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Isleem UN, Zaidat B, Ren R, Geng EA, Burapachaisri A, Tang JE, Kim JS, Cho SK. Can generative artificial intelligence pass the orthopaedic board examination? J Orthop 2024; 53:27-33. [PMID: 38450060 PMCID: PMC10912220 DOI: 10.1016/j.jor.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 03/08/2024] Open
Abstract
Background Resident training programs in the US use the Orthopaedic In-Training Examination (OITE) developed by the American Academy of Orthopaedic Surgeons (AAOS) to assess the current knowledge of their residents and to identify the residents at risk of failing the Amerian Board of Orthopaedic Surgery (ABOS) examination. Optimal strategies for OITE preparation are constantly being explored. There may be a role for Large Language Models (LLMs) in orthopaedic resident education. ChatGPT, an LLM launched in late 2022 has demonstrated the ability to produce accurate, detailed answers, potentially enabling it to aid in medical education and clinical decision-making. The purpose of this study is to evaluate the performance of ChatGPT on Orthopaedic In-Training Examinations using Self-Assessment Exams from the AAOS database and approved literature as a proxy for the Orthopaedic Board Examination. Methods 301 SAE questions from the AAOS database and associated AAOS literature were input into ChatGPT's interface in a question and multiple-choice format and the answers were then analyzed to determine which answer choice was selected. A new chat was used for every question. All answers were recorded, categorized, and compared to the answer given by the OITE and SAE exams, noting whether the answer was right or wrong. Results Of the 301 questions asked, ChatGPT was able to correctly answer 183 (60.8%) of them. The subjects with the highest percentage of correct questions were basic science (81%), oncology (72.7%, shoulder and elbow (71.9%), and sports (71.4%). The questions were further subdivided into 3 groups: those about management, diagnosis, or knowledge recall. There were 86 management questions and 47 were correct (54.7%), 45 diagnosis questions with 32 correct (71.7%), and 168 knowledge recall questions with 102 correct (60.7%). Conclusions ChatGPT has the potential to provide orthopedic educators and trainees with accurate clinical conclusions for the majority of board-style questions, although its reasoning should be carefully analyzed for accuracy and clinical validity. As such, its usefulness in a clinical educational context is currently limited but rapidly evolving. Clinical relevance ChatGPT can access a multitude of medical data and may help provide accurate answers to clinical questions.
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Affiliation(s)
- Ula N. Isleem
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bashar Zaidat
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Renee Ren
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric A. Geng
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aonnicha Burapachaisri
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin E. Tang
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Ozdag Y, Hayes DS, Makar GS, Manzar S, Foster BK, Shultz MJ, Klena JC, Grandizio LC. Comparison of Artificial Intelligence to Resident Performance on Upper-Extremity Orthopaedic In-Training Examination Questions. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:164-168. [PMID: 38903829 PMCID: PMC11185884 DOI: 10.1016/j.jhsg.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/28/2023] [Indexed: 06/22/2024] Open
Abstract
Purpose Currently, there is a paucity of prior investigations and studies examining applications for artificial intelligence (AI) in upper-extremity (UE) surgical education. The purpose of this investigation was to assess the performance of a novel AI tool (ChatGPT) on UE questions on the Orthopaedic In-Training Examination (OITE). We aimed to compare the performance of ChatGPT to the examination performance of hand surgery residents. Methods We selected questions from the 2020-2022 OITEs that focused on both the hand and UE as well as the shoulder and elbow content domains. These questions were divided into two categories: those with text-only prompts (text-only questions) and those that included supplementary images or videos (media questions). Two authors (B.K.F. and G.S.M.) converted the accompanying media into text-based descriptions. Included questions were inputted into ChatGPT (version 3.5) to generate responses. Each OITE question was entered into ChatGPT three times: (1) open-ended response, which requested a free-text response; (2) multiple-choice responses without asking for justification; and (3) multiple-choice response with justification. We referred to the OITE scoring guide for each year in order to compare the percentage of correct AI responses to correct resident responses. Results A total of 102 UE OITE questions were included; 59 were text-only questions, and 43 were media-based. ChatGPT correctly answered 46 (45%) of 102 questions using the Multiple Choice No Justification prompt requirement (42% for text-based and 44% for media questions). Compared to ChatGPT, postgraduate year 1 orthopaedic residents achieved an average score of 51% correct. Postgraduate year 5 residents answered 76% of the same questions correctly. Conclusions ChatGPT answered fewer UE OITE questions correctly compared to hand surgery residents of all training levels. Clinical relevance Further development of novel AI tools may be necessary if this technology is going to have a role in UE education.
