September 23, 2013

AAOS Approves Appropriate Use Criteria (AUC) for Rotator Cuff Tears

New AUC to provide recommendations on common treatment scenarios

ROSEMONT, Ill. – The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors approved new appropriate use criteria (AUC) on optimizing the management of full-thickness rotator cuff (RC) tears. RC tears are both common and can be age-related and, in 2008, nearly 2 million people in the United States went to a doctor because of a rotator cuff problem.  The prevalence and potential cost burden of RC tears make this condition an ideal topic for an AUC. 
This AUC covers five possible treatments –nonsurgical modalities, partial repair and/or debridement, repair, reconstruction and arthroplasty (joint replacement) – and presents 432 different patient scenarios to help clinicians identify for whom and when the treatments are appropriate. 
“In many patient/treatment combinations, we found that nonsurgical treatments, or less invasive options (partial repair or debridement), were determined appropriate,” said James O. Sanders, MD, section leader and moderator during the AUC’s development. “Major surgery, such as reconstruction or arthroplasty was an option found to be most appropriate for patients who have not responded to conservative care, are healthy, have large or massive tears, and chronic changes on MRI.”
Out of more than 1,100 different patient/treatment combinations:
  • 16 percent were rated as “Appropriate”
  • 31 percent were rated as “May Be Appropriate”
  • 53 percent were rated as “Rarely Appropriate”
“Currently, many orthopaedic problems have little evidence to support one treatment over another,” said Dr. Sanders. “Most physicians and other professionals try  to provide the most appropriate treatments, but the AUC combines the evidence we do have available from the literature with the sound clinical judgment of experts, so patients can receive the best care possible.”
Additional AUCs covering a variety of orthopaedic conditions, diseases, and diagnostic procedures will soon follow. The complete AUC document is available online at
“In this value-driven era of medicine, physicians have an obligation and an opportunity to define the appropriate indications for the diagnostic and therapeutic interventions they perform,” says Kevin Bozic, MD, MBA, Chair of the AAOS Council on Research and Quality. “Appropriate use criteria incorporate the most up-to-date and available evidence along with clinician experience, thus providing physicians and their patients with valuable tools for shared medical decision making, even in the absence of high-quality evidence.” 
Appropriateness is determined by three separate panels: 
  • The writing panel combined clinical and procedural expertise with evidence-based information from the AAOS Clinical Practice Guideline on Optimizing the Management of Rotator Cuff Problems to define and describe the criteria for this procedure.
  • The review panel provided suggestions regarding improvement of the materials constructed by the writing panel.
  • The voting panel utilized clinical expertise from multiple medical specialties and evidence-based information to assign the appropriateness of various treatments for each of the patient scenarios developed by the writing group.

Complementing this AUC is a web-based app that is optimized to work on many devices, including Smartphones and tablets. The app ( allows the clinician to select a variety of patient characteristics and, once submitted, receive appropriateness recommendations for each of the five treatments covered by this AUC.  
Funding for this AUC was provided by AAOS. Development of AUC is overseen by the AUC section of the Evidence-Based Quality and Value Committee and the Council on Research and Quality. 

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Volunteers from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment. Practitioners are advised to consider management options in the context of their own training and background and institutional capabilities

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Lauren Pearson Riley
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