Efficacy of problem-based learning combined with case-based learning versus lecture-based learning in orthopedic education: a systematic review and meta-analysis

Abstract

Objective

To systematically evaluate the effectiveness of the Problem-based learning (PBL) combined with Case-based learning (CBL) teaching method compared with the Lecture-based learning (LBL) method in orthopedic education and provide evidence for optimizing orthopedic teaching methods.

Methods

Literature was systematically searched in Chinese and English databases and screened using strict inclusion/exclusion criteria. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the literature. Meta-analyses were performed with RevMan 5.3 and Stata 16 software. We compared the application effects of the PBL-CBL teaching method versus the LBL teaching method in orthopedic education across multiple dimensions: theoretical knowledge mastery, practical skill proficiency, comprehensive competency development, and satisfaction with teaching methods.

Results

(1) 15 studies involving 980 participants were included. (2) Meta-analysis showed significant superiority of PBL-CBL over LBL in: ①Objective outcomes: theoretical knowledge (SMD = 1.46, P < 0.0001), practical skills (SMD = 1.53, P < 0.0001), physical examination (SMD = 1.64, P < 0.0001), case analysis (SMD = 1.30, P < 0.0001), and plaster immobilization (SMD = 2.42, P < 0.0001); ② Subjective outcomes: debridement proficiency (RR = 1.44, P = 0.001), aseptic awareness (SMD = 1.58, P = 0.003), and other comprehensive competencies (self-learning, learning interest, learning efficiency, clinical thinking, team collaboration, etc., P < 0.001 for all). Satisfaction with the teaching method was also significantly higher (RR = 1.34, P < 0.0001). (3) Heterogeneity was observed in the study (I² = 77–87%), which may be related to differences in teaching duration, case design, and assessment criteria. However, sensitivity analysis showed good stability of the results, indicating that the conclusions are informative.

Conclusion

Meta-analysis demonstrates that, in orthopedic education, the PBL-CBL teaching method offers significant advantages over LBL in enhancing students’ theoretical knowledge, clinical skills, and comprehensive abilities. It also stimulates learning interest, improves teaching satisfaction, and facilitates the cultivation of orthopedic clinical talent. However, its generalizability requires further verification through research in different countries.

Introduction

Orthopedics, a key branch of the medical field, is a clinical discipline emphasizing the close integration of theory and practice. It focuses on the diagnosis, treatment, and rehabilitation of diseases affecting the musculoskeletal system (e.g., bones, joints, ligaments, tendons, and nerves), which are essential for maintaining human motor function and health [1]. Due to population aging, sports injuries, and traffic accidents, the incidence of orthopedic diseases has increased, and the societal demand for orthopedic professionals has grown correspondingly [2]. Consequently, high-quality teaching methods have become a critical guarantee for training skilled orthopedic surgeons and improving medical services.

In traditional Chinese orthopedic education, the LBL method has been predominantly employed. In this approach, instructors systematically deliver knowledge in the classroom, allowing them to easily control the teaching pace. This method is suitable for the mechanical memorization of theoretical knowledge and is colloquially referred to as “cram-style” teaching [3]. Focused on the acquisition of theoretical knowledge, LBL helps students establish a systematic knowledge framework. Moreover, it is familiar to teachers, straightforward to implement, and cost-effective in terms of human and financial resources. While this teaching method allows substantial knowledge to be transmitted within limited time, it has significant drawbacks. Students are placed in a passive learning state, lacking initiative and engagement. A prominent issue is the disconnection between theory and practice, which hinders the cultivation of clinical reasoning and practical problem-solving abilities [4,5,6,7]. Given the limitations of traditional teaching approaches, exploring more suitable methodologies for orthopedic education is imperative.