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Affiliation(s)
- Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Daniel S. Hayes
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Gabriel S. Makar
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Shahid Manzar
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Brian K. Foster
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Mason J. Shultz
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Joel C. Klena
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Louis C. Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
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Baylor JL, Luciani AM, Tokash JS, Foster BK, Klena JC, Grandizio LC. Fifty Most-Cited Research Articles in Elbow Surgery: A Modern Reading List. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:630-637. [PMID: 37790825 PMCID: PMC10543795 DOI: 10.1016/j.jhsg.2023.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 03/07/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose Bibliometric analysis is a common method for evaluating current trends within a scientific field. The primary aim of this study was to define and analyze the 50 most frequently cited articles in the field of elbow surgery, both of all time and those published during the 21st century. Methods We searched the Journal Citation Report to identify articles related to elbow surgery within academic journals. Articles were sorted by total citations. The overall top 50 articles and those published since 2000 were identified, and data were collected, including title, journal of publication, publication year, country of publication, citation density, level of evidence, article type, institution, and sex of the lead and senior authors, and inclusion on the reference list for the Orthopaedic In-Training Examination within the last 5 years. Descriptive statistics were reported, and correlation analysis was performed using Spearman test. Results For the most-cited elbow surgery articles, "fracture" was overall the most reported topic, whereas "lateral epicondylosis" and "fracture" were equal for those published since 2000. The United States was the most represented overall and for articles published since 2000. Women comprised 1/50 (2%) of lead authors overall, increasing to 8/50 (16%) for articles published during the 21st century. Most articles in during both periods contained level IV evidence, with level I evidence appearing infrequently (4%). Six percent of the most-cited articles of all time had appeared on the reference list of the Orthopaedic In-Training Examination within the past 5 years. Conclusions The top 50 most-cited elbow surgery articles often assess fracture and lateral epicondylosis, most commonly originating from the United States. Level IV retrospective series comprises over half of the articles on this list. Women remain underrepresented as authors. Clinical Relevance This study provides a modern reading list for upper-extremity surgeons about impactful elbow surgery articles.
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Affiliation(s)
- Jessica L. Baylor
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - A. Michael Luciani
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Jeremy S. Tokash
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Brian K. Foster
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Joel C. Klena
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Louis C. Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
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Analysis of Questions in Sections of the Orthopaedic In-Training Examination: A Scoping Review. J Am Acad Orthop Surg 2023; 31:e318-e326. [PMID: 36622936 DOI: 10.5435/jaaos-d-22-00874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/27/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The purpose of this review was to assess all available studies that analyzed the types of questions in individual sections of the Orthopaedic In-Training Examination, which may be used as a reference for residents studying for their examination. METHODS Following the Providing Innovative Service Models and Assessment extension for Scoping Reviews guidelines, a systematic review was conducted on studies that report on sections or question categories of the Orthopaedic In-Training Examination using PubMed, MEDLINE, and Web of Science databases. Two reviewers and an arbitrator reviewed and extracted relevant data from 20 included studies which made up the systematic review. RESULTS All 20 studies in the review reported the mean number of questions per section, with the highest coming from musculoskeletal trauma (18.9% to 19.0%). 18 studies reported the Buckwalter taxonomic classification; 42.0% of questions were T1, 18.2% were T2, and 39.5% were T3 with a wide range from section to section. Primary sources were nearly three times more likely to be cited when compared with textbook sources. There were 12 journals that were commonly cited with the most being the Journal of Bone and Joint Surgery: American Volume (17/18). DISCUSSION This study accurately portrays the characteristics of each section of the Orthopaedic In-Training Examination over the past 10 years. These data suggest that orthopaedic residents may be inclined to focus on musculoskeletal trauma, topics related to clinical management, and primary journal sources for studying. In addition, residency programs may choose to focus on higher yield sources or material to prepare their residents for the examination.
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LeBrun DG, Premkumar A, Ellsworth B, Shen TS, Cross MB, Fufa DT. Analysis of Hand Surgery Questions on Orthopedic In-training Examination From 2014 to 2019. Hand (N Y) 2022; 17:975-982. [PMID: 33103480 PMCID: PMC9465776 DOI: 10.1177/1558944720964960] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The orthopedic in-training examination (OITE) continues to evolve over time. It is important for orthopedic residents and residency programs to have an up-to-date understanding of the content and resources being used on the OITE to study and tailor curricula accordingly. This study presents an updated analysis of the OITE hand domain from 2014 to 2019. METHODS All OITE questions related to hand surgery from 2014 to 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, and bibliometric factors related to cited references. RESULTS Of the 1600 OITE questions, there were 113 hand surgery questions (7.1%) over a 6-year period. The most commonly tested topics were nerve (n = 22; 19%), fracture/dislocation (n = 21; 19%), and tendon/ligament (n = 19; 17%). Complex clinical management questions were the most common taxonomic category (n = 66; 58%). Two hundred fifty-two references were cited, the most common of which were from the Journal of Hand Surgery (American Volume) (n = 76; 30%), Journal of the American Academy of Orthopaedic Surgeons (n = 27; 11%), and Hand Clinics (n = 21; 8%). Publication lag decreased over the study period (P = .009). Twenty-five questions (22%) used imaging modalities, and 21 (19%) used clinical photos. Compared with a prior analysis from 2002 to 2006, there were more questions related to nerves (19.5% vs 9.8%, P = .041). CONCLUSIONS Residents and residency programs can benefit from an updated understanding of OITE hand surgery content and resources. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE.
