46 AAOSNow January2011 ResearchandQuality ResearchandQuality January2011 AAOSNow 47

foundwidevariationsinsurgeonpreferences.

Inthiscontext,theAAOSas-sembledanevidence-basedClinicalPracticeGuideline(CPG)workgrouptoidentifythemostimpor-tantquestionsfortreatmentoftherotatorcuffandthebestevidenceavailabletoassistorthopaedicsur-geonsindeterminingthebeststan-dardofcare.

Fourteen recommendationsTheCPGworkgroupformedforoptimizingthemanagementofrotatorcuffproblemsidentified14recommendationsthataddressnonsurgicaltreatment,surgicalin-dications,andpostoperativetreat-ment(Table1).Theworkgroupconsideredthefollowingissues:1.Decision-makingforasymptom-

aticpatientswithfullthicknesstears

2.Indicationsfornonsurgicaltreatmentinpatientswithsymptomatictears

3.Therelativeroleofphysicaltherapy,steroidinjections,anti-inflammatories,andothermodalitiesfornonsurgicaltreatment

4.Indicationsforrotatorcuffrepair

5.Theroleofprognosticfactors6.Thebestpractice,rehabilitation

principlesAdjunctsurgicalissues—suchas

theuseofbonetunnelsorsutureanchorsandtheadditionofbiolog-icstoenhancehealing—werealsoaddressed.

Althoughtheworkgroupini-tiallyevaluatedanextensivebodyofliterature—morethan4,000articles,theyfoundveryfewthatactuallymettheAAOScriteriaforevidence.Asaresult,ofthemulti-plerecommendationsintheguide-line,nonecarrya“strong”grade.

Becausetheworkgroupbrokeseveraloftherecommendationsintodifferentparts,thefinalCPGhas31totalrecommendations—4classifiedwithamoderategrade,6withaweakgrade,and19asinconclusive.Inaddition,tworec-ommendationscarryaconsensusofexpertopinion,madeintheab-senceofanyreliableevidenceandafterconsideringtheknownharmsandbenefitsassociatedwiththetreatment.

Unfortunately,theabsenceofevidencewasthemostimportantfindingofthisguidelineprocess.Itiscertainlyconsistentwiththemultiplecontroversiessurroundingrotatorcuffdiseaseaswellaswiththewidevariationsseenintreat-ment.Alinktothesummaryofrecommendations,thefullguide-

lines,andsupportingdocumentscanbefoundontheAAOSWebsite(www.aaos.org/guidelines).

Theworkgroupstronglyrecom-mendsthatpractitionersnotrelysolelyonthesummary,butthattheyalsoconsultthefullguidelineandevidencereport.Treatmentdecisionsforanindividualpatientdependonthatpatient’scircum-stancesandmutualcommunicationbetweenthepatientandthetreat-ingpractitioner.

Need for future researchThisevidence-basedprocessunder-scoresthestrongneedforqualityevidencethatorthopaedicsurgeonscanrelyoninprovidingclinicalcaretopatientswithrotatorcuffdisease.Giventheclinicalimpor-tanceofrotatorcuffdisease,theabsenceofgoodevidencerepre-sentsaseriousknowledgedeficit.

Theissueregardingevidencewasnotvolume-related—itwasrelatedtoqualityproblems.Al-thoughanumberofresearchpub-licationsexistonthetreatmentoftherotatorcuff,theoverallqualityofthestudieswasdisappointing,givenmoderncriteriaforgoodevidence.Thelackofprevious,high-levelresearchdoesnotneces-sarilydisprovepreviousfindingsorunderminecurrentstandardofcarepractices.Itisentirelypos-siblethathigherlevelstudieswillsimplyconfirmtheuseofpopulartreatmentstrategiessuchassteroidinjections,tendon-to-bonerepairof

rotatorcuffs,andphysicaltherapy.Additionally,nohigh-levelstudiesrefutedcurrentpopulartreatmentpractices;however,futurehigh-levelresearchwillbeimportanttoimproveconfidenceinspecifictreatmentpracticesandtobetterstandardizecare.

Theworkgroupconcludedthathigherqualityresearchthatad-dressesthemostimportantissuesofrotatorcufftreatmentisneeded.Inparticular,thefollowingareaswouldbenefitfromhighqualityLevel1orLevel2studies:1.Identifyingriskfactorsforpro-

gressionofrotatorcuffdisease.Somerotatorcufftears,bothpartialandfull-thickness,willenlargeordegeneratewithtime.Becauseearlytreatmentinter-ventioninthesecasesmaybeimportant,identifyingriskfac-torsisanessentialpartoffor-mulatingtreatmentindications.