PBL was introduced by Barrows in 1969 [8]. This student-centered approach is grounded in authentic clinical problems, through which learners construct knowledge systems via faculty-guided independent inquiry, analytical reasoning, and problem-solving. It emphasizes the cultivation of independent learning and lifelong learning competencies [9,10,11]. Multiple studies have demonstrated its promising applications in medical education [12,13,14,15]. CBL originated from Harvard Medical School [16]. This teaching methodology relies on clinical cases and is instructor-facilitated, designed to engage students’ active participation. Through guiding students to think, analyze, and discuss, it reinforces the mastery of knowledge points while enhancing clinical reasoning and practical skills [17, 18]. Substantial research evidence indicates that this teaching model has shown significant potential in the medical education domain [19,20,21,22,23].

Medicine is a highly interdisciplinary field, and a single teaching methodology has not sufficed to meet the evolving demands of medical education reform [24]. The combined PBL-CBL teaching model aligns closely with the requirements of medical education, as its integration enables students to acquire and master knowledge through practical application. This approach emphasizes the process of self-directed learning, focuses on maximizing student initiative, and aims to cultivate lifelong learning abilities. Concurrently, it also underscores teamwork, allowing students to learn from and support one another while enhancing collaborative and communication skills. Its advantages have been widely acknowledged in the medical education literature [25,26,27,28,29].

In recent years, the PBL-CBL teaching model has been increasingly applied in orthopedic education. However, most studies on its use in orthopedic clinical teaching suffer from small sample sizes, limiting the ability of results to adequately reflect teaching efficacy. Additionally, a systematic evaluation of differences between this model and LBL remains lacking. Therefore, a comprehensive meta-analysis of these studies is necessary to objectively and accurately compare the application effects of the two teaching approaches in orthopedic education, thereby providing a scientific foundation for orthopedic teaching reform.

Methods

Selection strategy

The PICOS framework was used to develop inclusion and exclusion criteria for literature screening.

Inclusion criteria

(1) Participants were clinical medical students or residents undergoing training in the Department of Orthopedic Surgery. (2) The intervention group received PBL combined with CBL, while the control group was taught using LBL. (3) Outcome measures included objective indicators, such as student performance metrics post-teaching, including theoretical scores, practical skills scores, case analysis scores, physical examination skills, and plaster immobilization skills; and subjective indicators, such as debridement technique proficiency, aseptic awareness, self-learning ability, learning interest, learning efficiency, clinical thinking ability, team collaboration ability, communication and expression abilities, CTDI-CV total score, and satisfaction with the teaching method. (4) Study designs were limited to prospective randomized or quasi-randomized controlled trials (RCTs or Q-RCTs). At least 1 objective indicator and 2 subjective indicators were required for inclusion.

Exclusion criteria

(1) Duplicate studies. (2) Reviews, conference papers, bibliometric analyses, and other study types that do not report the required outcomes. (3) Studies with unclear or severely flawed research designs. (4) Studies from which data could not be extracted.

Search strategy

A comprehensive literature search was independently conducted by two authors in PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP. Keywords extracted from Medical Subject Headings (MeSH) were systematically applied to search for studies published up to April 2025 (with PubMed as an example, Table 1). Search terms included: PBL, CBL, problem-based learning, case-based learning, orthopedics, orthopaedics, surgery, spinal orthopedics, joint surgery, traumatic orthopedics, sports medicine, musculoskeletal system, bone and joint diseases, and their combinations. All retrieved literature was imported into NoteExpress for processing.

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Data extraction

Data from eligible papers were independently extracted by two authors in accordance with a predetermined protocol. The following information was extracted from the 15 included studies [2, 30,31,32,33,34,35,36,37,38,39,40,41,42,43]: authors, year, study types, teaching subjects, teaching methods, age, sample size, theoretical scores, physical examination scores, case analysis scores, plaster immobilization skills, debridement technique proficiency, aseptic awareness, practical skills scores, self-learning ability, learning interest, learning efficiency, clinical thinking skills, team collaboration, communication and expression abilities, critical thinking disposition inventory-chinese version (CTDI-CV) total score, and satisfaction with teaching methods. When relevant data were missing from a study, the study authors were contacted to obtain the data. Disputes arising during the extraction process were resolved by consulting a third independent reviewer.

