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AAOS Clinical Practice Guidelines
Instructional for Assembling a Guideline
Introduction
Table of Contents
Background ................................................................................................................................................................................ 3
List of Data Sources ....................................................................................................................................................... 3
Example Introductions from Past Guidelines .............................................................................................................. 4
Management of Hip Fractures in the Elderly CPG ................................................................................................. 4
Management of Anterior Cruciate Ligament Injuries CPG ................................................................................ 8
Background
Traditionally the construction of all guideline introductions has been completed by the guideline
workgroup chairs with help from AAOS staff. Some areas of the introduction are easier than others
to complete. For instance the patient population section is usually easier to construct than the
incidence/prevalence rates, which require some kind of evidential support (i.e. citations).
In the past, workgroup chairs have approached constructing the introduction drafts in two ways:
1) One chair creates the first draft of the introduction and passes it to the second chairs for
revisions OR,
2) The chairs agree to split up the sections and then review each other’s section after the first
drafts are compiled.
The chairs do have AAOS staff at their disposal, so if the chairs know of articles that they could cite
in the introduction (e.g. if the abstracts are found in PubMed), but do not have access to the full text
articles staff can obtain the full text articles for them. There are also helpful data sources available
for some disease topics, so the chairs are encouraged to utilize them if relevant/helpful. These
sources are listed below.
If you have any questions regarding the construction of the Introduction for your guideline or need
help gathering articles/data to support your statements, please contact Jayson Murray at
[email protected].
List of Data Sources
1. Burden of Musculoskeletal Diseases in the US (BMUS)http://www.boneandjointburden.org/
 Contains incidence/prevalence data, cost data, and other useful data relevant to
musculoskeletal diseases. Also has a report builder function that allows you to search
publicly available databases (e.g. NHDS, NHIS, etc.)
2. Healthcare Utilization Project (HCUP) - http://hcupnet.ahrq.gov/
 AHRQ-sponsored database of the National Inpatient Survey data, searchable by ICD-9 codes.
Uses hospital data for incidence/prevalence and some cost data.
3. PubMed - http://www.ncbi.nlm.nih.gov/pubmed/advanced
 Search for articles relevant to the CPG disease topic that may have cost or
incidence/prevalence data. Full texts can be obtained by AAOS staff, if needed.
Example Introductions from Past Guidelines
MANAGEMENT OF HIP FRACTURES IN THE ELDERLY CPG
(Highlighted areas indicate text that should be uniquely created for each guideline)
Overview
This clinical practice guideline is based on a systematic review of published studies with
regard to the management of hip fractures in patients over the age of 65. In addition to
providing practice recommendations, this guideline also highlights limitations in the
literature and areas that require future research.
This guideline is intended to be used by all qualified and appropriately trained physicians
and surgeons involved in the management of hip fractures in the elderly. It is also intended
to serve as an information resource for decision makers and developers of practice
guidelines and recommendations.
Goals and Rationale
The purpose of this clinical practice guideline is to help improve treatment based on the
current best evidence. Current evidence-based medicine (EBM) standards demand that
physicians use the best available evidence in their clinical decision making. To assist them,
this clinical practice guideline consists of a systematic review of the available literature
regarding the management of hip fractures in the elderly. The systematic review detailed
herein was conducted between April 2011 and September 2013 <AAOS STAFF CAN FILL
IN DATES> and demonstrates where there is good evidence, where evidence is lacking,
and what topics future research must target in order to improve the management of elderly
patients (defined as age 65 or older) with hip fractures. AAOS staff and the physician work
group systematically reviewed the available literature and subsequently wrote the
following recommendations based on a rigorous, standardized process.
Musculoskeletal care is provided in many different settings by many different providers.
We created this guideline as an educational tool to guide qualified physicians through a
series of treatment decisions in an effort to improve the quality and efficiency of care. This
guideline should not be construed as including all proper methods of care or excluding
methods of care reasonably directed to obtaining the same results. The ultimate judgment
regarding any specific procedure or treatment must be made in light of all circumstances
presented by the patient and the needs and resources particular to the locality or
institution.
Intended Users
This guideline is intended to be used by orthopaedic surgeons and physicians managing
elderly patients with hip fractures. Typically, orthopaedic surgeons will have completed
medical training, a qualified residency in orthopaedic surgery, and some may have
completed additional sub-specialty training. Insurance payers, governmental bodies, and
health-policy decision-makers may also find this guideline useful as an evolving standard of
evidence regarding management of hip fractures in the elderly. Adult primary care
physicians, geriatricians, hospital based adult medicine specialists, physical therapists,
occupational therapists, nurse practitioners, physician assistants, emergency physicians,
and other healthcare professionals who routinely see this type of patient in various
practice settings may also benefit from this guideline.
