Published 7/1/2007
Norman A. Johanson, MD; Michael W. Keith, MD; Janet Wies

How the guidelines came to be

Year-long process took two approaches
The construction of the new clinical guidelines adopted by the AAOS Board of Directors last month began nearly one year ago with the formation of the Guidelines Oversight Committee (GOC), chaired by William C. Watters III, MD.

The topics—prevention of symptomatic pulmonary embolism (PE) in patients undergoing total hip and knee arthroplasty and the diagnosis of carpal tunnel syndrome (CTS)—were selected at the first meeting of the GOC in July 2006. These topics were chosen based on disease burden, unit or aggregate cost of treatment or diagnosis, variation in the treatment or diagnosis, whether or not existing guidelines covered the topic, whether sufficient research was available to support the topic, and membership input and interest.

Norman A. Johanson, MD, chaired the workgroup for the guideline on the prevention of symptomatic PE; Michael W. Keith, MD, chaired the workgroup developing the guideline on the diagnosis of CTS. Workgroup members, appointed by the chairs, had expressed an interest in serving, represented additional subspecialty groups, and were also trained in evidence-based medicine (see “Workgroup members”).

Two roads to completion
Due to time constraints, the PE workgroup coordinated their efforts and developed the evidence for their guidelines with the Evidence Research Team from Tufts New England Medical Center. The CTS workgroup used the new AAOS guideline unit to develop the supporting evidence for their recommendations. The development process for both guidelines included defining the scope of the guidelines, extensive literature searches, data extraction, evidence table construction, analyses, and a final presentation of the evidence at the recommendation meeting held for each work group. The workgroups then completed the recommendations by writing supporting rationales and approving the final documents.

Both guidelines were further reviewed and approved by the GOC, the Evidence-Based Practice Committee, the Council on Research, Quality Assessment and Technology, and the Board of Directors. After being approved by the Board, the guidelines were immediately posted and made available on the AAOS Web site, at www.aaos.org/research_guide.asp.

In addition, both guidelines have been submitted to various venues including the National Guidelines Clearinghouse. As part of the Academy’s education efforts, CME course modules based on incidence of PE and the PE guideline are being developed to train fellows on how to institute evidence-based practice measures into their orthopaedic practices.

The impact on practice
The guideline on the prevention of symptomatic PE is important to orthopaedic surgeons who perform hip and knee replacement surgery for several reasons. Unlike many other guidelines for the prevention of thrombophlebitis and possible PE, these guidelines are risk-stratified. Risk stratification enables the orthopaedic surgeon to select an appropriate prophylactic regimen against PE in hip and knee replacement patients based on a balance between bleeding-related risks and medical adverse effects, on one hand, and the expected effectiveness in preventing symptomatic PE on the other.

Risk stratification within the PE treatment guideline provides the treating physician with important latitude in determining the appropriate prophylaxis—one that provides maximum protection against PE while it also minimizes treatment risks to the patient. The optimal prophylactic regime for a particular patient should reflect the clinical judgment of the physician regarding the relative risks of both adverse medical events—major bleeding and symptomatic PE. Future research work needs to be focused on identifying appropriate risk stratifications of patients and prophylactic regimens.

Likewise, the guideline on the diagnosis of CTS is also important. CTS is among the most common disorders of the upper extremity, with a high disease burden and significant impact on a patient’s quality of life issues. Further, if the condition is diagnosed early, progression to irreversible damage to the nerve can be avoided in some patients. Proper diagnosis provides relief of the condition and minimizes such issues as healthcare costs and work time loss, while contributing to increased improvement in a patient’s daily functioning.

What’s next?
At its most recent meeting, the GOC appointed Dr. Keith as chair of a new workgroup to develop CTS treatment guidelines; John C. Richmond, MD, will serve as the chair of the workgroup to develop treatment guidelines for osteo-arthritis of the knee. The AAOS guidelines unit has begun work on these guidelines; their development may also include collaboration with other specialty societies.

Norman A. Johanson, MD, and Michael W. Keith, MD, served as workgroup chairs for the new guidelines; Janet Wies is manager, clinical practice guidelines, in the AAOS research department.

Workgroup members

Diagnosis of carpal tunnel syndrome:

  • Michael W. Keith, MD (Chair)
  • Victoria Masear, MD (Co-chair)
  • Kevin Chung, MD, MS
  • Kent Maupin, MD (representative for orthopaedic surgery)
  • Michael Andary, MD, MS (representative from the American Academy of Physical Medicine and Rehabilitation and the American Association of Neuromuscular and Electrodiagnostic Medicine)
  • Peter C. Amadio, MD
  • Richard W. Barth, MD (representative from the Board of Councilors)

Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty:

  • Norman A. Johanson, MD (Chair)
  • Paul F. Lachiewicz, MD (representative from The Hip Society)
  • Jay R. Lieberman, MD
  • Paul A. Lotke, MD (representative from The Knee Society)
  • Javad Parvizi, MD (representative from the American Association of Hip and Knee Surgeons)
  • Vincent Pellegrini, MD
  • Theodore L. Stringer, MD (representative from the Board of Councilors)
  • Paul A. Tornetta III, MD (representative from the Orthopaedic Trauma Association)