Quality assessment

The methodological quality of the included literature was assessed by two independent researchers using the Cochrane Risk of Bias Assessment Tool. The assessment covered seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. The risk of bias in each domain was categorized as three categories: low, unclear, or high. Any disputes were resolved through discussing with a third researcher.

Assessment of heterogeneity

Inter-study heterogeneity was evaluated using the χ2 test and I2 statistics. Heterogeneity was considered significant when the P value of the χ2 test < 0.10 and I2 >50%. The principle for model selection was as follows: if I2 ≤ 50%, a fixed-effects model was used; otherwise, a random-effects model was selected. For outcome indicators with ≥ 10 included studies and strong heterogeneity (I2 >50%), publication bias was visually evaluated via funnel plots, and quantitatively evaluated by Egger’s test using Stata 16.0 software. Subgroup analysis was conducted to explore the sources of heterogeneity, and single studies were excluded one by one to perform sensitivity analyses, aiming to assess the robustness of the results and explore the impact of single studies on the heterogeneity of the results. Finally, the trim-and-fill analysis was used to assess the impact of publication Bias on the meta-analysis results. If the final heterogeneity remained high, a random-effects model was used. For outcome indicators involving fewer than 5 studies with high heterogeneity (I2 >50%), a random-effects model was directly used due to the insufficient number of studies to effectively explore the sources of heterogeneity.

Statistical analysis

Meta-analyses were conducted using RevMan 5.3 and Stata 16.0 software. For dichotomous variables, risk ratios (RR) were calculated; for continuous variables, weighted mean differences (WMD) were used when outcome indicators and measurement units were consistent across studies. Standardized mean differences (SMD) were applied when outcome indicators varied or units could not be standardized. All estimates were reported with 95% confidence intervals (CIs), and statistical significance was defined as P < 0.05. Results were visualized using forest plots and funnel plots to depict meta-analytic findings.

Results

Study selection and basic characteristics

A systematic search of databases identified 453 studies, which were screened down to 161 after removal of duplicates and exclusion of irrelevant studies. Further screening based on titles and abstracts shortlisted 52 studies, which underwent full-text review and rigorous screening according to inclusion/exclusion criteria, yielding 15 studies (Fig. 1). Of these, 14 were RCTs and 1 was a Q-RCT. All studies were published between 2016 and 2025, with a total of 980 participants enrolled (490 in the experimental group using the PBL + CBL teaching model and 490 in the control group using the LBL teaching model). Among the 15 included studies, 4 targeted clerks as teaching subjects, 5 focused on interns, and 6 were conducted with residents as teaching subjects. Baseline characteristics of the included studies are summarized in Table 2.

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Assessment of risk bias

A systematic review of the included studies was conducted using the Cochrane Risk of Bias Assessment Tool (Figs. 2 and 3). Among these, one Q-RCT study was classified as having a high risk of bias in random sequence generation and an uncertain risk of bias for allocation concealment, as it implemented odd-even grouping based on admission examination scores before random allocation. The remaining studies demonstrated good performance in terms of random sequence generation and allocation concealment. However, blinding of participants and personnel, as well as blinding of outcome assessment, were generally inadequate, potentially due to the interactive nature of the educational intervention and some subjective scoring criteria. The risk of bias related to incomplete outcome data and selective reporting was low, and the risk of other biases was also low. Overall, most of the included studies demonstrated low bias risk and high methodological quality.

