CPGs and AUCs Address Combat and Civilian Traumatic Orthopaedic Injuries

The American Academy of Orthopaedic Surgeons (AAOS) released a series of new Clinical Practice Guidelines (CPG) and Appropriate Use Criteria (AUC) to help physicians who treat combat and civilian trauma patients.

The new materials are intended to offer guidance on diagnosis and management decisions for adult patients with severe extremity trauma. Each was created as part of a joint effort between a volunteer workgroup of musculoskeletal trauma surgery experts, military surgeons, and AAOS research staff – part of the Major Extremity Trauma and Rehabilitation Consortium.

“The development of new CPGs and AUCs stem from the first-ever grant awarded to the AAOS from the US Department of Defense,” explained Kevin G. Shea, MD, chair of the AAOS Committee on Evidence-Based Quality and Value.


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“The trauma-related injury topics identified through the grant were areas in which significant variation in orthopaedic 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.”

Highlights of the treatment tools include:

  • CPG for limb salvage or early amputation. This CPG specifies the factors that should weigh heavily on an initial decision to amputate (survival of the patient and resuscitative efforts), and findings that should inform subsequent discussion with the patient, but not necessitate an acute amputation (vascular or nerve status, injury scores, and smoking status). It also defines the important criteria that may make lower-extremity limb salvage more or less advisable in the short term. These characteristics will help physicians have an informed and data-driven conversation with patients as to the eventual expectations of function and potential complications with either treatment pathway.
  • AUC for limb salvage or early amputation. The AUC online tool provides algorithms on how to optimally treat the injury or condition, including hypothetical scenarios and possible treatments ranked for appropriateness based on the latest research, clinical expertise, and experience. The limb salvage AUC offers 7 indication profiles covering lower-extremity injury variables including the limb site (leg, foot/ankle, or both), type and severity of injury, presence and degree of contamination, and comorbidities. When these parameters are selected, a recommendation is provided with regard to salvage or amputation.
  • CPG for evaluation of psychosocial factors influencing recovery from adult orthopaedic trauma. Based on a formal systematic review of published studies, this CPG addresses psychosocial factors influencing clinical, functional, and quality-of-life recovery following military and civilian adult orthopaedic trauma. It recommends that clinicians shift toward a holistic, interdisciplinary approach evaluating the following factors: anxiety, PTSD, depression, premorbid psychiatric conditions, smoking, lower education level, social support, and resilience issues.
  • AUC for the diagnosis and management of ACS. Acute compartment syndrome (ACS) is a potentially devastating complication that can occur after a severe injury to a limb, such as in a motor vehicle collision, and that requires prompt and accurate diagnosis to prevent permanent disability and tissue death. This resource provides clinicians with an algorithm-style tool for choosing management pathways based on the patient’s presenting indications, as entered by the physician..

“This collaboration was a fruitful example of many stakeholders in musculoskeletal healthcare working together to achieve a common goal,” said Benjamin J. Miller, MD, FAAOS, from 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.”

The full CPGs and AUCs are intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’s OrthoGuidelines website and free mobile app.

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