AAOS approves guideline updates to strengthen clinical decision making and patient outcomes

The AAOS Board of Directors (BoD) approved the rapid update to the 2018 Clinical Practice Guideline (CPG) for the management of Acute Compartment Syndrome, the new Appropriate Use Criteria (AUC) for the Treatment of Mid-Shaft Clavicle Fractures, and an AAOS Position Statement on Psychosocial Factors Associated with Patient Outcomes in Adult Trauma.

Management of acute compartment syndrome clinical practice guideline
The CPG was first published in 2018 and was originally developed through a U.S. Department of Defense grant in collaboration with the Major Extremity Trauma and Rehabilitation Consortium, which are not included in this update. While new studies have been published since its release, AAOS has determined the available evidence is not sufficient at this time to justify changing the guideline's scope.

Due to the limited amount of new evidence, this CPG was updated using the AAOS Rapid Updates Methodology. Rapid updates are used when the original scope of the guideline remains relevant and no significant new evidence has emerged since the last literature search. Through this process, the recommendation on operative fixation (external or internal) for the initial stabilization of long-bone fractures with acute compartment syndrome requiring fasciotomy was strengthened, shifting from a consensus recommendation to a limited recommendation based on the newly available evidence.

This CPG also retained four moderate, three limited, and seven consensus recommendations, with no change in their strength from the original guideline. More methodology details on the full AAOS CPG Rapid Update Methodology are available at www.aaos.org/quality/research-resources/methodology/

Treatment of mid-shaft clavicle fractures AUC
The AAOS Board also approved the new “AUC for the Treatment of Mid-Shaft Clavicle Fractures.” This AUC was developed using evidence-based research combined with physician clinical expertise to define key clinical indications and outline treatment options that support appropriate surgical and nonsurgical decision making for patients with mid-shaft clavicle fractures.

To build the document, the writing panel created 96 patient scenarios, each including two potential treatment options. A separate multidisciplinary rating panel composed of both specialists and nonspecialists then evaluated each scenario using a nine-point appropriateness scale:

• Appropriate: median rating seven to nine,
• May be appropriate: median rating four to six,
• Rarely appropriate: median rating one to three.

The following patient indications and classifications were then developed by the AUC writing panel:

Fracture type

• displaced (>100%) and shortened (≥2 cm)
• displaced (>100%) not shortened
• nondisplaced
• angulation >10° (medial segment relative to lateral segment)

Comminution

• Yes
• No

Age

• adolescent (post-pubescent) (<18 years)>
• adult (>18 years)

Identifiable factors that negatively affect healing or outcomes

• identifiable factors that negatively affect healing or outcomes present (e.g., poorly controlled diabetes, smoking, etc.)
• no identifiable factors that negatively affect healing or outcomes

Pre-injury activity level of the patient

• high (patients experiencing substantial stress/strain on their shoulder on a regular basis; contact sports, heavy labor jobs/activities, overhead labor activities, etc.)
• moderate (general recreational activity)
• low (low activity, regular activities of daily living)

Treatment options addressed

• nonoperative treatment
• operative treatment (including internal fixation)

Example scenario

When the following patient profile is entered into the online tool:

• Fracture type: Displaced (>100%) and shortened (≥2 cm)
• Comminution: Yes
• Age: Adult (>18 years)
• Identifiable factors affecting healing: None
• Pre-injury activity level: Moderate

The tool provides these recommendations:

• operative treatment (including internal fixation): Median rating eight — “Appropriate”
• nonoperative treatment: Median rating four — “May be appropriate”

This online tool is designed to help clinicians deliver evidence-based care for patients with mid-shaft clavicle fractures. The complete AUC, along with all tables and figures and a detailed methodology, is available at aaos.org/clavicleauc.

Psychosocial factors associated with patient outcomes in adult orthopaedic trauma position statement
Recognizing the growing evidence that mental and social health strongly affect recovery after orthopaedic trauma, the AAOS Board approved a new “Position Statement on Psychosocial Factors Associated with Patient Outcomes in Adult Orthopaedic Trauma.” The statement recommends that clinicians include key psychosocial factors in patient assessment, noting that doing so carries minimal risk.

Although most current research shows correlations rather than proven causation, the findings are consistent: Psychosocial factors are closely linked to symptom severity and functional limitations. AAOS also emphasizes that better evidence is needed to guide how these factors are screened for and evaluated.

This position is built on work from a now-retired AAOS CPG and incorporates findings from previously reviewed studies.

These updates underscore AAOS' continued focus on strengthening clinical care through timely, evidence-based guidance.