AAOS Board approves treatment criteria for carpal tunnel syndrome and knee osteoarthritis

December 12, 2016

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors has approved new Appropriate Use Criteria (AUC) for the management of carpal tunnel syndrome (CTS) and the surgical management of osteoarthritis of the knee. The AUCs provide specific diagnostic criteria, complementing and building upon the clinical practice guidelines (CPGs) "Management of Carpal Tunnel Syndrome" and "Surgical Management of Osteoarthritis of the Knee." The CPGs and AUCs are available at OrthoGuidelines.org.

"Appropriate Use Criteria for the Management of Carpal Tunnel Syndrome" provides 135 diagnostic scenarios to assist and other clinicians in determining whether or not a patient has CTS, and if so, the optimal treatment—from non-operative, such as a splint or a steroid injection, to surgery.

Carpal is a common condition that causes pain, numbness, and tingling in the hand and arm. The condition occurs when one of the major nerves in the hand—the median nerve—is squeezed or compressed due to hand and wrist overuse. A variety of conditions such as diabetes, rheumatoid arthritis and thyroid gland imbalance also can cause or exacerbate CTS.

The AUC scenarios include patient-reported pain and impairment, and whether or not an examination and/or electrodiagnostic testing were performed and the outcomes.

"Carpal tunnel is a complex diagnosis," said Robert H. Quinn, MD, AUC Section Leader on the Committee on Evidence-Based Quality and Value. "With a very common condition like , which has seen a significant variation in the approach, diagnosis and treatment, the AUC succinctly directs the provider toward a fairly narrow and evidence-based decision making and treatment pathway."

When there is insufficient evidence to support CTS, "the decision making shifts to investigating alternative diagnoses," said Dr. Quinn.

AUC on surgical management of osteoarthritis of the knee

"Appropriate Use Criteria for the Surgical Management of Osteoarthritis of the Knee" looks at three types of surgical treatment—total replacement (TKR), unicompartmental knee replacement (partial replacement of the knee joint), and realignment osteotomy (cutting and reshaping either the tibia/shinbone or femur/thighbone to relieve pressure on the knee joint)—and the scenarios when each is appropriate.

Osteoarthritis is a degenerative "wear-and-tear" type of arthritis, in which the cartilage gradually wears away, affecting approximately 26 million Americans. Osteoarthritis develops slowly and the pain typically worsens over time.

The knee AUC includes 864 scenarios that take into account pain, knee instability, patient age, and extension, the number of knee compartments affected, and varus/valgus (the direction that the distal segment of the joint points). For the most part, the criteria lean more toward TKR in older patients, and to unicompartmental surgery and realignment osteotomy in younger patients and those with more limited osteoarthritis.

"The younger you are the longer you will have to live with the treatment, and a higher likelihood that your treatment will have to be revised," said Dr. Quinn. "We want to preserve as much of the normal anatomy as possible for as long as possible."

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