Board Adopts Position Statement on Impact of Obesity

Two patient safety information statements also approved

During its meeting on Monday, March 23, the AAOS Board of Directors appointed the chair of the 2016 Nominating Committee, endorsed a consensus statement prepared by the Orthopaedic Trauma Association (OTA) as a companion document to the AAOS Clinical Practice Guideline (CPG) on the Management of Hip Fractures in the Elderly, and adopted a position statement on the impact of obesity on bone and joint health, two information statements relating to patient safety, and a new uniform agenda governing AAOS priorities on regulatory activities.

Nominating Committee Chair
Past President John R. Tongue, MD, was appointed chair of the 2016 Nominating Committee, in accordance with the bylaws of the American Association of Orthopaedic Surgeons (AAOS). At the Association Business Meeting on Thursday, March 26, nominations for members of the committee will be accepted from the fellowship. Six members will be elected by the fellowship after the Annual Meeting and will be responsible for selecting the slate of officers for the upcoming year.

First companion consensus statement
In response to new procedures adopted by the AAOS regarding the development of CPGs, the first companion consensus statement was presented and endorsed by the AAOS Board of Directors. The OTA companion Consensus Statement on Hip Fractures in the Elderly addresses three questions that were initially raised in the development of the CPG on Management of Hip Fractures in the Elderly.

Under the AAOS methodology process, preliminary CPG recommendations, or PICO (Patient, Intervention, Comparison, Outcome) questions, that are not supported by evidence after a systematic literature review and that do not meet established criteria for forming an AAOS consensus statement (ie, in instances where not making a recommendation would lead to loss of life or limb) are separated from the final CPG and turned over to relevant specialty societies to form companion consensus statements, as appropriate.

With regard to the CPG on the Management of Hip Fractures in the Elderly, three recommendations were initially proposed but were found by AAOS to be unsupported by evidence. Thus, the CPG workgroup suggested that they be sent to the OTA to construct companion consensus statements.

The following consensus statements were proposed by the OTA and endorsed by the AAOS Board of Directors:

1. Initial Patient Evaluation—In the absence of reliable evidence, OTA recommends that patients with a presumed hip fracture be initially evaluated with radiographs to include an anteroposterior (AP) radiograph of the pelvis and hip and a cross-table lateral radiograph of the hip.

2. Negative Plain Films and Examination—In the absence of reliable evidence, OTA recommends that patients with a negative physical examination and negative plain films should be evaluated for other causes of symptoms.

3. Long Cephalomedullary Nails—In the absence of reliable evidence, OTA recommends that long cephalomedullary nails be used for subtrochanteric and reverse obliquity fractures.

New position statement
The AAOS Board also adopted a position statement on “The Impact of Obesity on Bone and Joint Health,” which was developed by a Communications Cabinet workgroup formed after the AAOS Now Forum on “Obesity, Orthopaedics, and Outcomes.”

The position statement notes that “The AAOS believes that orthopaedic surgeons and patients should maintain an open dialogue about the detrimental effects of obesity on musculoskeletal health, and the increased risks of obesity on orthopaedic pre- and postsurgical complications and inferior outcomes.” It also outlines several steps recommended for patients with morbid obesity (body mass index [BMI] of 40 or higher) to take prior to undergoing elective orthopaedic surgery. These steps include the following:

  • Discuss with their physician(s) and consider carefully the impact of their weight on possible complications and results after surgery.
  • Speak with their physician(s) about resources available to help them lose weight before surgery. A delay in surgery is not a judgmental statement, but rather a risk reduction tool to avoid potentially serious and life-changing complications.
  • If it is in the patient’s best interest, consider delaying certain surgeries, such as joint replacement, where losing weight could improve the outcome of treatment, to provide time to take interventions for obesity.
  • Participate in a weight-loss program before undergoing total joint arthroplasty or replacement.
  • Develop a plan to manage comorbidities.
  • Assess nutritional status and address any deficiencies. Patients with obesity have a high incidence of altered nutritional status, and poor nutrition may contribute to comorbidities such as diabetes, in which blood sugar should be brought to reasonable levels to reduce risk.
  • Talk about rehabilitation protocols with their physicians and determine their ability and commitment level to follow them.

Consider signing a commitment letter to lose weight, exercise, and eat better to demonstrate responsibility for personal health. Even after surgery, patients must make an ongoing commitment to keep weight down for their overall health and for issues such as the longevity of total knee arthroplasty.

Patient safety statements
The AAOS Board also adopted two information statements developed by the AAOS Patient Safety Committee. The “Information Statement on Consistency for Safety in Orthopaedic Surgery” adopted by the AAOS Board, supports the regular use of standardized, validated, evidence- or consensus-based processes, often summarized as surgical checklists.

The statement reviews the rationale for the routine use of checklists in surgery, and notes that “effective implementation of standardized safety processes in surgery involves more than the introduction of simple item lists to be ‘ticked’ by the surgeon and operating room personnel.” It states:

The AAOS recognizes that mandated use of ‘one-size-fits-all’ surgical checklists often do not achieve the intended result of improved patient safety and outcomes. Checklists are most effective when they are modified locally and developed to best suit specific surgical settings and/or location needs. Such checklists are more likely to be endorsed by local surgeons and surgical team members, leading to regular use and improved protection for the patient populations they are designed to serve.

The AAOS is dedicated to providing safe care in all orthopaedic surgical settings and supports the consistent use of evidence-based processes, including checklists by surgeons and their surgical teams, as a tool to help improve the safety and outcomes of orthopaedic patients.

The second information statement adopted by the Board focuses on surgical site and procedure confirmation. The “Information Statement on Surgical Site and Procedure Confirmation” states the following:

The AAOS believes that surgeons, surgical teams, and patients are responsible for reliably confirming all surgical information needed to properly identify and perform any planned preventive, diagnostic, and therapeutic services. Proper confirmation is essential for the improvement of both the individual patient and general population and is supported through effective communication, informed patient choice, and shared decisionmaking.

The AAOS believes that immediately prior to incision the surgeon and entire operative team should confirm the identity of the patient, read aloud and confirm the informed surgical consent, and confirm proper surgical site marking. The surgeon should lead the process of procedure confirmation. If the planned surgery involves multiple surgical sites, procedures, and implants, each should be individually identified during the initial surgical ‘Brief’, the surgical ‘Time-Out’, and the final ‘De-Brief’, as well as confirmed individually with a ‘Time-Out’ before each planned separate site, procedure, and implant.

2015 Annual Meeting News
Tuesday through Friday, March 24 – 27, 2015.
http://www.aaos.org/news/acadnews/2015/aaos4_3_25.asp