Published 10/1/2014

AAOS Moves Forward on Quality Initiatives

Board approves 3 new CPGs, 1 new AUC

During its meeting on Sept. 5, 2014, the AAOS Board of Directors took several steps on quality issues, approving three new clinical practice guidelines (CPGs) and one new appropriate use criteria (AUC). The CPGs and AUC were presented by Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality.

Hip Fracture CPG
The new evidence-based CPG on “Management of Hip Fractures in the Elderly” is based on a systematic review of the current scientific and clinical research. This guideline has been endorsed by the Orthopaedic Trauma Association, The Hip Society, the American Association of Clinical Endocrinologists, and the U.S. Bone and Joint Initiative. The purpose of this clinical practice guideline is to help improve treatment and management based on the current evidence.

This CPG addresses “a global healthcare challenge, because the occurrence of hip fractures is increasing related to the aging of the population and current prevalence of osteoporosis,” said Karl C. Roberts, MD, vice-chair of the work group that developed the CPG.

Many of the recommendations in the new CPG have the ultimate goal of reducing delirium or acute confusion, a common condition in hip fracture patients, according to W. Timothy Brox, MD, who chaired the work group. Multiple studies have found that patients with postoperative delirium are less likely to return to their pre-injury level of function, are more frequently placed in nursing homes, and have an increased rate of mortality.

“The more you can reduce the incidence of delirium, the faster and more effectively the patient will recover,” said Dr. Brox.

The importance and magnitude of hip fracture as a clinical challenge resulted in this new CPG covering 25 recommendations, more than any previous CPG. (See “Managing Hip Fractures in the Elderly.”)

The new CPG on “Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip (DDH) in Infants Up to 6 Months of Age” was also approved. Based on a systematic review of the current scientific and clinical research, this guideline has been endorsed by the Society of Diagnostic Medical Sonography, the Society of Pediatric Radiology, and the Pediatric Orthopaedic Society of North America.

“There is a widely held public perception that screening and early detection of DDH is a good thing, and the CPG does not refute this,” said Kit M. Song, MD, who served as vice-chair of the work group for this CPG. He added, however, that “more research is needed to better define who needs treatment and what that treatment should be.”

Although DDH screening most often includes an ultrasound before age 6 months, the new CPG recommends selective ultrasound screening if an infant has the following DDH risk factors: breech presentation at birth, a family history of DDH, or signs or a history of hip instability. The nine recommendations in this CPG are designed to help improve treatment and management based on the current evidence. (See “DDH Guideline Highlights.”)

Anterior cruciate ligament (ACL) tears are among the most common injuries occurring in athletes participating in high-demand sports like soccer, football, and basketball. The third CPG, on “Management of Anterior Cruciate Ligament Injuries,” has been endorsed by the National Academy of Sports Medicine (NASM), the American Orthopaedic Society for Sports Medicine (AOSSM), and the National Athletic Trainers’ Association (NATA).

“In an active patient, if you wait too long to surgically repair the ACL, there is a risk for additional injury to the knee,” said Kevin G. Shea, MD, who chaired the ACL CPG work group. “Therefore, surgery within 5 months of injury may have some advantages. Nonsurgical treatment also is appropriate for some patients, including those with less active lifestyles who do not place significant demands on the knee.”

The ACL guideline contains 20 recommendations. (See “Strong Recommendations Support ACL Treatment.”)

AUC: Pediatric supracondylar fractures
AAOS AUC are developed by three clinician panels—a writing panel, a review panel, and a voting panel—using the RAND/UCLA Appropriateness Method. AUC combine the best available scientific evidence with clinical expertise; the Academy’s AUC are supported by a mobile app that can be accessed from any computer web browser, tablet, or mobile device.

The literature search was derived from the clinical practice guideline on “The Treatment of Pediatric Supracondylar Humerus Fractures (PSHF),”published in 2011, as well as an updated literature search. This PSHF AUC covers 14 treatments and presents 220 different patient scenarios to help clinicians identify for whom and when the treatments are appropriate. (See “Newest AUC App Focuses on Supracondylar Humerus Fractures.”)

According to James O. Sanders, MD, who chaired the AUC work group, “These criteria will be helpful for clinicians who treat these injuries on an occasional basis.” Once the user identifies the correct scenario, the app shows the related treatments ranked for their appropriateness, “helping to ensure optimal care and the best long-term outcome for resuming functional use of the elbow,” said Dr. Sanders.

More online
The full CPG documents—including the systematic review of the literature, the work group disclosures, and all supporting documentation—are available on the AAOS website at

The full AUC document containing the results of the appropriate use criteria ratings is available on the AAOS website at www.aaos.org/auc; the mobile-optimized web app can be accessed at www.aaos.org/aucapp