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Theoretical scores

A total of 920 students from 14 studies comparing the PBL-CBL group with the LBL group were included to assess differences in theoretical scores [2, 30,31,32,33,34,35, 37,38,39,40,41,42,43]. The PBL-CBL group demonstrated significantly higher theoretical scores than the LBL group (SMD = 1.46, 95% CI: 1.15–1.78, P < 0.0001, I2 = 77%) (Fig. 4). Publication bias was assessed via funnel plot visualization (Fig. 5) and Egger’s test was performed using Stata 16.0 software. The test suggested that there was publication Bias in 14 included studies (intercept = 6.70, t = 4.88, P < 0.001, 95% CI: 3.70–9.70) (Figs.S1 and S2). Subgroup analysis of the teaching subjects, sample sizes, and publication year revealed that heterogeneity was 47.6% (moderate heterogeneity) in groups when sample sizes ≥ 80, while it reached 77% in groups when sample sizes < 80. This suggests that smaller sample sizes may be a source of heterogeneity. Subgroup analysis of the remaining two indicators showed that high heterogeneity persisted, indicating these two indicators are not the primary factors contributing to heterogeneity (Table 3 and Fig. S3). Further sensitivity analysis, performed by sequentially removing individual studies, demonstrated that the change in heterogeneity after deleting any single study was insignificant, and the point estimate of the combined effect size remained within the 95% CI of the total combined effect size, suggesting good overall stability (Fig. 6). Finally, the trim-and-fill analysis (with 5 virtual studies added) was used to assess the impact of publication bias on the meta-analysis results (Figs. 7 and S4). Before trimming, the heterogeneity test yielded Q = 58.692 (P < 0.001), with a random-effects model pooled effect size of SMD = 1.489, 95% CI (1.171–1.807). After trimming, the heterogeneity test yielded Q = 117.63 (P < 0.001), and the random-effects model pooled effect size was SMD = 1.121, 95% CI (0.772–1.470). The results show that although the effect size decreased after trimming, the 95% CI did not include 0, and the direction of effect did not reverse. This indicates that publication bias had a limited influence and the conclusions are robust. In summary, despite significant heterogeneity, the results retain reference value.

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Practical skills scores

A total of 760 students from 12 studies comparing the PBL-CBL group with the LBL group were included to assess differences in practical skills scores [2, 30,31,32,33, 35, 37, 38, 40,41,42,43]. The PBL-CBL group was found to perform significantly higher than the LBL group in practical skills scores (SMD = 1.53, 95% CI: 1.07-2.00, P < 0.0001, I2 = 87%, Fig. 8). Publication bias was assessed via funnel plot visualization (Fig. 9) and Egger’s test was performed using Stata 16.0 software. The test suggested that there was publication Bias in 12 included studies (intercept = 8.92, t = 4.07, P = 0.002, 95% CI: 4.03–13.82) (Figs.S5 and S6). Subgroup analysis of the teaching subjects, sample sizes, and publication year revealed that heterogeneity was 13.4% (low heterogeneity) in groups when sample sizes ≥ 80, while it reached 90.5% in groups when sample sizes < 80. This suggests that smaller sample sizes may be a source of heterogeneity. Subgroup analysis of the remaining two indicators showed that high heterogeneity persisted, indicating these two indicators are not the primary factors contributing to heterogeneity (Table 4 and Fig. S7). Further sensitivity analysis, by sequentially removing individual studies, demonstrated that the change in heterogeneity after deleting any single study was insignificant, and the point estimate of the combined effect size remained within the 95% CI of the total combined effect size, suggesting good overall stability (Fig. 10). Finally, the trim-and-fill analysis (with 3 virtual studies added) was used to assess the impact of publication bias on the meta-analysis results (Figs. 11 and S8). Before trimming, the heterogeneity test yielded Q = 90.320 (P < 0.001), with a random-effects model pooled effect size of SMD = 1.558, 95% CI (1.084–2.032). After trimming, the heterogeneity test yielded Q = 167.308 (P < 0.001), and the random-effects model pooled effect size was SMD = 1.104, 95% CI (0.566–1.641). The results show that although the effect size decreased after trimming, the 95% CI did not include 0, and the direction of effect did not reverse. This indicates that publication bias had a limited influence and the conclusions are robust. In summary, despite significant heterogeneity, the results retain reference value.

