Published 8/1/2014
Mary Ann Porucznik

Board Takes Positions on Modular THA, Obesity, Patient Safety

Adopts risk stratification algorithm, information and revised position statements

The AAOS Board of Directors, at its meeting in June, adopted a risk stratification algorithm for management of patients with dual modular tapered total hip arthroplasty (THA), as well as several new information statements on issues concerned with patient safety. In addition, position statements on comparative effectiveness research, the need for daily physical activity, and power lawnmower safety were revised. On the recommendation of the Health Care Systems Committee and the Council on Advocacy, it also voted to sunset the position statement on Hip Fracture in Seniors: A Call for Health System Reform.

Consensus on risk stratification
The Risk Stratification Algorithm for Management of Patients with Dual Modular Taper THA, presented by the AAOS Council on Research and Quality (CORQ) is a consensus statement developed by members of the AAOS, the American Association of Hip and Knee Surgeons, and The Hip Society.

The algorithm notes that mechanical failures, such as fractures of the modular neck and dissociation of modular components, have been reported. In addition, concerns are increasing about the number of THA revision surgeries in patients with dual taper femoral stems due to the occurrence of adverse local tissue reactions (ALTR). These ALTRs are “thought to result from corrosion at the neck-stem taper junction, secondary to reciprocating movement at the modular junction leading to fretting corrosion in a process described as mechanically assisted crevice corrosion.”

The consensus paper summarizes clinical challenges in the diagnosis and treatment of patients with ALTRs, reviews current evidence, and identifies areas for future research. Importantly, the document states that it “is not intended to be proscriptive in any fashion.” The algorithm presents differential diagnoses and breaks patients into three risk stratification groups (low, medium, and high), based on patient factors, symptoms, clinical and laboratory findings, and radiographic evidence and presents treatment recommendations for each risk group.

Treatment recommendations range from annual examinations to revision surgery and would apply to all patients with a dual taper femoral stem device, including those with a device that has been recalled by the manufacturer. However, it does recommend that the surgeon inform patients about any recalls and direct them to the manufacturer’s website for additional information.

In summary, reads the document, “There should be a low threshold to perform a systematic evaluation of patients with dual taper stem THA as early recognition and diagnosis will facilitate the initiation of appropriate treatment prior to significant adverse biologic reactions. … While specialized tests such as metal ion analysis and MARS MRI are useful modalities for assessing dual taper stem THA, over-reliance on any single investigative tool in the clinical decision-making process should be avoided. Future research focusing on validation of the current diagnostic tools for detecting adverse local tissue reactions as well as optimization of clinical indication and patient selection for dual taper stem utilization is warranted.”

Patient safety information statements
Information statements are developed as educational tools based on the opinions of the authors and are not products of systematic reviews. Readers are encouraged to consider the information presented and reach their own conclusions.

The AAOS Patient Safety Committee developed three information statements that were presented to the board. Two were adopted and one was sent back to the committee for revision. Each statement notes that “The American Academy of Orthopaedic Surgeons (AAOS) believes that the development of high quality information that defines which diagnostic, treatment, and prevention services are most effective for specific patients and populations will improve informed patient choice and shared decision-making. Such efforts will maximize the improvement of health status of individuals and populations.”

The two statements that were adopted covered “Orthopaedic Surgical Consent” and “Disruptive Behavior and Orthopaedic Patient Safety.”

Orthopaedic Surgical Consent—According to the statement, “Orthopaedic surgeons and surgical teams recognize the importance of a surgeon-led timely, accurate, understandable, and complete surgical consent process as a key component of surgical safety.” It calls for “routine utilization of patient-centered surgical consent processes to minimize—with a goal of eliminating—preventable surgical harm.”

Disruptive Behavior and Orthopaedic Patient Safety—According to this statement, “The AAOS supports adherence to a code of conduct for all surgeons and surgical team members that fosters a cooperative, collegial working environment and that identifies and addresses ‘disruptive behaviors’ within the health care team. Isolated egregious disruptive events or patterns of disruptive behavior should not be tolerated.” It clearly states that “controversial ideas or well-intended criticisms of the medical systems or situations by surgeons or team members should not be labeled disruptive.”

Finally, it calls upon orthopaedic surgeons to take an active role, noting that they, as leaders of the patient care team, “must foster work environments that are collegial and cooperative. Patients are best served by healthcare teams that function harmoniously in which all team members feel respected for their contributions and empowered to speak freely regarding any patient safety concerns.”

Obesity information statement
The board adopted an information statement on obesity and musculoskeletal care that was presented by the CORQ. The statement provides background information on the obesity epidemic and discusses the impact of obesity on various aspects of care.

In conclusion, the statement notes that “AAOS recognizes that obesity is not a choice, but rather a complex, multifactorial process that affects a large number of our patients and in most cases contributes negatively to their musculoskeletal problems. Our approach to their problems should encompass aid in the medical management of the issues associated with their obesity, as well as the potential surgical care that can help with both their general health as well as specific musculoskeletal problems. Likewise, it is equally important to assure the safety of healthcare facilities addressing those situations specific to the obese patient.”

Position statements
Like information statements, position statements are developed as educational tools, are not the products of systematic reviews, and are based on the opinions of the authors. Readers are encouraged to consider the information presented and reach their own conclusions. The CORQ presented an updated position statement on comparative effectiveness research, which was approved.

Comparative effectiveness research—The AAOS has had a position statement on comparative effectiveness research (CER) since 2009. In this first 5-year review of the statement, significant changes were made reflecting not only the advances in research but also the impact of health policies adopted since then.

The position statement recognizes the Academy’s commitment to “working with a broad range of stakeholders to develop methods for CER related to musculoskeletal care and specifically for procedures that involve implants.” Among the methods mentioned are the increased use and transparency of outcome data through shared databases and the elimination of outcome variations due to training and use.

The statement also supports the role of an independent public–private entity that would prioritize, fund, conduct, and coordinate CER.

Power lawnmower safety—The Communications Cabinet presented an updated position statement on power lawnmower safety. The statement includes a number of steps that can be taken to reduce preventable injuries caused by power lawnmowers, including educational efforts, the use of protective gear, and age limits on drivers of power lawnmowers.

The need for daily physical activity—The Communications Cabinet also presented an updated position statement on the need for daily physical activity. The statement outlines the benefits of physical activity, provides a list of suggested activities, and includes safety tips.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

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