AAOS Now

Published 4/1/2019
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Terry Stanton; Kaitlyn Sevarino, MBA

Academy Issues Two Updated CPGs on PJI and Rotator Cuff Injuries

The Academy’s Board of Directors met last month during the AAOS 2019 Annual Meeting and approved two completely updated Clinical Practice Guidelines (CPGs): one on periprosthetic joint infection (PJI) and the other on rotator cuff injuries (RCIs).

Both CPGs were originally published in 2010, when the available evidence for management of those orthopaedic conditions was relatively limited and the field of evidence-based medicine itself was maturing rapidly. In the nine years since then, clinician-scientists have published thousands of papers on each topic, strengthening the evidence base supporting the new CPGs’ recommendations. Tables 1 and 2 further define the growth of available literature from 2010 to 2019, as well as the drastic increase of included articles, or supporting evidence, for both CPGs.

RCIs

The guideline on RCIs is distinguished by the large number (n = 11) of Strong recommendations (those backed by the highest-strength evidence). Among them are:

  • Both physical therapy (PT) and operative treatment result in significant improvement in patient-reported outcomes (PROs) for those with symptomatic small to medium full-thickness rotator cuff tears.
  • Although PROs improve with PT in symptomatic patients with full-thickness tears, tear size, muscle atrophy, and fatty infiltration may progress over five to 10 years with nonoperative management.
  • MRI and magnetic resonance angiography, as well as ultrasound, are useful adjuncts to clinical examinations for identifying tears.
  • Similar clinical outcomes and PROs are seen between early and delayed mobilization in patients who have undergone arthroscopic repair of small to medium full-thickness tears.
  • Among patients with high-grade partial thickness tears, there is support for either conversion to full-thickness or transtendinous/in situ repair.
  • Workers’ compensation claims are associated with poorer PROs after rotator cuff repair.

Stephen Weber, MD, cochair for the RCI CPG development group, commented that the overriding factor accounting for the improved level of evidence since 2010 was “the improvement of the evidence in general. This speaks to one of the goals of CPGs, which is to provide the impetus for future research.”

Although the CPG is supported by an impressive number of Strong or Moderate (n = 9) recommendations, Dr. Weber noted, “The strongest evidence is often the least controversial. Few surgeons would argue with the Strong recommendation for the use of MRI in the diagnosis of rotator cuff tears. Appropriately, the CPG highlights the areas where controversy persists because solid evidence is lacking.” For example, among the consensus statements (which have no evidence or conflicting evidence and are based on the development group’s clinical opinion) is a recommendation against platelet-rich plasma in nonoperative management of full-thickness tears. Another states, “Multiple steroid injections may compromise the integrity of the rotator cuff, which may affect attempts at subsequent repair.”

Dr. Weber said the most noteworthy of the recommendations is the Moderate strength statement that healed rotator cuff repairs show improved PROs and functional outcomes compared to PT and unhealed rotator cuff repairs. “This is consistent with the clinical experience of most rotator cuff surgeons,” he said. “It also changes the impetus of further research from the question of whether it is important for the tendon to heal to exploring options for improving the healing rate of surgically repaired tendons.”

He also noted that each recommendation in the CPG has a section for future research. “While the pat answer is ‘more level 1 research,’” he said, “the increased pressure on orthopaedists from all sides to practice value-based health care means that performing these studies is more than academic. The greatest deficit in developing this rotator cuff CPG has been the absence of long-term data to define treatment of rotator cuff disease.”

PJI

The new CPG for PJI expands the scope of the original 2010 AAOS guideline, which focused exclusively on the diagnosis of PJI. Some of the 2010 recommendations were revisited and strengthened by new evidence, such as an inconclusive recommendation for the use of CT scan for diagnosis being updated to a Limited recommendation in favor of that practice. Due to a dearth of available literature on risk factors for PJI, the 2010 CPG also included a consensus recommendation by the workgroup that testing strategies be catered to a patient’s higher or lower probability of PJI. The 2019 CPG parses out individual risk factors, with Moderate evidence in support of one risk factor (obesity) and Limited evidence supporting 14 others.