Hip fracture management is based on the assumption that decisions are predicated on the
patient and / or the patient’s qualified heath care advocate having physician
communication with discussion of available treatments and procedures applicable to the
individual patient. Once the patient and or their advocate have been informed of available
therapies and have discussed these options with his/her physician, an informed decision
can be made. Clinician input based on experience with conservative management and the
clinician’s surgical experience and skills increases the probability of identifying patients
who will benefit from specific treatment options.
Patient Population
This document addresses the management of low energy hip fractures in elderly patients
defined as those 65 years of age and older. It is not intended to address management of
patients with fractures as a result of high energy trauma or those with fractures related to
pathologic bone lesions.
Burden of Disease
The economic burden of managing elderly hip fractures was estimated at $17-20 billion in
2010.M1, M2
A typical patient with a hip fracture spends US $40000 in the first year following hip
fracture for direct medical costs and almost $5000 in subsequent years.
Costs to be considered include:
1. Direct Medical Cost
2. Long-term Medical Cost
3. Home Modification Costs
4. Nursing Home Costs
Etiology
Hip fractures in the elderly are the result of low energy trauma and often are associated
with osteoporosis/low bone mass and other associated medical conditions that may
increase the prevalence of falls.
Incidence and Prevalence
There was an estimated 340,000 hip fracture patients per year in United States in 1996
with most fractures occurring in women older than age 65 years, and an annual worldwide
incidence of approximately 1.7 million.M1, M7
Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100 000
(95% confidence interval [CI], 921.7-992.9) for women and 414.4 per 100 000 (95% CI,
401.6-427.3) for men.M1
With rising life expectancy, the number of elderly individuals and those with chronic health
conditions is increasing and it is estimated that the prevalence of hip fractures will
continue to increase. The number of people older than age 65 years is expected to increase
from 37.1 million to 77.2 million by the year 2040, and the occurence of hip fractures is
expected increase concomitantly, with an estimated 6.3 million hip fractures predicted
worldwide by 2050.M7
Risk Factors
Risk factors for sustaining a hip fracture in the elderly include, but are not limited to, low
bone mass, impaired physical function or balance, diabetes, impaired vision, and
inadequate home safety or supervision.
Emotional and Physical Impact
Elderly patients with hip fractures are at risk for:
1. Increased rate of mortality M8
2. Inability to return to prior living circumstances M8
3. Need for increased level of care and supervision M3, M4
4. Decreased quality of life M3, M4
5. Decreased level of mobility and ambulation M8
6. Secondary osteoporotic fractures including a “second or contralateral side” hip
fracture M5, M6
Potential Benefits, Harms, and Contraindications
Most treatments are associated with some known risks, especially invasive and operative
treatments. Contraindications vary widely based on the treatment administered. A
particular concern when managing hip fractures in the elderly is the potential for the
overall fracture treatment to result in increased patient mortality or decreased level of
mobility and independence (compared to status prior to hip fracture). Additional factors
may affect the physician’s choice of treatment including, but not limited to: associated
injuries the patient may present with, as well as the individual’s co-morbidities, and/or
specific patient characteristics including low bone mass and osteoarthritis. Clinician input
based on experience increases the probability of identifying patients who will benefit from
specific treatment options. The individual patient and/or their decision surrogate dynamic
will also influence treatment decisions, therefore, discussion of available treatments and
procedures applicable to the individual patient rely on mutual communication between the
patient and/or decision surrogate and physician, weighing the potential risks and benefits
for that patient. Once the patient and/or their decision surrogate have been informed of
available therapies and have discussed these options with the patient’s physician, an
informed decision can be made.
Future Research
Consideration for future research is provided for each recommendation within this document.
Review of the published literature does indicate that the men and women are different with regard
to rate of hip fracture incidence, morbidity after hip fracture and medical comorbidity profiles. Further, due to the paucity of sex segregated data reporting in published
research for this disease topic, the workgroup strongly suggests that future research studies
publish both overall results and sex segregated results. The availability of sex segregated results
will allow stratification of meta-analyzed data by sex, affording guideline developers the ability to
make specific recommendations for men and women, which may lead to improved patient care.
