The Academy's roster of Appropriate Use Criteria (AUC) has grown by three, with the addition of two online applications covering management of hip fractures in the elderly (acute treatment and postoperative rehabilitation of low-energy hip fractures) and one for treatment of pediatric patients with osteochondritis dissecans (OCD) of the femoral condyle. The AUC were approved at the December 2015 meeting of the AAOS Board of Directors.
A new feature of the two ACU covering hip fractures is the addition of checklists on preoperative considerations and perioperative measures for prevention of future fractures. All materials can be easily accessed at the OrthoGuidelines website (www.orthoguidelines.org).
AUC are algorithm-style applications that incorporate evidence and recommendations from previously developed Clinical Practice Guidelines (CPGs). Physicians enter information about the patient's condition and characteristics, and the application responds with treatment recommendations appropriate for the scenario.
All AUC apps open to a set of assumptions and disclaimers applicable to the condition and the patient. For the AUC on acute treatment of hip fractures in the elderly, for example, the module specifies that the "elderly" patient is age 60 or older and has been optimized for surgical intervention. In addition, it notes that a restrictive blood transfusion trigger (hemoglobin < 8) is observed, based on the AAOS CPG on Management of Hip Fractures in the Elderly.
The AUC for the postoperative rehabilitation specifies that the recommendations only cover cases of single, low-energy isolated hip fractures and that the outcome of surgery for the fracture was successful; it also summarizes risk factors and general considerations.
The AUC for OCD treatment describe a number of specific assumptions and caveats concerning symptoms, imaging findings (such as a plain radiograph definition of instability—whether a fragment is partially or totally displaced) and specific guidance on MRI findings dependent on whether the patient has open or closed physes). It also notes conditions for which the tool is not applicable, including some types of irregular epiphyseal ossification and several epiphyseal dysplasias such as dwarfing syndrome and genetic syndromes that may mimic OCD.
When patient characteristics and findings are entered into the application, an AUC provides recommendations ranked by levels of appropriateness. A color-coded numeric value is used, with 1–3 being "rarely appropriate" (red icon); 4–6 signifying "may be appropriate" (yellow); and 7–9 as "appropriate" (green).
Relation to CPGs
"What these AUC offerings do is delineate, in a very easy manner, the most appropriate treatments in each category," said Robert Quinn, MD, AUC Section Leader for the AAOS Committee on Evidence-Based Quality and Value (EBQV Committee). "The physician can plug in the patient's specific circumstances, and the AUC highlight where the evidence matches the recommendation."
That evidence derives from the CPG that precedes the creation of an AUC. AUC combine the findings contained in a CPG and a survey of expert opinion to yield a functional tool for clinical practice, explained David Jevsevar, MD, MBA, chair of the AAOS EBQV Committee.
"CPGs tell us if something works or doesn't work, or that we don't know," he said. "The AUC tell us when it works and in whom we should consider using it." He used an example from the recently released CPG on Surgical Management of Osteoarthritis of the Knee (SMOAK) (See "Evidence Bolsters Recommendations in New CPG.")
"In creating the AUC, only the positive recommendations are included. Because the SMOAK CPG says drains don't work in knee replacement, drains as a treatment option won't be included in the AUC when it is developed.
"AUC fill in the gray areas," he continued. "Because the SMOAK CPG says that the evidence for using antibiotic cement is limited, people will want to know when it should be used. So the AUC will address that question."
The evidence issue
The three newly released AUC also reflect the differences in the body of evidence for various musculoskeletal conditions. Fractures of the hip in the elderly are a widespread problem and the subject of considerable research. OCD is a rarer phenomenon with a less-definitive base of knowledge to guide its management. Several recommendations in the CPG on OCD issued by the AAOS in 2010 were based on physician opinion in the absence of reliable evidence.
"There is no magic bullet for this poorly understood condition," Dr. Quinn said. "It is very challenging to find consensus about appropriate treatment because evidence of what leads to good outcomes is inconclusive. These criteria are the best attempt to narrow down what treatment methods under what conditions are effective so far."
Echoing the sentiment, Dr. Jevsevar said, "The OCD is an important AUC because we didn't have much evidence, so this at least gives our members some guidance on what to consider."
For a number of OCD scenarios (the patient with pain, mechanical symptoms, open growth plates, and imaging showing a stable fragment), excision of the fragment is not recommended. Instead, nonsurgical therapies such as bracing and restricted weight bearing are favored, as is drilling of an intact lesion and fixation with or without bone grafting.
The AUC on acute treatment for hip fractures in the elderly provide recommendations on which procedures are recommended for various scenarios. For example, in a patient with a nondisplaced femoral neck fracture (Garden 1 or 2), a high level of function and/or high demand, and no preexisting or sympathetic arthritis, multiple screw fixation is noted as an "appropriate" treatment, hemiarthroplasty is in the yellow "may be appropriate" category, and total hip arthroplasty (THA) is rated "rarely appropriate." For a patient with a similar fracture and functional level, but with preexisting and symptomatic arthritis, both THA and screw fixation are considered "appropriate."
The hip fracture AUC on postoperative/rehabilitative includes recommendations on the following:
- interdisciplinary care to prevent deep vein thrombosis
- prevention or management of postoperative delirium
- multi-modal perioperative pain management
- interdisciplinary management of recovery at rehabilitation and skilled-nursing facilities
- home care therapy following discharge
- osteoporosis assessment and management.
The accompanying checklists for the two hip fracture AUC provide a resource both in the fracture management phase and in the crucial effort to prevent future fracture. The preoperative checklist counsels against using preoperative traction, addresses management of blood-thinning medication, and initiates predischarge consideration of the home environment.
The postoperative and prevention instrument covers topics such as osteoporosis therapy, including alternatives to bisphosphonates, and fall prevention strategies.
"It is important to think ahead to make the right choices for care after a fracture is repaired," said Dr. Quinn.
Terry Stanton is a senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org
Diagnosis and Treatment of Osteochondritis Dissecans AUC
Hip Fractures for Elderly Patients: Treatment AUC
Hip Fractures for Elderly Patients: Postoperative/Rehabilitation AUC
Hip fractures in the Elderly: Preoperative Checklist