Levels of evidence in foot and ankle surgery literature: progress from 2000 to 2010?

The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade.

All of the articles in the literature from the years 2000, 2005, and 2010 in Foot & Ankle International and Foot and Ankle Surgery, as well as all foot and ankle articles from The Journal of Bone and Joint Surgery (JBJS, American [A] and British [B] Volumes) were analyzed. Animal, cadaver, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence were excluded. Articles were ranked by a five-point level-of-evidence scale, according to guidelines from the Centre for Evidence-Based Medicine.

A total of 720 articles from forty-three different countries were analyzed. The kappa value for interobserver reliability showed very good agreement between the reviewers for types of evidence (κ = 0.816 [p < 0.01]) and excellent agreement for levels of evidence (κ = 0.869 [p < 0.01]). Between 2000 and 2010, the percentage of high levels of evidence (Levels I and II) increased (5.2% to 10.3%) and low levels of evidence (Levels III, IV, and V) decreased (94.8% to 89.7%). The most frequent type of study was therapeutic. The JBJS-A produced the highest proportion of high levels of evidence.

There has been a trend toward higher levels of evidence in foot and ankle surgery literature over a decade, but the differences did not reach significance.