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Displaced Clavicle Fractures inAdolescents: Facts, Controversies,

and Current TrendsTo the Editor: As members of the

American Academy of Orthopaedic

Surgeons (AAOS) Council on Re-

search and Quality, we read with

great interest the correspondence

between Dr. Rickert1 and Drs. Ho-

salkar, Pandya, and Namdari2

concerning the article Displaced

Clavicle Fractures in Adolescents:

Facts, Controversies, and Current

Trends.3

When it comes to dis-cussing evidence-based practice,

unintentional misuse of language

can misinform the reader; thus, we

feel obliged to comment.

Dr. Rickerts criticism that

Dr. Hosalkar and his colleagues

present no evidence whatsoever

might more appropriately be stated

as presenting evidence comprised

only of individual studies. It does

not appear that the authors either

systematically evaluated the litera-ture or based their position on mul-

tiple evidence data points akin to

treatment recommendations found

in evidence-based clinical practice

guidelines.

Dr. Hosalkars claim that [f]rom

the perspective of AAOS guidelines,

[level III and IV studies] do not meet

the criteria to be included in any

evidence-based recommendation as

even modest evidence clearly mis-

states the process used by the AAOSin developing evidence-based clinical

practice guidelines. As recommended

by seminal guideline developers in

medicine,4 the AAOS uses the best

available evidence to determine the

strength of a recommendation (as

Strong, Moderate, or Limited) in a

guideline and does indeed use level

III studies to formulate recommen-

dations when these provide the best

evidence available. Although point-

ing out that no level I or II studies

have been published on the subject

of nonsurgical management of clav-

icle fractures may be true, Dr. Ho-

salkar and coauthors imply that

level I and II studies are the only

studies that the AAOS uses to gen-

erate clinical practice guidelinesrecommendations. Inaccurate state-

ments such as this can lead to mis-

perceptions about AAOS guidelines

and ultimately undermine their

value to the end user.

The AAOS should be proud of

the work done by its many volun-

teers and staff to develop and im-

prove the process for creating

evidence-based CPGs. We invite

Dr. Rickert, Dr. Holsakar and his

coauthors, and other readers of theJournal of the American Academy

of Orthopaedic Surgeons to learn

more about AAOS Clinical Practice

Guidelines by logging on to http://

www.aaos.org/guidelines.

Michael J. Goldberg, MD

Rosemont, Illinois

David Jevsevar, MD, MBA

St. George, Utah

Kevin J. Bozic, MD, MBA

San Francisco, California

References

1. Rickert JB: Displaced clavicle fracturesin adolescents: Facts, controversies,and current trends. J Am Acad OrthopSurg2013;21(1):1-2.

Dr. Goldberg or an immediate family

member serves as a board member,

owner, officer, or committee member

of the American Academy of

Orthopaedic Surgeons. Dr. Jevsevar

or an immediate family member is a

member of a speakers bureau or

has made paid presentations on

behalf of Medacta USA; has stock

or stock options held in OMNIlife

science; and has received research

or institutional support from Medacta

USA. Dr. Bozic or an immediate

family member serves as a board

member, owner, officer, or

committee member of the American

Academy of Orthopaedic Surgeons,

the American Association of Hip and

Knee Surgeons, American JointReplacement Registry, the American

Orthopaedic Association, California

Joint Replacement Registry Project,

the California Orthopaedic

Association, Harvard Business

School, and the Orthopaedic

Research and Education

Foundation.

http://dx.doi.org/10.5435/

JAAOS-21-04-199

Correspondence

April 2013, Vol 21, No 4 199

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2. Hosalkar H, Pandya N, Namdari S:Facts, controversies, and current trends.

J Am Acad Orthop Surg2013;21(1):1-2.

3. Pandya NK, Namdari S, Hosalkar HS:Displaced clavicle fractures inadolescents: Facts, controversies, andcurrent trends. J Am Acad Orthop Surg2012;20(8):498-505.

4. Cook DJ, Mulrow CD, Haynes RB:Systematic reviews: Synthesis of bestevidence for clinical decisions. AnnIntern Med1997;126(5):376-380.

200 Journal of the American Academy of Orthopaedic Surgeons