The AAOS Clinical Practice Guidelines

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With the approval of the Academy's Board of Directors, JAAOS this year began publishing summaries of the AAOS evidence-based clinical practice guidelines (CPGs). Development of these CPGs began in 2006, when the board made a commitment to providing Academy members with evidence-based guidelines, in contrast with earlier, consensus-driven guidelines for clinical care, which were prone to bias and lacked transparency.

The initial effort was led by Joshua Jacobs, MD, former Chair of the Council on Research, Quality Assessment and Technology, and Charles Turkelson, PhD, Director of the Department of Research and Scientific Affairs. As additional AAOS staff members were assembled to assist in guideline development, the first AAOS CPG, concerning pulmonary embolism prophylaxis after total hip and total knee arthroplasty, was produced using outside consultants. A summary was published in the March 2009 issue of JAAOS.1 The next two CPGs, summaries of which appear in this month's Journal,2,3 focus, respectively, on the diagnosis and treatment of carpal tunnel syndrome. The AAOS intends to develop four CPGs annually, beginning this year. Previously approved CPGs can be viewed in their entirety at

The rationale behind the development of CPGs is to develop a series of recommendations on clinical care supported by the best available evidence. The goal is to promote best practices and improve patient outcomes. The process involves undertaking a comprehensive, systematic review of the available literature and obtaining quality input across a broad spectrum of practitioners. Each CPG undergoes formal peer review and public commentary before approval by the Board of Directors. Those who read these CPGs should be able to readily perceive the data and methods used to reach the final recommendations. Each recommendation is assigned a grade indicating the level of confidence readers can have in that recommendation. Recommendations given with high confidence are more likely to stand the test of time than are those given with lower confidence, which are more susceptible to being overturned by future research.

Hundreds of guidelines are available on many topics, produced by professional medical associations and the federal government. It is difficult for the average clinician to differentiate between a poor CPG and one that has been rigorously developed. The AAOS decision to use a strict methodology allows the guidelines to be of the highest quality. In addition, the AAOS CPGs are produced with no funding from industry, and any potential conflicts of individual work group members are disclosed. In a recent article in JAMA, Ted Epperly, MD, president of the American Academy of Family Physicians, described the AAOS recommendations on knee osteoarthritis as “balanced, fair and accurate.”4 Other medical associations are starting to notice the AAOS efforts; the American Association of Neurological Surgeons and the Congress of Neurological Surgeons recently voted to endorse the CPG Treatment of Carpal Tunnel Syndrome.

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