What Would Be the Effect of Lowering the Threshold of Statistical Significance From 0.05 to 0.005 in Foot and Ankle Randomized Controlled Trials?

BACKGROUND The threshold for statistical significance (p < 0.05) has been debated in recent years, with proposals to lower it to p < 0.005 to reduce the frequency of papers concluding with false-positive results, which can result in patients receiving overtreatment, and potentiating the problem of nonreplicable results in medical research. However, to our knowledge the impact of modeling that suggestion-in terms of how many studies might be reclassified as no-difference studies and how much larger studies would need to become to implement that suggestion-has not been assessed in orthopaedic surgery. QUESTIONS/PURPOSES We used randomized trials in foot and ankle research to answer the question: If the threshold for statistical significance were lowered from p < 0.05 to p < 0.005, (1) what proportion of foot and ankle RCTs would be reclassified as no-difference trials under a stricter p value threshold, and (2) how much larger would studies have needed to be to retain or obtain 80% power at the p < 0.005 level? METHODS We manually reviewed all articles published between 2019 and 2024 in the top 10 ranked orthopaedic journals and the top three foot and ankle-specific journals, both selected based on their 2023 two-year journal Impact Factor, focusing on foot and ankle studies. Studies were included if they met the following criteria: (1) RCT design, (2) focus on foot and ankle conditions or interventions, (3) published in English, and (4) reported p values for primary outcomes. After screening, a total of 123 RCTs met these criteria and were included in the final analysis. Those studies' p values for primary endpoints were extracted and analyzed under both thresholds. If a study had multiple primary endpoints or evaluated the primary endpoint from multiple domains, all p values were included. We categorized p values into three groups based on the classification proposed by Ioannidis: (1) p < 0.005 as "statistically significant," (2) 0.005 ≤ p < 0.05 as "suggestive," and (3) p ≥ 0.05 as "nonsignificant." For studies with sufficient power analysis data, we calculated the required sample size increase needed to maintain 80% statistical power (1 - beta) at an alpha level of 0.005, using the variance reported in the source studies. The effect size (delta) was inferred from the between-group differences reported in each study. Additionally, multivariable logistic regression analysis was performed to identify factors associated with maintaining statistical significance under the p < 0.005 threshold. RESULTS Among 281 primary endpoints identified from 123 trials, 44% (124 of 281) were statistically significant using the threshold defined in those articles (p < 0.05). Of these significant endpoints, only 42% (52 of 124) of endpoints met the proposed threshold (p < 0.005), whereas 58% (72 of 124) fell between 0.005 and 0.05. Following the classification proposed by Benjamin et al., these endpoints would be reclassified as "suggestive" rather than statistically significant. Overall, only 19% (52 of 281) of all endpoints remained statistically significant under the threshold of 0.005 proposed. Twenty-five percent (31 of 123) of trials maintained statistically significant primary endpoints. Among the 123 trials, 54% (66 of 123) had sufficient power analysis data. Assuming an alpha of 0.005, power of 80%, and effect sizes derived from reported between-group differences, maintaining statistical power under the new threshold would require a mean increase of 69% in the sample size. Logistic regression analysis revealed that extracorporeal shock wave therapy (OR 6.8; p < 0.001) and injection therapy (OR 3.3; p = 0.008) were associated with maintaining significance under the stricter threshold. CONCLUSION Adopting a threshold of p < 0.005 would substantially impact the interpretation of published foot and ankle RCTs; using that threshold, more than one-half of published RCTs in foot and ankle surgery would have been reclassified as having only "suggestive" or no-difference findings on one or more primary study endpoints. CLINICAL RELEVANCE Lowering the p value threshold to 0.005 would require larger sample sizes, posing feasibility challenges in foot and ankle surgery because of smaller patient populations. While this shift aims to reduce false-positives, it risks excluding meaningful findings from underpowered studies. More importantly, this debate highlights that no single p value threshold is universally appropriate. Instead of rigidly applying 0.05 or 0.005, researchers should adjust thresholds based on study context-allowing more relaxed thresholds for exploratory studies and stricter ones for high-risk interventions.