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Physical examination scores

A total of 202 students from 3 studies comparing the PBL-CBL group with the LBL group were included to assess differences in physical examination scores [30, 37, 39]. The PBL-CBL group had significantly higher physical examination scores than the LBL group (SMD = 1.64, 95% CI: 0.83–2.44, P < 0.0001, I2 = 82%) (Fig. 12A).

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Case analysis scores

A total of 248 students from 4 studies comparing the PBL-CBL group with the LBL group were included to assess differences in case analysis scores [2, 30, 31, 41]. The PBL-CBL group demonstrated significantly higher case analysis scores than the LBL group (SMD = 1.30, 95% CI: 0.65–1.95, P < 0.0001, I2 = 81%) (Fig. 12B).

Plaster immobilization skills

A total of 100 students from 2 studies comparing the PBL-CBL group with the LBL group were included to assess differences in plaster immobilization skills [36, 39]. The PBL-CBL group demonstrated significantly better mastery of plaster immobilization skills than the LBL group (SMD = 2.42, 95% CI: 1.89–2.95, P < 0.0001, I2 = 40%) (Fig. 12C).

Debridement technique proficiency

A total of 100 students from 2 studies comparing the PBL-CBL group with the LBL group were included to assess differences in debridement technique proficiency [40, 43]. The PBL-CBL group demonstrated better debridement technique proficiency than the LBL group (RR = 1.44, 95% CI: 1.15–1.80, P = 0.001, I2 = 0%) (Fig. 12D).

Aseptic awareness

A total of 100 students from 2 studies comparing the PBL-CBL group with the LBL group were included to assess differences in aseptic awareness [40, 43]. The PBL-CBL group demonstrated significantly better aseptic awareness than the LBL group (SMD = 1.58, 95% CI: 1.17–2.12, P = 0.003, I2 = 0%) (Fig. 12E).

Self-learning ability

A total of 296 students from 6 studies comparing the PBL-CBL group with the LBL group were included to assess differences in self-learning ability [2, 33, 39,40,41, 43]. The PBL-CBL group outperformed the LBL group in self-learning ability (RR = 1.55, 95% CI: 1.34–1.80, P < 0.0001, I2 = 0%) (Fig. 12F).

Learning interest

A total of 330 students from 5 studies comparing the PBL-CBL group with the LBL group were included to assess differences in learning interest [2, 33, 34, 39, 42]. The PBL-CBL group outperformed the LBL group in enhancing learning interest (RR = 1.35, 95% CI: 1.19–1.53, P < 0.0001, I2 = 0%) (Fig. 13A).

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Learning efficiency

A total of 98 students from 2 studies comparing the PBL-CBL group with the LBL group were included to assess differences in learning efficiency [41, 42]. The PBL-CBL group outperformed the LBL group in improving learning efficiency (RR = 1.59, 95% CI: 1.21–2.10, P = 0.0009, I2 = 4%) (Fig. 13B).

Clinical thinking ability

A total of 212 students from 4 studies comparing the difference between the PBL-CBL group with the LBL group were included to assess differences in clinical thinking ability [2, 33, 41, 42]. The PBL-CBL group had a higher clinical thinking ability rate than the LBL group (RR = 1.47, 95% CI: 1.25–1.72, P < 0.0001, I2 = 0%) (Fig. 13C).

Team collaboration ability

A total of 308 students from 5 studies comparing the PBL-CBL group with the LBL group were included to assess differences in team collaboration ability [33, 34, 36, 39, 42]. The PBL-CBL group outperformed the LBL group in team collaboration ability (RR = 1.86, 95% CI: 1.54–2.25, P < 0.0001, I2 = 16%) (Fig. 13D).

