"Clinical practice guidelines (CPGs) are becoming increasingly important in the practice of medicine,” Matthew E. Oetgen, MD, said. “They’re a resource to improve quality and efficiency of care and to decrease variability. But data are limited—especially in orthopaedics—regarding their actual clinical impact.”

Dr. Oetgen presented data from his study, “Impact of Clinical Practice Guidelines on the Treatment of Pediatric Femur Fractures,” at the annual meeting of the Pediatric Orthopaedic Society of North America (POSNA).

“In June 2009, AAOS approved a CPG on the Treatment of Pediatric Diaphyseal Femur Fractures,” Dr. Oetgen continued. “It contained 14 recommendations on a variety of treatment topics. We attempted to assess the impact of the guideline on treatment by examining changes in clinical care associated with its introduction.”

Focus on seven recommendations
Dr. Oetgen and his colleagues performed a retrospective chart review of 361 pediatric patients with midshaft femur fractures who were seen at a single center. Overall, 143 patients were classified into a pre-CPG group (January 2007 to June 2009), while 218 were classified as post-CPG (July 2009 to December 2012).

“Of the 14 recommendations in the guideline, six were inconclusive because there wasn’t enough data for a recommendation one way or another,” said Dr. Oetgen. “So we didn’t include them. We also did not include the guideline supporting the optional use of waterproof cast liners for spica casts because we didn’t have enough information in our own records to conduct a proper assessment.”

As a result, the research team based its assessment on the following seven recommendations:

• We recommend that children younger than 36 months with a diaphyseal femur fracture be evaluated for child abuse.
• Treatment with a Pavlik harness or a spica cast are options for infants 6 months and younger with a diaphyseal femur fracture.
• We suggest early spica casting or traction with delayed spica casting for children age 6 months to 5 years with a diaphyseal femur fracture with less than 2 cm of shortening.
• When using the spica cast in children 6 months to 5 years of age, altering the treatment plan is an option if the fracture shortens greater than 2 cm.
• It is an option for physicians to use flexible intramedullary (IM) nailing to treat children age 5 to 11 years diagnosed with diaphyseal femur fractures.
• Rigid trochanteric entry nailing, submuscular plating, and flexible IM nailing are treatment options for children age 11 years to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near piriformis entry rigid nailing are not treatment options.
• Regional pain management is an option for patient comfort perioperatively.

“Treatments were performed by 12 different surgeons at our institution,” explained Dr. Oetgen. “The average age of patients was 64 months, with the highest volume of injuries in the 7-month to 5-year range. We had good distribution across the groups.”

Minimal impact
In general, the researchers found that publication of the CPG was associated with a minimal impact on clinical care.

“In fact, only one recommendation displayed a statistically significant difference before and after publication of the CPG,” said Dr. Oetgen. “Despite the guideline’s statement that flexible IM nailing could be a treatment option for children aged 11 years and older, the use of flexible IM nails actually dropped—from 66 percent of patients in the pre-CPG group to 43 percent of patients in the post-CPG group.

“In addition, two areas of care—evaluation for child abuse and spica casting for children age 6 months to 5 years—demonstrated a small trend inconsistent with the recommendations.”

Dr. Oetgen and his colleagues suggested several reasons for the lack of impact that the CPG appeared to have on treatment at their institution, including surgeon disapproval or ignorance of the CPG, challenges in the guideline development process, or difficulties in encouraging change in clinical practices.

“CPGs are likely to have a significant and growing influence in clinical care and reimbursement,” said Dr. Oetgen. “We can take heart in the fact that the Academy has a process of exceptional quality and standards in place to produce these guidelines. The early guidelines are limited, most likely due to the lack of data. But I believe we must continue to evaluate the clinical impact of CPGs to determine the usefulness of the current CPG process and to improve the development process in the future.”

Disclosure information: Dr. Oetgen—Medtronic, AAOS, POSNA, Scoliosis Research Society.

Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at ppollack@aaos.org

Bottom Line

• In 2009, AAOS adopted a CPG on the treatment of pediatric diaphyseal femur fractures.
• At a single institution, posting of the CPG was associated with minimal impact on clinical interventions.