Among the recommendations characterized as Strong, one supports the use of three blood tests to aid in diagnosis of PJI: serum erythrocyte sedimentation rate, serum C-reactive protein, and serum interleukin-6. The workgroup also found that Moderate evidence does not support the use of two other tests: peripheral blood leukocyte count and serum tumor necrosis factor-a. Strong evidence also was found to support the diagnostic use of histopathology.

The third Strong recommendation supports that preoperative prophylactic antibiotics be given prior to revision surgery in patients at low preoperative suspicion for periprosthetic infection, particularly in those with an established diagnosis of PJI of known pathogen who are undergoing reoperation. Two other recommendations offer guidance on when use of antimicrobials may be avoided.

Creighton C. Tubb, MD, cochair of the PJI development group, commented, “The workgroup wanted to not only update the very important work done on the original product but also explore recommendations related to prevention of PJIs. So, where the original CPG focused on diagnosis, this CPG provides clinicians guidance on diagnosis and prevention of PJI, which is horribly devastating to the individual patient and a tremendous burden on the healthcare system.”

He noted that the strongest evidence is found in the area of diagnosis, which “still argues for the use of a variety of tests to reach the diagnosis.” Clinicians, he said, “should attack the diagnostic process for PJI through a multipronged strategy of blood, synovial fluid, and tissue specimen tests that we know have Strong to Moderate evidence in their utility.”

In its analysis of the literature, Dr. Tubb said, the workgroup found that “understanding the patient risk factors as well as systems in place to mitigate risk for PJI still needs a lot of work. Evidence is quite lacking in the realm of understanding the interplay of patient risk factors and preventive strategies.”

The case for CPGs

Of the Academy’s now well-established CPG initiative, Dr. Weber commented: “The CPG development process is very rigorous and often difficult to understand for those who are not familiar with it. AAOS is working to improve education around quality initiatives and how they can be utilized in the value-based healthcare system for quality improvement and regulatory support for what our surgeons do in day-to-day clinical practice. Furthermore, many treatments that we all learned historically, and applied routinely, simply have not have stood the test of rigorous analysis. New data are available almost daily, and for our members, AAOS is committed to continue to improve the analysis of our CPGs in order to stay up to date and help us serve our patients better.”

Dr. Tubb concurred: “CPGs, in general, provide an opportunity to capitalize on a comprehensive understanding of the current research,” he said. “As they are released, surgeons can lean on the work that AAOS has done to reflect on their unique practice.”

New AUC covers SSIs
During the AAOS 2019 Annual Meeting, the Board of Directors also approved new Appropriate Use Criteria (AUC) for the management of surgical site infections (SSIs). An AUC is presented via an online diagnostic tool; the SSI offering includes treatment recommendations for diagnosed SSI with or without hardware and/or biological implant present, and the new AUC supports an existing AAOS Clinical Practice Guideline, Management of SSIs.

AUCs are developed by two clinician panels—writing and voting—using the RAND/UCLA Appropriateness Method. AUCs specify when it is “appropriate” to use a procedure, based on the following explanation:

“An ‘appropriate’ procedure is one for which the expected health benefits exceed the expected health risks by a wide margin. Often, sound data are not available or do not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice. Nevertheless, physicians must make daily decisions about when to use or not use a particular procedure. AUCs facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians in order to determine the appropriateness of performing a procedure.”

To access the AUC, visit https://bit.ly/2YIs9iF.

The other cochair for the RCI CPG is Jaskarndip Chahal, MD. The other cochair for the PJI CPG is Gregory G. Polkowski, MD.

To view the full recommendations and their supporting evidence—and to access all the CPGs and Appropriate Use Criteria, visit orthoguidelines.org.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.

Kaitlyn Sevarino, MBA, is the senior manager of clinical quality and value at AAOS.