Published 5/1/2009

Questioning guidelines, radiation research

I read with interest Dr. Canale’s editorial “You can (guide) a horse to water ...” in the March AAOS Now. I do appreciate that the AAOS guidelines supposedly protect us from malpractice actions by providing a set of guidelines.

I have been provided by my colleagues with a substantially differing view from Chest (2009;135:513-520), which goes to some length to criticize the AAOS published guidelines for the prevention of thromboembolism. This article accuses AAOS of accepting lower quality evidence in making determinations of accepted treatment.

I hope that AAOS will step up to the plate in a spirited defense of this issue.

Stephen F. Emery, MD
Cody, Wyoming

The AAOS guidelines team appreciates your comments. To our knowledge, no data suggest that guidelines have been used successfully by the prosecution or defense in cases of medical malpractice. Guidelines are not mandates. They provide physicians and other medical professionals guidance based on the best available clinical evidence for specific treatments. The physician must use his or her best judgment to make decisions based on a patient’s individual situation.

The AAOS has formally submitted a response to the recent Chest article commenting on the differences between the AAOS and Chest guidelines related to deep venous thrombosis (DVT) and pulmonary embolism (PE) prophylaxis. Specifically, we stressed the point that orthopaedic surgeons remain concerned about the use of DVT as a surrogate marker for PE and about the potential for iatrogenic hemorrhage in the joint replacement patient (with its associated complications) that can result from PE prophylaxis.

Kristy L. Weber, MD
Chair, Council on Research, Quality Assessment, and Technology

When I saw the article “Radiation exposure in the OR: Is it safe?” (December 2008), I thought that since minimally invasive spine surgery is all the rage now, finally, someone is looking to see if it is safe for the patient. But I was wrong...it was all about the surgeon and the staff and it only involved 10 cases.

If I were the patient, I would rather have a skilled surgeon who could place pedicle screws without [using a] C-arm and [with] a slightly larger incision than get the large dose of radiation that fluoroscopy requires. Furthermore, no good evidence exists that the minimally invasive approach really results in a better outcome than a smaller incision open approach.

Let us not forget the most important part of the equation—the patient. Although the article indicates that the patient is only exposed to radiation once, that is not true. The diagnosis and follow-up for spine issues such as this involve multiple exposures to ionizing radiation.

Research in operating room safety for both patient and caregiver is essential, and the quoted research does not do the issue justice. Details concerning lead thickness standards, eyewear standards, distance requirements, C-arm types, patient density and size issues, and outcomes are essential to developing any meaningful conclusions on this issue.

Alexander A. Davis, MD
Modesto, Calif.

If you want to set Now straight, send your letters to the Editor, AAOS Now, 6300 N. River Rd., Rosemont, IL 60018; fax them to (847) 823-8033; or e-mail them to aaoscomm@aaos.org