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Orthopaedic In-Training Examination: History, Perspective, and Tips for Residents. J Am Acad Orthop Surg 2021; 29:e427-e437. [PMID: 33417380 DOI: 10.5435/jaaos-d-20-01020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/06/2020] [Indexed: 02/01/2023] Open
Abstract
Introduced in 1963, the orthopaedic in-training examination (OITE) is a standardized, national test administered annually to orthopaedic residents by the American Academy of Orthopaedic Surgeons. The examination consists of 275 multiple-choice questions that cover 11 domains of orthopaedic knowledge, including basic science, foot and ankle, hand, hip and knee, oncology, pediatrics, shoulder and elbow, spine, sports medicine, trauma, and practice management. The OITE has been validated and is considered predictive of success in both orthopaedic surgery residency and on the American Board of Orthopaedic Surgery part I examination. This article provides a historical overview of the OITE, details its current structure and scoring system, and reviews currently available study materials. For examination preparation, the residents are encouraged to (1) start the examination preparation early, (2) practice on old OITE or self-assessment examination questions, (3) focus on the questions answered incorrectly, (4) focus on comprehension over memorization, and (5) recognize and avoid burnout. Finally, the residents should have a systemic way of approaching each multiple-choice question, both during practice and on the actual examination.
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Hoskins T, Goyette D, Patel JN, Romanelli F, Mazzei C, Sonnylal L, Sampat R, Wittig JC. Updated Analysis of the Oncology Section of the OITE from 2007 to 2019. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2021; 36:10-15. [PMID: 32725416 DOI: 10.1007/s13187-020-01840-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The Orthopaedic In-Training Exam (OITE) is administered annually to orthopedic surgery residents to assess their medical knowledge. The authors provide a comprehensive review of the orthopedic oncology portion of the exam in order to aid residents in preparation for future in-training and licensing examinations as well as to help guide oncology residency education curriculum. All of the orthopedic oncology questions on the OITE from 2007 to 2019 were reviewed. Analysis included (1) the number of oncology questions each year, (2) question topic, (3) question taxonomy (knowledge versus interpretation), (4) the type of imaging modalities (radiological, histological), (5) most commonly cited references, and (6) level of evidence. Descriptive statistics were utilized to compare means between variables. From 2007 to 2019, there was a total of 292 tumor-related questions with a mean of 22.5 tumor-related questions (range 19-28) per year. Of the questions, 54.8% pertained to malignant tumors and 45.2% to benign tumors. Assessment of question taxonomy showed that 79.8% of questions required interpretation of imaging and analysis of the information provided versus 20.2% of questions being knowledge recall type. Of the questions, 76.7% required interpretation of radiological images, pathological images, or both. Orthopaedic Knowledge Update, Journal of the American Academy of Orthopaedic Surgeons, and Journal of Bone and Joint Surgery were the three most commonly cited question sources. Only 29 (9.84%) oncology questions over the past 13 years have been supported by level I or II sources of evidence. Better understanding of the OITE make-up, question distribution, and number and style of question, reference sources can improve an orthopedic residents' performance as well as better guide educational curriculum to prepare residents in their orthopedic oncology education.
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Affiliation(s)
- Tyler Hoskins
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA
| | - David Goyette
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA
| | - Jay N Patel
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA.
