On June 12-13, 2015, the AAOS board of directors met for the first time in the new orthopaedic headquarters building.


Published 7/1/2015
Mary Ann Porucznik

AAOS Quality Efforts Continue

Board approves new AUC, innovation position statement

During its June 12–13, 2015, meeting, the AAOS board of directors took the following actions that support and extend quality and advocacy efforts on behalf of orthopaedic surgeons:

  • approved new appropriate use criteria (AUC) for pediatric supracondylar humerus fractures with vascular injuries
  • endorsed a companion consensus statement to the AAOS clinical practice guidelines (CPG) on the management of anterior cruciate ligament (ACL) injuries
  • reissued the CPG on the treatment of pediatric diaphyseal femur fractures
  • adopted an information statement on principles of patient-reported outcome measures (PROMs) reporting
  • adopted a position statement on innovation and new technologies in orthopaedic surgery
  • amended position statements on the financing of graduate medical education, emergency orthopaedic care, and principles of Medicare reform and access to specialty care
  • retired the information statement on wrong-site surgery and the position statement on the relationship between healthcare plans and trauma systems

In addition, the board held strategic discussions on conflicts of interest and advocacy as unity. It also adopted revisions to the policies and procedures of the Political Action Committee of the American Association of Orthopaedic Surgeons (Orthopaedic PAC) to add a resident fellow and the chair of the AAOS Advocacy Resource Committee to the Orthopaedic PAC Executive Committee.

The AAOS approved a CPG on the treatment of supracondylar pediatric fractures in 2011, and followed that with the release of an AUC in 2014. Because several members of the work group that developed the AUC were concerned about a specific subset of patients—those with vascular injuries—efforts continued to develop an AUC directly for the treatment of these patients.

An in-depth article on the new AUC will appear in the August 2015 issue of AAOS Now; a web-based application for all AUC may be accessed at www.orthoguidelines.org/go/auc

Consensus statement on ACL injuries
The AAOS released a CPG on the management of ACL injuries in 2014. As part of the development process, clinical experts define the scope of the guideline by creating preliminary recommendations (questions) that directed the literature search. If questions formulated at the introductory meeting result in no evidence, the AAOS will not create consensus recommendations unless there is a threat of life or limb. Instead, these preliminary recommendations are sent to a relevant specialty society, which is asked to create a companion consensus statement. AAOS staff works with the specialty society to create and lead a writing panel and rating panel to construct these statements.

Four preliminary recommendations constructed by the volunteer clinician workgroup for the CPG on the management of ACL injuries had no evidence. The workgroup suggested the National Athletic Trainers’ Association (NATA), the American Orthopaedic Society for Sports Medicine (AOSSM), and the American Physical Therapy Association (APTA) as the most relevant organizations to construct companion consensus statements. NATA developed two consensus statements, and the AOSSM and the APTA each developed one statement.

The statements are as follows: In the absence of reliable evidence, NATA recommends that people who sustain an acute traumatic knee joint injury with symptoms (e.g., feel or hear a pop, experience a giving way episode, pain, swelling or difficulty weight bearing) receive a physical examination by a qualified health care professional that assesses the structural integrity of the knee joint capsule, ligaments and menisci, and includes a neurovascular exam as soon as possible following injury. Immediate treatment with ice, compression, elevation, immobilization, and crutches is also indicated and patients should be referred for further musculoskeletal evaluation, unless signs and symptoms indicate that an emergent condition is present (eg, neurovascular, gross deformity, uncontrollable pain).

In the absence of reliable evidence, NATA recommends that following an acute traumatic knee joint injury, patients with an abnormal neurovascular finding on physical exam, gross deformity, or severe and uncontrollable pain should receive emergent care to include immobilization and ongoing serial assessments of neurovascular function during transport to an emergency medical facility.

In the absence of reliable evidence, AOSSM recommends that physicians consider aspirating painful, tense effusions after knee injury.

In the absence of reliable evidence, it is the recommendation of APTA that a patient with an ACL tear who is not having ACL reconstruction undergo rehabilitation with goals of (1) full and pain free-knee joint range of motion (ROM) is restored (equal to that of the contralateral limb), (2) thigh muscle strength and single-hop test indexes are at least 90 percent (ratio of involved to uninvolved limb performance), and (3) self-reported knee function on reliable, valid, and responsive questionnaires is at least 90 percent.

CPG reissue
The AAOS CPG on the treatment of diaphyseal femur fractures was originally released in 2009. AAOS CPGs are updated every 5 years. In the event that no additional evidence that would change the recommendations of the CPG has been released during that period, the CPG is reissued.

PROMs information statement
This information statement is designed to educate the AAOS membership on the importance of collecting and recording PROMs. The statement identifies key informational items for future development of measures. Among these principles are the following:

  • PROs are important to patients and providers.
  • Measuring PROs is not a research effort, but one aimed at practice improvement.
  • Patients and orthopaedic surgeons should work together to make PROs data as complete and accurate as possible.
  • The orthopaedic community, through the AAOS, should look to develop agreement on a common set of metrics.
  • Both generic and condition-specific measures of health-related quality of life should be used.
  • Members selecting survey tools for PROM acquisition should be sure that those instruments are easily administered, validated, and free to use (eg, no licensing fees for use).
  • Every effort should be made to make the gathering of PROM data as easy and reliable as possible for patients and providers.

Innovation position statement
Position statements are developed as educational tools and are based on the opinion of the authors. They are not a product of a systematic review, but a presentation of information that readers may consider and use to reach their own conclusions. The position statement on innovation and new technologies in orthopaedic surgery notes that new devices, biologics, and surgical procedures are being introduced at an increasing rate and are necessary to support continued progress in orthopaedics.

The American Academy of Orthopaedic Surgeons (AAOS) believes surgeons have an obligation to offer their patients the most efficacious, safe and cost-effective non-surgical and surgical treatments available. They should be cognizant of the scientific basis for the different treatment options offered to their patients, including the benefits and risks of an operation, device, biologic, or pharmacologic intervention. These facts should be discussed with the patient in an open manner where the patient feels no hindrance to asking questions. In addition, the surgeon and team should be proficient in the use of this new treatment, so that the final outcome is optimized in an efficient and safe manner. It is essential for the safe and effective use of new technology that appropriate training methods for surgeons be available.

Amended, retired position statements
Every 5 years, previously adopted position and information statements are reviewed by the appropriate council or cabinet, which may then recommend that the statement be revised or retired. After review by the AAOS Council on Advocacy, the position statement on the relationship between healthcare plans and trauma systems was retired because the information was being added to the revised statement on emergency orthopaedic care. Similarly, the Council on Research and Quality recommended that the information statement on wrong-site surgery be retired because the information was supplanted by the information statements on confirmation and consistency, approved by the Board at its March 2015 meeting.

Position statements on the financing of graduate medical education, emergency orthopaedic care, and principles of Medicare reform and access to specialty care were revised.

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

Position Statements:
Emergency Orthopaedic Care

The Financing of Graduate Medical Education

Principles of Medicare Reform

Principles of Health Care Reform and Specialty Care

Information Statements:
Surgical Site and Procedure Confirmation

Consistency for Safety in Orthopaedic Surgery