This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
The coronavirus epidemic has caused all of us to “rethink” many things. Several days ago, a radiologist asked me whether 3 of my requested imaging studies were high priority in light of the pandemic. My response was, “God bless you. No, none of those is urgent.”
I am 79 years old and think back to my first year of orthopaedic residency, 1968. In 2020, the expectation among many patients is for immediate relief, and many orthopaedists try to deliver that. Whatever “new normal” emerges after the COVID-19 surge subsides, how will patients and physicians work together to arrive at a decision when to proceed to a knee replacement? Although knee replacement can result in pain and function salvation for patients with end-stage knee osteoarthritis, as many as 20% of patients report “unsatisfactory” results.
A recent “appropriateness” analysis of data from 2 multicenter cohort studies classified 3,417 potential knee replacements as follows:
- Timely—total knee replacement took place within 2 years after the procedure had met “potentially appropriate” criteria
- Potentially Appropriate but Not Replaced (for >2 years after the procedure had met appropriateness criteria)
- Premature—a replacement that the authors deemed inappropriate but was performed anyway.
The authors found that surgery for 9% of the knees for which replacement was potentially appropriate took place in a “timely” manner. But overall, there was a high prevalence of both delayed and premature surgery. Specifically, 91% of the knees for which replacement was potentially appropriate were not replaced, and 26% of the 1,114 total knee replacements that were performed were considered to be “likely inappropriate” and therefore “premature.”
The likelihood of a knee being classified as potentially appropriate but not undergoing replacement was greater among black patients, and the likelihood of having premature total knee replacement was lower among participants with a body mass index of >25 kg/m2 and those with depression.
In a Commentary on this study, Michael G. Zywiel, MD noted that the Escobar appropriateness criteria used in the analysis focuses predominantly on physician-assessed rather than patient-assessed factors. This all begs the question: Now that we have joint-replacement tools that we could not even dream of in 1968, how do we as responsible surgeons help guide our patients in deciding when the time is right to use them?
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.
Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.
It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.
The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”
However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.
For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.
But perhaps the most compelling question is — why do we need an AUC app in the first place? Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories? And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.
However, there is another, critically important theme to the AUC story. Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide. As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.” If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.
With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome. More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.
Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.
Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD and Grigory Gershkovich, MD.
The AAOS recently reviewed the evidence for surgical management of osteoarthritis of the knee (SMOAK) and issued a set of appropriate use criteria (AUC) that help determine the appropriateness of clinical practice guidelines (CPGs). These AUC can be accessed on the OrthoGuidelines website: www.orthoguidelines.org/auc.
The AUC were developed after a panel of specialists reviewed the 2015 CPGs on SMOAK and made appropriateness assessments for a multitude of clinical scenarios and treatments. The panel found 21% of the voted-on items “appropriate”; 25% were designated “maybe appropriate,” and 54% were ranked as “rarely appropriate.”
Importantly, these AUC do not provide a substitute for surgical decision making. The physician should always determine treatment on an individual basis, ideally with the patient fully engaged in the decision.
This OrthoBuzz post summarizes some of the updated conclusions according to three clinical time points—pre-operative, peri-operative, and postoperative—specifying the strength of supporting evidence. This post is not intended to review appropriateness for every clinical scenario. We encourage physicians to explore the OrthoGuidelines website for complete AUC information.
Strong evidence: Obese patients exhibit minimal improvement after total knee arthroplasty
(TKA), and such patients should be counseled accordingly.
Moderate evidence: Diabetic patients have a higher risk of complications after TKA.
Moderate evidence: An 8-month delay to TKA does not worsen outcomes.
Strong evidence: Both peri-articular local anesthetics and peripheral nerve blocks decrease postoperative pain and opioid requirements.
Moderate evidence: Neuraxial anesthesia may decrease complication rates and improve select peri-operative outcomes.
Moderate evidence: Judicious use of tourniquets decreases blood loss, but tourniquets may also increase short-term post-operative pain.
Strong evidence: The use of tranexamic acid (TXA) reduces post-operative blood loss and the need for transfusions.
Strong evidence: Drains do not help reduce complications or improve outcomes.
Strong evidence: There is no difference in outcomes between cruciate-retaining and posterior stabilized implants.
Strong evidence: All-polyethylene and modular components yield similar outcomes.
Strong, moderate, and limited evidence to support either cemented or cementless techniques, as similar outcomes and complication rates were found.
Strong evidence: There is no difference in pain/function with patellar resurfacing.
Moderate evidence: Patellar resurfacing decreases 5-year re-operation rates.
Moderate evidence shows no difference between unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).
Moderate evidence favors TKA over UKA to avoid future revisions.
Strong evidence against the use of intraoperative navigation and patient-specific instrumentation, as no difference in outcomes has been observed.
Strong evidence: Rehab/PT started on day of surgery reduces length of stay.
Moderate evidence: Rehab/PT started on day of surgery reduces pain and improves function.
Strong evidence: The use of continuous passive motion machines does not improve outcomes after TKA.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.
Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science.
The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children. The authors performed detailed chart reviews on 361 patients treated for a pediatric diaphyseal femoral fracture between 2007 and 2012. They analyzed each patient record to determine whether age-specific CPGs—which were published for this condition in 2009—were followed.
The results are somewhat discouraging. Oetgen et al. identified little if any impact of the CPG on clinical practice. Is that because surgeons are unaware of these tools? Or do they feel they know better than the literature synthesis at their disposal? Without more research, we will not know the answer to that question, but I suspect that recognition of the utility of CPGs will take a decade at least. I have the impression that younger surgeons are more accepting of the concepts of meta-analysis and levels of evidence as they influence clinical decision making—and as they were utilized to develop CPGs. Waiting longer to make judgments about the impact of CPGs seems appropriate.
There is another factor also. These documents are guidelines, not restrictive formulas. Oetgen et al. emphasize that point in their introduction. Physicians everywhere wish to retain the privilege of making the best educated decision for each patient and family; this fact is partly responsible for the pushback that AAOS leadership received when starting down the CPG path. Additionally, during decision making for children with femoral shaft fractures, parental preferences will play a very strong role, regardless of the guidelines. This reality may ultimately limit efforts to accurately measure the clinical impact of CPGs by analyzing administrative databases.
So let’s give these guidelines a little more time to mature, and let’s give our orthopaedic community more time to become familiar with the utility of these documents. And, above all, let’s not turn guidelines into “cookbook” patterns of clinical decision making. Inputs from the treating physician, patient, and family should always be preeminent.
Marc Swiontkowski, MD