AAOS Approves Two New Appropriate Use Criteria on ACL Injury and Secondary Hip Fracture

During the December 2023 meeting, the AAOS Board of Directors approved the Appropriate Use Criteria (AUC) titled Return to Play to Pre-Injury Level Following Anterior Cruciate Ligament (ACL) Injury. The AUC is based on evidence from the 2022 AAOS Clinical Practice Guideline (CPG) on the Management of ACL Injuries.

Additionally, recommendations from the 2021 AAOS CPG on the Management of Hip Fractures in Older Adults formed the basis for the AUC on the Prevention of Secondary Fractures, also now approved by the Board of Directors.

The CPGs played a crucial role in guiding the decisions made by both the AUC writing and rating panels.

Hip Fracture AUC
The focus of the new Hip Fractures in Older Adults AUC is prevention of secondary hip or fragility fractures in patients who have had a previous frailty hip fracture and received surgical intervention. To assist with treatment recommendations, the AUC online tool presents the clinician with three patient indicators:

1. bisphosphonate treatment (No [never], Yes [Previous], Yes [Current])
2. pre–hip fracture functional status (non-mobile/bedbound, ambulator [with or without assistance])
3. prognosis (less than or equal to 1 year prognosis, greater than 1 year prognosis)

Before the clinician consults an AUC, it is assumed that the clinician is aware of indications/contraindications; has had an informed discussion with the patient regarding treatment options and understands that these may change over time; considers the values and preferences of the patient; has obtained informed consent; and initiates treatments/assessments as soon as reasonably practicable.

Once assumptions are confirmed, the clinician selects the appropriate patient indication profiles. Once submitted, the AUC provides procedure recommendations, with green circled checkmarks reflecting “Appropriate” treatments, yellow caution symbols highlighting treatments that “May Be Appropriate,” and red circled X’s indicating treatments that are “Rarely Appropriate.”

For this AUC, treatment recommendations would provide appropriateness ratings on the following potential treatments:

1. fall risk assessment
2. maintaining physical activity
3. serology screening
4. fall prevention programs
5. bone density assessment
6. use of calcium and vitamin D supplements
7. bisphosphonate treatment
8. consideration for additional pharmacological agents
9. smoking cessation and excessive alcohol counseling

ACL AUC
The AUC for the Return to Play to Pre-Injury Level Following ACL Injury was developed to assess the appropriateness of a patient returning to the activity that caused the injury or participating in a comparable level of activity. Assumptions integral to this AUC include that the patient: is seeking to re-engage in physical activity; is psychologically ready; has functional range of motion and the ability to perform necessary functional skills; if available, would participate in an ACL prevention program upon return to sports; and has completed functional balance and strength tests. Additional assumptions can be found at bit.ly/ReturntoPlayAUC.

Indication profiles for this AUC include:

1. ACL tear treatment (non-operative, operative)
2. level of athletic participation (low, high)
3. objective knee stability (objectively stable, objectively unstable)
4. subjective knee stability (subjectively stable, objectively unstable)
5. functional strength, balance limb symmetry index for performance (low, medium, high)
6. time from surgery or initiation of rehabilitation (3 months, 6 months, 9 months, 12 months)

Once this information is submitted, procedure recommendations will provide appropriateness ratings of the following procedural recommendations:

1. continued rehabilitation
2. modified return to play
3. full return to play

These AUCs, as well as an additional 26 additional AUCs spanning various orthopaedic topics, are available at OrthoGuidelines via either the website or the free mobile app. Visit orthoguidelines.org to get started.

Barbara Krause is a quality-improvement specialist for clinical quality and value at AAOS.