MANAGEMENT OF ANTERIOR CRUCIATE LIGAMENT INJURIES CPG
Overview
This clinical practice guideline is based on a systematic review of published studies on the
treatment of anterior cruciate ligament (ACL) injuries in skeletally mature and immature
patients. In addition to providing practice recommendations, this guideline also highlights
gaps in the literature and areas that require future research.
This guideline is intended to be used by all appropriately trained surgeons and all qualified
physicians managing the treatment of anterior cruciate ligament injuries. It is also intended
to serve as an information resource for decision makers and developers of practice
guidelines and recommendations.
Goals and rationale
The purpose of this clinical practice guideline is to help improve treatment based on the
current best evidence. Current evidence-based medicine (EBM) standards demand that
physicians use the best available evidence in their clinical decision making. To assist them,
this clinical practice guideline consists of a systematic review of the available literature
regarding the treatment of ACL injuries. The systematic review detailed herein was
conducted between June 11, 2011 and June 27, 2013 and demonstrates where there is good
evidence, where evidence is lacking, and what topics future research must target in order
to improve the treatment of patients with anterior cruciate ligament injuries. AAOS staff
and the physician work group systematically reviewed the available literature and
subsequently wrote the following recommendations based on a rigorous, standardized
process.
Musculoskeletal care is provided in many different settings by many different providers.
We created this guideline as an educational tool to guide qualified physicians through a
series of treatment decisions in an effort to improve the quality and efficiency of care. This
guideline should not be construed as including all proper methods of care or excluding
methods of care reasonably directed to obtaining the same results. The ultimate judgment
regarding any specific procedure or treatment must be made in light of all circumstances
presented by the patient and the needs and resources particular to the locality or
institution.
Intended Users
This guideline is intended to be used by orthopaedic surgeons and physicians managing
patients with anterior cruciate ligament injuries. Typically, orthopaedic surgeons will have
completed medical training, a qualified residency in orthopaedic surgery, and some may
have completed additional sub-specialty training. Insurance payers, governmental bodies,
and health-policy decision-makers may also find this guideline useful as an evolving
standard of evidence regarding treatment of anterior cruciate ligament injuries. Physical
therapists, occupational therapists, nurse practitioners, athletic trainers, emergency room
physicians, primary care physicians, physiatrists, physician assistants and other healthcare
professionals who routinely see this type of patient in various practice settings may also
benefit from this guideline.
ACL treatment is based on the assumption that decisions are predicated on patient and
physician mutual communication with discussion of available treatments and procedures
applicable to the individual patient. Once the patient has been informed of available
therapies and has discussed these options with his/her physician, an informed decision can
be made. Clinician input based on experience with conservative management and the
clinician’s surgical experience and skills increases the probability of identifying patients
who will benefit from specific treatment options.
Patient Population & Scope of Guideline
This document is intended for use for both skeletally immature and skeletally mature
patients who have been diagnosed with an ACL injury of the knee.
Burden of Disease
Persons who suffer ACL injuries are at increased risk for developing arthritis later in life.M9 Females
are two to eight times more likely to suffer an ACL injury compared to males.M9
Etiology
ACL rupture is typically the result of a traumatic, sports-related injury. This injury may be
contact or non-contact.
Incidence and Prevalence
The annual rate of patients who present with anterior cruciate ligament injuries has been
estimated at 252,000.M9
Risk Factors
List applicable risk factors.
Potential Benefits, Harms, and Contraindications
Most treatments are associated with some known risks, especially invasive and operative
treatments. Contraindications vary widely based on the treatment administered. A
particular concern when treating ACL injuries is routine surgical complications such as
infection, DVT, anesthesia complications, etc. Other complications associated with ACL
surgery include: postoperative loss of motion or arthrofibrosis, ongoing instability
episodes, neurovascular injury, etc. Additional factors may affect the physician’s choice of
treatment including but not limited to associated injuries the patient may present with as
well as the individual’s co-morbidities, skeletal maturity, and/or specific patient
characteristics including obesity, activities, work demands, etc.. Clinician input based on
experience increases the probability of identifying patients who will benefit from specific
treatment options. The individual patient and the patient’s family dynamic will also
influence treatment decisions therefore, discussion of available treatments and procedures
applicable to the individual patient rely on mutual communication between the patient and
the patient’s guardian (when appropriate for minor patients) and physician, weighing the
potential risks and benefits for that patient. Once the patient and patient’s guardian has
been informed of available therapies and has discussed these options with the patient and
guardian (if appropriate), an informed decision can be made.