| | - Filippo Romanelli
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA
- Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Christopher Mazzei
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA
| | - Laura Sonnylal
- St. George's University - School of Medicine, West Indies, Grenada
| | - Rohan Sampat
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA
- Seton Hall University, South Orange, NJ, USA
| | - James C Wittig
- Division of Orthopedic Oncology & Sarcoma, Department of Orthopedic Surgery, Morristown Medical Center - Atlantic Health System, Carol G. Simon Cancer Center 2nd Floor, 100 Madison Avenue, Morristown, NJ, 07960, USA
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Luginbuhl JC, Sobel AD, Mulcahey MK. Analysis of the Sports Medicine Section of the Orthopaedic In-Training Examination: Improvements in Levels of Evidence and Question Taxonomy Over a 12-Year Period. Orthopedics 2020; 43:e460-e464. [PMID: 32602922 DOI: 10.3928/01477447-20200619-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/20/2019] [Indexed: 02/03/2023]
Abstract
There has been a recent shift within the orthopedic literature to publish articles with higher levels of evidence. In this investigation, the trends in question taxonomy and the levels of evidence of the references for sports medicine questions on the Orthopaedic In-Training Examination (OITE) during a 12-year period were evaluated. Sports medicine questions were obtained from the OITEs administered between 2005 and 2007 and between 2014 and 2016. The taxonomy of each question was characterized, and levels of evidence for all references were assigned using American Academy of Orthopaedic Surgeons guidelines. Question taxonomy and article levels of evidence from 2005 to 2007 were compared with those from 2014 to 2016. Sports medicine questions comprised 8% of the OITEs in both examination groups. The questions from 2014 to 2016 had a higher mean taxonomic level (2.26 vs 1.52, P=.0001) and a greater proportion of studies with high levels of evidence (levels 1 and 2) (21% vs 10%, P=.027). However, references with low levels of evidence or nonprimary resources made up 82.2% and 68.5% of the total references on the older and more recent examinations, respectively. References from 2014 to 2016 were, on average, 2 years older than those from earlier examinations. This study indicated that sports medicine questions on recent OITEs cite references of higher levels of evidence and contain higher taxonomic question structure than examinations 10 to 12 years ago. However, the majority of questions still cite articles with low levels of evidence or nonprimary sources. These findings can be used to guide resident education and continue improvements in the selection of references for questions on the Sports Medicine section of the OITE. [Orthopedics. 2020;43(5):e460-e464.].
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Barroso TS, Cavalcante MC, dos Santos JBG, Belloti JC, Faloppa F, de Moraes VY. Evidence hierarchies relating to hand surgery: current status and improvement. A bibliometric analysis study. SAO PAULO MED J 2017; 135:556-560. [PMID: 29166434 PMCID: PMC10016020 DOI: 10.1590/1516-3180.2017.0146260617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 06/26/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hierarchy of evidence is an important measurement for assessing quality of literature. Information regarding quality of evidence within the Brazilian hand surgery setting is sparse, especially regarding whether research has improved in either quality or quantity. This study aimed to identify and classify hand surgery studies published in the two most important Brazilian orthopedics journals based on hierarchy of evidence, with comparisons with previously published data. DESIGN AND SETTING Bibliometric analysis study performed in a federal university. METHODS Two independent researchers conducted an electronic database search for hand surgery studies published between 2010 and 2016 in Acta Ortopédica Brasileira and Revista Brasileira de Ortopedia. Eligible studies were subsequently classified according to methodological design, based on the Haynes pyramid model (HP) and the JBJS/AAOS levels of evidence and grades of recommendations (LOR). Qualitative and quantitative data were gathered regarding all studies. Previous data were considered to assess whether the proportion of high-quality studies had improved over time (2000-2009 versus 2010-2016). RESULTS The final analysis included 123 studies, mostly originating from the southeastern region (78.8%) and private institutions (65%), with self-funding (91.8%). Methodological assessment showed that 15.4% were classified as level I/II using HP and 16.4% using LOR. No significant difference in proportions of high-quality studies was found between the two periods of time assessed (5% versus 12%; P = 0.13). CONCLUSION Approximately 15% of hand surgery studies published in two major Brazilian journals were likely to be classified as high-quality through two different systems. Moreover, no trend towards quality-of-evidence improvement was found over the last 15 years.
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Affiliation(s)
- Thaís Silva Barroso
- MD. Hand Surgery Resident, Department of Orthopedics and Traumatology, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo (SP), Brazil.
| | - Marcelo Cortês Cavalcante
- MD. Resident in Orthopedic Surgery, Department of Orthopedics and Traumatology, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo (SP), Brazil.
| | - João Baptista Gomes dos Santos
- MD, PhD. Adjunct Professor, Department of Orthopedics and Traumatology, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo (SP), Brazil.
| | - João Carlos Belloti
- MD, PhD. Adjunct Professor, Department of Orthopedics and Traumatology, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo (SP), Brazil.
| | - Flávio Faloppa
- MD, PhD. Full Professor, Department of Orthopedics and Traumatology, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo (SP), Brazil.
| | - Vinícius Ynoe de Moraes
- MD, PhD. Orthopedic Surgeon, Department of Orthopedics and Traumatology, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo (SP), Brazil.
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