2.Determiningtheeffectivenessofmultiple,commonlyemployednonsurgicaltreatmentmea-sures,suchastheuseofsteroidinjectionsoranti-inflamatorymedicationsonthelong-termprognosisofconservativeman-agementofrotatorcufftears.

3.Establishingwhetherandinwhomrotatorcuffhealingisimportant.Rotatorcuffrepairandhealingaregenerallythegoalsofsurgicaltreatment;however,somepatientshavegoodresultseventhoughtheteardoesnotheal.Identifyingwhorequireshealingandwho

doesnotwillbeimportanttodeterminingwhattypeofsurgi-caltreatmentisnecessary.

4.Determiningtheoptimalreha-bilitationprotocolafterrotatorcuffrepair.Issuessuchaswhentostartmotion(earlyvs.de-layed)andwhentostartresis-tiveexercisesarestillcontroversial.

5.Determiningthepreferredsur-gicalrepairstrategy.Multipleoptions,suchasdoublerowvs.singlerowrepair,arestillcon-troversial.Evidenceisneededtobetterstandardizerepairmethods.

6.Increasingourunderstandingoftheroleofcomorbidities—suchasage,diabetes,orsmokinghistory—ontheprognosisafterrotatorcuffrepair.Thesefactorscanaffectsurgicalindications.

7.Determiningthebestsurgi-calpracticetotreatthelarge,chronictearthathasalowerlikelihoodofhealingafterre-pair.Theserepairsmaybenefitonlyfromdébridementor,con-versely,fromlargerreconstruc-tionssuchastendontransfersortheuseofbiologics.NOW

Disclosureinformation:Dr.Yamaguchi—PrimaryInvestiga-torNIH-RO1grantontherotatorcuff;royaltiesfromTornier(totalelbowimplant)andZimmer(totalshoulderimplant).

KenYamaguchi,MD,servedasvice-chairoftheworkgroup.

HowtheguidelinescametobeTheClinicalPracticeGuidelineonOptimizingtheManagementofRotatorCuffProblems,ad-optedbytheAAOSBoardofDirectorsattheirDecember2010meeting,wasdevelopedbyamul-tidisciplinaryvolunteerworkgroupthatincludedorthopaedicsurgeonswhopracticeinavarietyofsettings,alongwithassistancefromtheAAOSguidelinesunit.TheyincludedRobert A. Pedowitz, MD, PhD, chair;Ken Yamaguchi, MD,vice-chair;Christopher S. Ahmad, MD; Robert T. Burks, MD; Evan L. Flatow, MD; Andrew Green, MD; Joseph P. Iannotti, MD, PhD; Bruce S. Miller, MD, MS; Robert Z. Tashjian, MD; William C. Watters III, MD;Kristy L. Weber, MD; CharlesM.Turkelson,PhD;JanetL.Wies,MPH;SaraAnderson,MPH;JustinSt.Andre,MA;PatrickSluka,MPH;KevinBoyer,LauraRaymond,MA;andKristinHitch-cock,MSI. Amongthegroupsthatparticipatedinpeerre-viewofthisguidelineweretheAmericanSocietyofSurgeryoftheHand,AmericanSocietyofShoulderandElbowTherapists,andtheAmericanPhysical

TherapyAssociation.Participationinthepeerre-viewprocessdoesnotconstituteanendorsementoftheseguidelinesbytheparticipatingorganization. FundingwasprovidedsolelybytheAAOS. Theguidelineisbasedonasystematicreviewofthecurrentscientificandclinicalinformationonacceptedapproachestotreatment.Theentireprocessincludedareviewpanelofinternalandexternalcommittees,publiccommentaries,andfinalapprovalbytheAAOSBoardofDirectorsonDecember,3,2010. Themethodsusedtopreparethisguidelinewererigorous,employedtominimizebiasandtodevelopasetofreliable,transparent,andaccurateclinicalrecommendationsfortreatingsymptomaticosteoporoticspinalcompressionfractures.Thesemethodsaredetailedinthefullguideline. ThedevelopmentofAAOSevidence-basedclin-icalpracticeguidelinesisoverseenbytheGuide-linesandTechnologyOversightCommitteeandtheEvidence-BasedPracticeCommittee.Theguidelineisavailableatwww.aaos.org/guidelines

AAOS Now_January 2011.indd 47 12/22/2010 3:40:42 PM