Communication and expression abilities

A total of 172 students from 4 studies comparing the PBL-CBL group with the LBL group were included to assess differences in communication and expression abilities [33, 39, 40, 43]. The PBL-CBL group demonstrated better communication and expression abilities than the LBL group (RR = 1.41, 95% CI: 1.19–1.66, P < 0.0001, I2 = 0%) (Fig. 13E).

CTDI-CV total score

A total of 162 students from 2 studies comparing the PBL-CBL group with the LBL group were included to assess differences in CTDI-CV total score [30, 37]. The PBL-CBL group had a higher CTDI-CV total score than the LBL group (MD = 31.25, 95% CI: 28.25–34.25, P < 0.0001, I2 = 39%) (Fig. 13F).

Satisfaction with teaching methods

A total of 468 students from 7 studies comparing satisfaction with the teaching methods between the PBL-CBL and LBL groups were included [31,32,33,34,35,36, 42]. The PBL-CBL group showed higher satisfaction with the teaching methods than the LBL group (RR = 1.34, 95% CI: 1.23–1.45, P < 0.0001, I2 = 0%) (Fig. 14).

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Discussion

Principal findings

The meta-analysis of 14 RCTs and 1 Q-RCT demonstrated that the integration of PBL and CBL significantly enhances students’ theoretical knowledge and clinical skills (including physical examination, plaster casting, wound debridement, case analysis, and aseptic concepts). It also improves self-directed learning ability, learning interest, teamwork, learning efficiency, communication skills, clinical reasoning, and total scores on CTDI-CV, with higher satisfaction rates reported for this teaching model. However, this approach is less suitable for teaching foundational knowledge. Its emphasis on problem-solving and practical application may cause students to neglect systematic learning of foundational content, thereby impeding the development of a robust knowledge framework and potentially affecting subsequent in-depth learning [33].

Comparisons with previous literature and potential mechanisms

To our knowledge, no other meta-analyses have compared the effectiveness of PBL combined with CBL versus LBL. The present study indicates that the PBL-CBL teaching method can significantly enhance students’ theoretical knowledge and clinical skills (including practical skills scores, case analysis scores, physical examination scores, plaster immobilization skills, debridement technique proficiency, and aseptic awareness)—a conclusion consistent with findings from similar studies [44, 45]. In theoretical learning, students deepen their understanding and retention of knowledge through active problem-solving and case analysis. In practical skills, theoretical knowledge is better translated into practical abilities via hands-on case exercises and discussions. PBL and CBL each have distinct characteristics; when combined in teaching, they complement one another. This allows students to not only master theoretical knowledge solidly but also receive ample training in practical operations and case analysis, laying a robust foundation for future clinical practice [46, 47].

This study demonstrates that the PBL-CBL teaching method outperforms the LBL approach in enhancing students’ self-learning ability, learning interest, learning efficiency, clinical thinking skills, team collaboration, communication and expression, and CTDI-CV total score, findings consistent with previous research [48, 49].This superiority is attributed to PBL, which, driven by real clinical problems, fosters teacher-student interaction, enhances critical thinking, and stimulates students’ enthusiasm for active knowledge exploration [50]. CBL, meanwhile, is based on real-world cases, guiding students to apply theoretical knowledge to practical scenarios and developing their analytical and problem-solving skills [51]. Over the long term, the PBL-CBL teaching method improves students’ clinical reasoning, teamwork, and communication skills, competencies crucial for their future professional development [52]. Promoting this teaching model is therefore beneficial for cultivating orthopedic professionals capable of meeting the demands of modern medical practice.

In terms of teaching satisfaction, students reported higher satisfaction with the PBL-CBL teaching method, consistent with previous findings [53, 54]. This student-centered approach uses real-world cases and problem-driven guidance to encourage active student participation in learning. It not only stimulates learning interest but also helps students master essential knowledge. The relaxed learning atmosphere fostered by this model promotes teacher-student interaction, thereby enhancing student satisfaction [25, 26, 55].

