AAOS releases appropriate use criteria for management of glenohumeral OA
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Key takeaways:
- The American Academy of Orthopaedic Surgeons has released two new appropriate use criteria.
- The recommendations included indications and scenarios for managing patients with glenohumeral joint osteoarthritis.
The American Academy of Orthopaedic Surgeons has released two new appropriate use criteria to address clinical scenarios for physicians when managing patients with glenohumeral joint osteoarthritis.
According to an AAOS press release, the new appropriate use criteria (AUC) are designed for patients with glenohumeral joint OA who are presumed to have failed nonoperative treatment with an intact rotator cuff and no conditions that would limit their ability to undergo total shoulder arthroplasty (TSA).
The first AUC is for humeral component design during primary TSA. The second AUC is for the treatment of shoulder OA with an intact rotator cuff and severe glenoid retroversion.
Other patient scenarios and surgical recommendations from the AAOS can be found at: www.orthoguidelines.org/go/auc.
Perspective
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AUC specify when it is appropriate to perform a medical procedure or service, such as a knee replacement, clavicle fixation or an MRI. An “appropriate” procedure is one for which the expected health benefits substantially exceed the expected health risks. Ideally, AUC are evidence-based, but when the evidence is insufficient it may be directed by a consensus of experts. Medical specialty societies develop and disseminate AUC, which are typically classified in terms of the quality of the evidence on which they are based. AUC are scored from one to nine, where seven to nine is “appropriate” and four to six “may be appropriate.”
The AAOS has just released AUC for shoulder osteoarthritis, specifically for selection of humeral component design in anatomic TSA and for selection of surgical treatment for shoulder OA with an intact rotator cuff and severe glenoid retroversion. These two topics are certainly “hot,” so the release of these AUC is timely.
Regarding the selection of humeral component design (stem length) in anatomic TSA, there has been a global trend toward stemless humeral components, but good initial fixation in bone is needed, just as for stemmed implants. The AUC favored stemmed implants over stemless for cases of osteonecrosis, presumably because osteonecrosis may affect the metaphyseal bone. However, some cases of osteonecrosis are focal and arise following fracture malunion, so they are ideally suited for a stemless implant. The AUC for the treatment of shoulder OA in the setting of an intact rotator cuff and severe glenoid retroversion focused on the most common treatment options, but completely excluded one evidence-based option for young and active patients: the ream and run procedure comprising hemiarthroplasty with concentric glenoid reaming. Still, it is obvious that key thought leaders put a great effort into these AUC.
Overall, the AAOS needs to continue leading the charge in determining what is most appropriate and what is not for orthopedic surgeons and the patients we treat. But we should not forget that AUC are mere guidelines and exceptions abound because every patient is unique and cannot be described adequately by five or six features. Moreover, these AUC underscore the need for more robust level I evidence to help guide treatment and refine these AUC. I suspect that, someday, new AUC will be optimized using artificial intelligence processes rather than by expert opinion.
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