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Appropriate use criteria for care of trauma patients. Guidelines by AAOS.

The American Academy of Orthopaedic Surgeons released a series of new clinical practice guidelines and appropriate use criteria to offer guidance on diagnosis and management decisions for trauma patients. These guidelines and appropriate use criteria were created as part of the Major Extremity Trauma and Rehabilitation Consortium, a volunteer workgroup of musculoskeletal trauma surgery experts, military surgeons, and AAOS research staff.

“This collaboration was a fruitful example of many stakeholders in musculoskeletal healthcare working together to achieve a common goal,” added Benjamin J. Miller, MD, FAAOS, with the University of Iowa’s Department of Orthopaedics and Rehabilitation.

 

“The assembled work group not only informed the discussion with many different perspectives on patient management, but also represented a comprehensive cross section of the important musculoskeletal issues and goals in the care of patients with traumatic extremity injuries.”

Approximately 2 million individuals in the United States are living with limb loss, with nearly one half of those due to trauma and a substantial majority of trauma-related amputations involving the lower extremity. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances. Practitioners are advised to consider management options in the context of their own training and background and institutional capabilities. 

The full CPGs (clinical practice guidelines) and AUCs (appropriate use criteria) are intended for reference by orthopedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website.

New clinical practice guidelines

According to a press release from the AAOS, clinical practice guidelines for limb salvage or early amputation and evaluation of psychosocial factors that can influence recovery from adult orthopedic trauma are included in the treatment tools. The limb salvage or early amputation clinical practice guideline specifies factors that should weigh heavily on an initial decision to amputate, as well as findings that should inform subsequent discussions with patients but not necessitate an acute amputation. The release noted this clinical practice guideline also defines the important criteria that may make lower extremity limb salvage more or less advisable in the short term, providing physicians with the guidance necessary to have an informed and data-driven conversation with patients for an eventual expectation of function and potential complications with either treatment pathway.

Psychosocial factors that influence clinical, functional and quality of life recovery following military and civilian adult orthopedic trauma based on a formal systematic review of published studies are also addressed, according to the AAOS. The clinical practice guideline suggests a shift toward a holistic, interdisciplinary approach through evaluation of anxiety, PTSD, depression, premorbid psychiatric conditions, smoking, lower education level, social support and resilience issues.

New appropriate use criteria

The release also noted new appropriate use criteria that provide algorithms for clinicians on how to optimally treat limb salvage or early amputation that are ranked for appropriateness based on the latest research, clinical expertise and experience. Seven indication profiles that cover lower extremity injury variables, including the limb site, type and severity of the injury, the presence and degree of contamination and comorbidities, are offered and, when selected, provide a recommendation for salvage or amputation.

The AAOS also released appropriate use criteria that stem from recommendations in clinical practice guidelines for the diagnosis and management of acute compartment syndrome, which can occur after a severe injury to a limb. The resource provides an algorithm-style tool for choosing management pathways based on the patient’s presenting indications as entered by the physician, according to the release.

“The development of new [clinical practice guidelines] CPGs and [appropriate use criteria] AUCs stem from the first-ever grant awarded to the AAOS from the U.S. Department of Defense,” Kevin G. Shea, MD, chair of the AAOS Committee on Evidence-Based Quality and Value, said in the release.

“The trauma-related injury topics identified through the grant were areas in which significant variation in orthopedic emergent care existed. We sought to provide physicians with a measure of when, how and for whom medical and surgical procedures should be used when dealing with traumatic extremity injuries to better optimize patient care — whether civilian traumatic events such as motor vehicle accidents or military scenarios.”

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