomized controlled trials, prospective comparative studies, and well-designed observational studies.
Budhiparama et al’s 1 video on the use of peroneus longus tendon in anterior cruciate ligament (ACL) reconstruction, provides an example of a Video Journal Level 2 publication.
An ACL reconstruction technique with peroneus longus tendon autograft is demonstrated. Highlighted portions include a tenodesis, tendon harvesting and graft passage. The highest level of evidence supporting the technique is a Level 2 systematic review of homogeneous cohort studies, demonstrating no significant differences in outcomes comparing peroneus longus vs hamstring tendon grafts. We have thus classified the publication as a Level 2 video.
We define Level 3 evidence to include videos with outcomes supported by controlled cohort studies, well-designed prospective case series, observational studies, and retrospective comparative studies.
Hevesi et al’s 3 video on inlay patellofemoral arthroplasty (PFA) and Recker et al’s 8 video for latissimusdorsi reconstruction are excellent examples of Level 3 video publications.
The background for this video publication focuses on the indications for inlay PFA, including osteoarthritis and maltracking. We have highlighted select portions of their technique. For outcomes they cited 2 sources, one of which included a retrospective cohort study and found no significant difference in mean clinical scores between isolated PFA and total knee arthroplasty. Given the citation of one Level 4 study, and 2 Level 3 cohort studies we classified this video publication as Level 3.
The background for our next Level 3 example describes indications for the operative technique, which include full thickness tears of the latissimus dorsi in young, high demand overhead throwing athletes. The following clips highlight portions of the technique. The outcomes data was mainly derived from a retrospective cohort study of 11 baseball athletes, with excellent outcomes at final follow-up. Given that all 3 outcome studies were Level 3, this video publication was defined as Level 3.
We define Level 4 video publications to include techniques based on case series and individual case reports with outcomes.
Miller et al’s 5 video on the Achilles Tendon Repair with a Giftbox Technique, and Johnson et al’s 4 video of Humeral Head Osteochondral Allograft Reconstruction provides excellent examples of Level 4 video publications.
The background for this video publication focuses on the qualities that differentiate the giftbox technique from the standard end to end, Krackow, and Bunnell techniques. The following clips provide highlights. Outcomes cited include a consecutive case series and a retrospective chart review. As both references are Level 4, this video publication is likewise designated as Level 4.
The background in this video reviews indications for the procedure, which include locked posterior dislocations and reverse Hills-Sachs defects. The following clips highlight portions of the technique. A case series of 20 patients described favorable outcomes. No other studies were cited, so this video publication was determined to be Level 4.
We define Level 5 video publications as techniques based on limited outcomes, simulated interventions, theoretical or mechanism-based reasoning, or expert opinion.
The Evolution and Role of the Bursal Acromial Reconstruction by Curtis et al, 2 and “Scopen” Scope to Open Hamstring Repair by Sivasundaram et al 10 are excellent examples of Level 5 video publications.
The authors described the addition of an acellular dermal matrix to the undersurface of the acromion, and the theoretical decrease in contact pressure experienced by the acromion.
The surgery is a modification of the Bursal Acromial Reconstruction (BAR) with acromial tunnels utilizing a cruciate suture technique described by Ravenscroft. 7 The following clips highlight portions of the technique.
The authors note that no outcomes data are available for this procedure, consistent with our designation as a Level 5 video publication.
Our next example delineates the advantages of the scopen technique, which is minimally invasive and provides improved visualization of the sciatic nerve and ischial tuberosity. The following clips highlight portions of the technique. The authors cite outcomes from a case series, which reported results from endoscopic and open hamstring repair as separate procedures. Although this outcome study qualifies as Level 4 evidence, it is not directly supportive of the described technique. We have thus designated this video publication as Level 5.
Understanding clinical outcomes of described techniques is imperative and necessary for patient care. Please remember that Video Journal Levels of Evidence should not be interpreted as treatment recommendations. Clinical decisions should be made with respect to individual patient circumstances, clinical judgment, and shared decision making. It is also important to keep in mind that there is an inherent risk of “lower-level evidence” being interpreted as stronger evidence, based on effect size.
Our video journal levels of evidence have been adapted from the 2011 publication from the Oxford Center for Evidence Based Medicine. 6
We recognize that understanding the indications and evidence for any technique are critical to scientific rigor and patient care. We hope that this VJSM editorial provides a useful framework to both authors and surgeons, to evaluate the level of evidence underlying a video publication. We thank you for your attention.