The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recently approved an AUC to help physicians treat patients with osteoarthritis (OA) of the knee. OA is a slowly progressing and degenerative disease that causes the joint cartilage to wear away.
In 2010, it was estimated that nearly 10 million adults had symptomatic OA of the knee, and risk factors of this condition can increase with age, especially in women. Genetics, high body mass, certain occupations or heredity also may increase one’s risk of developing this disease. Typically, patients try non-arthroplasty options for many months or years, before considering a total joint replacement surgery.
“The background for this AUC comes from the 2013 AAOS evidence-based clinical practice guideline on OA of the knee, a comprehensive review of all the available evidence,” said Michael Heggenness, MD, an orthopaedic surgeon who served as a non-voting moderator during the voting panel process. “This AUC is a tool that takes that guideline one step further; it marries the available evidence with expert medical opinion and is available at the touch of a web and mobile-based app.”
“Physicians outside of orthopaedic surgery also can benefit from this tool,” Dr. Heggenness added. “Knee pain is so common today and many patients might see their primary care doctor, rheumatologist or other physician for treatment, so we are hoping that other clinicians across medical disciplines familiarize themselves with this AUC and together we can help optimize patient care.”
This web-based app is optimized to work on a wide range of devices, including Smartphones and tablets. It allows a clinician to select a variety of patient characteristics and, once submitted, receive appropriateness recommendations for each of the treatments covered by this AUC.
What is osteoarthritis?
Osteoarthritis is a condition in which the natural cushioning between joints - cartilage - degenerates. Microtrauma (injury at a microscopic level) within the joint triggers an immune reaction, which - in an ill-fated attempt to repair the damage - causes inflammation that leads to a breaking down of cartilage tissue causing pain, swelling and deformity.
Cartilage is a firm rubbery material that covers the ends of bones in normal joints. It is primarily made up of water and proteins. The main function of cartilage is to reduce friction in the joints and serve as a “shock absorber”. The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed. It can do this because of its high water content.
When the cartilage is damaged - for example in a joint stressed by abnormal weight bearing loads - attempts by the immune system to repair the damaged cartilage cause it to swell. The cartilage becomes thin, soft and cracked, exposing the bone beneath and leading to the formation of small cysts and new outgrowths of bone called osteophytes, which further disrupt the way the joint works and aggravate the problem. The joint space becomes narrowed, further altering the mechanics and adding to the stresses within the joint. Other tissues in the joint such as the surrounding membrane (the synovium) ligaments and tendons may also be affected. This degeneration is a gradual process that may go on over many years, although there are occasional exceptions.
Osteoarthritis (OA) is divided into five stages: 0 is assigned to a normal, healthy knee. The highest stage, 4, is assigned to severe OA. OA that has become this advanced is likely causing significant pain and disruption to joint movement.
Stage 0 OA is classified as “normal” knee health. The knee joint shows no signs of OA, and the joint functions without any impairment or pain.
No treatment is needed for Stage 0 OA.
A person with Stage 1 OA is showing very minor bone spur growth. (Bone spurs are boney growths that often develop where bones meet each other in the joint.) Likely, a person with Stage 1 OA is not experiencing any pain or discomfort as a result of the very minor wear on the components of the joint.
Without outward symptoms of OA to treat, many doctors will not require patients to undergo any treatments for Stage 1 OA. However, if you have a predisposition to OA or are at an increased risk, your doctor may recommend you take supplements, such as glucosamine and chondroitin, or begin an exercise routine to relieve any minor symptoms of OA and slow the progression of the arthritis.
Treatment appropriateness is determined by three separate panels of clinicians who represent a variety of medical disciplines:
- The writing panel combined clinical expertise with evidence-based information from the AAOS Evidence Based Clinical Practice Guideline on Treatment of Osteoarthritis of the Knee to create a list of patient indications, assumptions, and treatments.
Scenarios ranged from a 25-year old patient with post-traumatic OA of the knee who wants to continue playing baseball, to an 80-year old patient who wants to continue walking with his grandchildren to the park.
- The review panel provided suggestions regarding improvement of the materials constructed by the writing panel.
- The voting panel utilized clinical expertise from multiple medical specialties and evidence-based information to assign the appropriateness of various treatments for each of the patient scenarios, using a 9-point appropriateness scale.
Stage 2 OA of the knee is considered a “mild” stage of the condition. X-rays of knee joints in this stage will reveal greater bone spur growth, but the cartilage likely remains at a healthy size - the space between the bones is normal, and the bones are not rubbing or scraping one another. Synovial fluid is also typically still present at sufficient levels for normal joint motion. However, this is the stage where people may first begin experiencing symptoms - pain after a long day of walking or running, greater stiffness in the joint when it’s not used for several hours, tenderness when kneeling or bending.
Talk with your doctor about your possible signs of OA. He or she may be able to detect and diagnose the condition at this early stage. If so, the two of you can develop a plan to prevent the condition from progressing rapidly.
“The panels put tremendous thought into this AUC with careful analysis of appropriate care both through the published literature and extensive clinical experience” said James Sanders, MD, AAOS AUC Section Leader who also served as a non-voting moderator.
The panels came up with 10 different treatment options across 576 patient scenarios. Out of more than 5,700 different patient/treatment combinations:
53 percent were rated as “Appropriate”
29 percent were rated as “May Be Appropriate”
18 percent were rated as “Rarely Appropriate”
“AUC’s can provide a useful framework for surgeons and their patients to consider the appropriateness of various treatment options, based on the medical evidence and the opinion and experience of experts,” added Kevin Bozic, MD, MBA, chair of the AAOS Council on Research and Quality. “However, in addition to the medical evidence, any treatment decision should also take into consideration the physician’s experience and expertise, and the patient’s preferences and values.”
Additional AUCs covering a variety of orthopaedic conditions, diseases, and diagnostic procedures will soon follow. Rotator cuff treatment and distal radius fracture AUC’s already are available. The complete AUC document, along with a list of panel members is available online at http://www.aaos.org/auc.
Funding for this AUC was provided by AAOS. Development of AUC is overseen by the AUC section of the Evidence-Based Quality and Value Committee and the Council on Research and Quality.
Volunteers from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment. Practitioners are advised to consider management options in the context of their own training and background and institutional capabilities
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American Academy of Orthopaedic Surgeons