Implications for clinical teaching practice and future studies

Our research provides insights for clinical teaching practice: the PBL-CBL teaching method is suitable for teaching scenarios across different stages of orthopedic clinical clerkships, internships, and residents’ training programs. In orthopedic teaching practice, teaching methods should be selected flexibly based on teaching content. During the foundational theoretical knowledge phase, the advantages of the LBL method can be leveraged to ensure students develop a solid knowledge framework [56]. In clinical practice segments, the strengths of the PBL-CBL teaching method should be fully utilized to cultivate students’ clinical reasoning and practical skills [57].

While the PBL-CBL teaching method offers significant advantages, it has limitations: it imposes high demands on teachers’ professional competence, clinical experience, and classroom management skills; preparation and implementation of this approach are time-consuming; teachers must explore and optimize teaching processes and strategies to meet educational objectives within limited time frames [25]; it requires students to have strong self-directed learning abilities, with extensive pre-class preparation needed, and some students accustomed to traditional education may experience significant pressure [25, 49]. This model emphasizes practical application and may lack systematic instruction in foundational knowledge, potentially hindering the development of a robust knowledge framework [33, 49]. Additionally, shortages of teaching resources such as case repositories and facilities may limit instructional effectiveness. To address these issues, it is recommended that teaching resource development be strengthened (e.g., establishing high-quality case repositories); teacher training be enhanced to improve their proficiency in applying this model; and the teaching evaluation system be refined to comprehensively and objectively assess student learning outcomes, thereby improving teaching quality.

Currently, significant gaps remain in research within this educational field. There is an urgent need for more high-quality, large-scale, multicenter, and double-blind studies to further validate the effectiveness of the PBL-CBL teaching method in orthopedic education. Appropriate teaching methods are critical for talent development and enhancing the quality of medical services.

Strengths

First, to our knowledge, this is the first meta-analysis on this topic, providing the most up-to-date and comprehensive evidence regarding the effectiveness of PBL-CBL versus LBL in orthopedic education. Second, through the integration of MeSH and free-text keywords, a comprehensive search was conducted across databases (PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP) to reduce the impact of publication bias on pooled results and enhance the reproducibility of findings. Finally, the trim-and-fill method was used to correct pooled effect sizes for publication bias, and the corrected results were consistent with the original analysis, indicating high reliability.

Limitations

This study also has certain limitations. First, as anticipated, high heterogeneity and publication bias were observed in indicators such as theoretical scores and practical skills scores across different studies. Although subgroup analyses (e.g., by teaching subjects, sample size, and publication year) were used to explore sources of heterogeneity, a sample size below 80 was identified as a potential source. However, due to limitations of the included studies, some potential sources of heterogeneity remain undetermined, such as gender, teaching duration, evaluation methods, and case complexity. Publication bias may be associated with small sample sizes and publication practices in Chinese journals (e.g., studies with positive results are more likely to be published). Nevertheless, sensitivity analyses and the trim-and-fill method confirmed that the results remain robust despite the presence of heterogeneity and publication bias. Second, the included studies had small sample sizes, variable quality, and none employed double-blind designs, which may affect the reliability of the results. Third, a lack of international data means all included studies were from China, and the generalizability of the results requires further validation.

Conclusion

Meta-analysis demonstrates that, in orthopedic education, the PBL-CBL teaching method offers significant advantages over LBL in enhancing students’ theoretical knowledge, clinical skills, and comprehensive abilities. It also stimulates learning interest, improves teaching satisfaction, and facilitates the cultivation of orthopedic clinical talent. However, its generalizability requires further verification through research in different countries.

Data availability

The data analyzed in our study were collected from available published articles.

Abbreviations

PBL:

Problem-based learning

CBL:

Case-based learning

LBL:

Lecture-based learning

CNKI:

Chinese National Knowledge Infrastructure

CI:

Confidence interval

RR:

Risk Ratio

SMD:

Standardized mean difference

RCT:

Randomized controlled trial

MeSH:

Medical Subject Heading

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