Open Access Open Badges Research article

Level of evidence in hand surgery

Roberto S Rosales1*, Luis Reboso-Morales2, Yolanda Martin-Hidalgo2 and Isabel Diez de la Lastra-Bosch3

Author Affiliations

1 Unit for Hand & Microsurgery, GECOT, Maria del Cristo Ossuna 20, La Laguna, Tenerife, 38204, Spain

2 Orthopaedic Surgery Service, University Hospital of “La Candelaria”, Carretera del Rosario s/n, La Laguna, Tenerife, 38110, Spain

3 Government Health Service, Oncology Programme, Canarian Health Service, Pérez de Rozas 5, 2nd floor, Santa Cruz de Tenerife, Tenerife, 38005, Spain

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BMC Research Notes 2012, 5:665  doi:10.1186/1756-0500-5-665

Published: 2 December 2012



Few investigations have been done to analyze the level of evidence in journals related to hand surgery, compared to other related research fields. The objective of this study was to assess the level of evidence of the clinical research papers published in the Ibero-american (RICMA), the European (JHSE) and American (JHSA) Journals of Hand Surgery.


A total of 932 clinical research papers published between 2005 and 2009 (RICMA 60, JHSE 461, and JHSA 411) were reviewed. Two independent observers classified the level of evidence based on the Oxford International Classification, 5 being the lowest level and 1 the highest level. The observed frequencies of the level of evidence for each journal were compared with the expected frequencies by a chi-square (χ 2) test for categorical variables with a significance level of 0.05.


Inter-observer agreement analysis showed a Kappa of 0.617. Intra-observer agreement analysis presented a Kappa of 0.66 for the observer 1, and a Kappa of 0.751 for the observer 2. More than 80% of the papers in RICMA and JHSE and a 67.6% in the JHSA presented a level of 4. No level 1 or 2 studies were published in RICMA, compared to JHSE (0.9% level 1 and 5.0% level 2) and JHSA (8.3% level 1 and 10% level 2). The percentage of papers with level 3 published in RICMA (16.7%) was higher compared to the JHSE (11.1%) and the JHSA (14.1%). All the results were statistically significant (χ2=63.945; p<0.001).


The level of evidence in hand surgery is dependent on the type of journal; being the highest level evidence papers those published in the JHSA, followed by the JHSE and finally the RICMA. Knowing the status of the level of evidence published in hand surgery is the starting point to face the challenges of improving the quality of our clinical research

Hand; Level of evidence; Hand surgery; Clinical research