Board Approves CPG on Management of Carpal Tunnel Syndrome

During its meeting on Monday, Feb. 29, the AAOS Board of Directors appointed the chair of the 2017 Nominating Committee, adopted a Clinical Practice Guideline (CPG) on the Management of Carpal Tunnel Syndrome, and voted to support the Choosing Wisely initiative and refer the public and patients to AAOS-prepared resources at the OrthoGuidelines website (www.orthoguidelines.org). It also presented certificates to several retiring Board members and one Council Chair, whose terms end with the 2016 Annual Meeting, recognizing the efforts of those individuals on behalf of the AAOS.

Nominating Committee Chair and Members
The AAOS Board appointed Past President Joshua J. Jacobs, MD, to serve as chair of the 2017 Nominating Committee. At the Association Business Meeting on Thursday, March 3, nominations for the other members of the 2017 Nominating Committee will be accepted from the fellowship. Six members will be elected by the fellowship after the Annual Meeting. The 2017 Nominating Committee will be responsible for selecting the slate of officers and other positions for the upcoming year.

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Members of the 2015-2016 AAOS Board of Directors take a break from their Monday meeting for a final group photo.

CPG on Management of Carpal Tunnel Syndrome
Since 2006, the AAOS has been developing evidence-based CPGs to improve patient care. The AAOS Committee on Evidence-Based Quality and Value appoints work groups to develop guidelines as educational tools for orthopaedic surgeons. The work groups consist of AAOS physician members and members of other specialty organizations who define the scope of the guideline by developing recommendations and defining inclusion criteria for the literature search. The AAOS Guidelines Unit supports members with data analyses and pertinent methodologic information.

The most recent CPG, Management of Carpal Tunnel Syndrome, consists of 35 recommendations with varying overall strength of evidence. Among the recommendations with “strong” levels of evidence (evidence from two or more “high”-quality studies with consistent findings for recommending for or against an intervention) were the following:

  • Strong evidence supports Thenar atrophy is strongly associated with ruling-in carpal tunnel syndrome, but poorly associated with ruling-out carpal tunnel syndrome.
  • Strong evidence supports not using the Phalen Test, Tinel Sign, Flick Sign, or Upper Limb Neurodynamic/nerve tension Test criterion A/B as independent physical examination maneuvers to diagnose carpal tunnel syndrome, because alone, each has a poor or weak association with ruling-in or ruling-out carpal tunnel syndrome.
  • Strong evidence supports that body mass index and high hand/wrist repetition rate are associated with the increased risk of developing carpal tunnel syndrome.
  • Strong evidence supports that the use of immobilization (brace/splint/orthosis) should improve patient-reported outcomes.
  • Strong evidence supports that the use of steroid (methylprednisolone) injection should improve patient-reported outcomes.
  • Strong evidence supports not using magnet therapy for the treatment of carpal tunnel syndrome.
  • Strong evidence supports that surgical release of the transverse carpal ligament should relieve symptoms and improve function.
  • Strong evidence supports that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months as compared to splinting, NSAIDs/therapy, and a single steroid injection.
  • Strong evidence supports no benefit to routine postoperative immobilization after carpal tunnel release.
  • The Academy Board of Directors approved the guideline unanimously. The new CPG can be reviewed in its entirety on the Academy’s OrthoGuidelines website (www.orthoguidelines.org).

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Kevin J. Bozic, MD, MBA, Chair, Council on Research and Quality, presents the new CPG on Management of Carpel Tunnel Syndrome to the AAOS Board of Directors.

Choosing Wisely
The Choosing Wisely Campaign is an initiative of the American Board of Internal Medicine (ABIM) Foundation, with the goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures. The AAOS developed a Choosing Wisely list in 2013. AAOS received some negative publicity regarding this list, with critics citing the AAOS recommendations as weak.

In 2015 and 2016, the Council on Research and Quality (CORQ) again reviewed the Choosing Wisely campaign and the history of the Academy’s recommendations. At the Board meeting on Monday, CORQ recommended the Academy adopt and issue a second Choosing Wisely list based on strong evidence from the existing clinical practice guideline recommendations already approved by the Board of Directors and published on the AAOS website.

A thorough discussion ensued. Ultimately, the Board voted to support the Choosing Wisely initiative, and refer physicians and patients to the AAOS OrthoGuidelines website for additional information.

Additional business
The Board also addressed several other items requiring action. The Board approved the following:

Revised language for CPGs regarding a CPG’s intended users

Recommendations from the Quality Outcomes Data Work Group, previously charged with investigating partnership opportunities for the collection of quality data and investigation and evaluation of appropriate instruments (such as Patient Reported Outcomes) 

A recommendation by the AAOS Performance Measures Committee regarding its review of 2016 Physician Quality Reporting System (PQRS) performance measures and identification of a set of PQRS performance measures that AAOS members can use to satisfy the 2016 quality reporting requirements

In addition, a series of information and position statements from various CORQ committees were approved: revisions to AAOS Information Statement 1019–Implant Device Recalls; revisions to AAOS Position Statement 1169–Consensus Standard for Medical Devices; revisions to AAOS Position Statement 1177–Off Label Use of Medical Products; and the sunsetting of Position Statement 1153–The Effects of Tobacco Exposure on the Musculoskeletal System and the adoption of a new Information Statement on Tobacco Use and Orthopaedic Surgery. A request from the Council on Advocacy for administrative funding of the Political Action Committee of the American Association of Orthopaedic Surgeons (Orthopaedic PAC) was approved. A request for support of a 2017 Bone and Joint Fitness and Fun Family Event Day: Volunteer Community Project was approved. A funding request from the Board of Councilors (BOC) for developing a member awareness video promoting the value of AAOS membership (and the BOC’s role in the AAOS) was approved. Finally, a proposal from the Resident Assembly was approved regarding how that body’s Action Items—similar to the advisory opinions submitted by the BOC and Board of Specialty Societies—should be considered by the AAOS.

Retiring board members and Council Chair recognized
At the conclusion of the meeting, AAOS Board President David D. Teuscher, MD, recognized the service of those board members and Council chair whose terms end with the 2016 Annual Meeting: Chair of the Council on Research and Quality Kevin J. Bozic, MD, MBA; Member-at-Large Jennifer M. Weiss, MD; Member-at-Large Raj D. Rao, MD; Chair of the Board of Specialty Societies David A. Halsey, MD; Chair of the Board of Councilors David J. Mansfield, MD; and Treasurer and Past President Frederick M. Azar, MD. In turn, First Vice-President Gerald R. Williams, Jr, MD, recognized the service of outgoing Board President Dr. Teuscher.

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