Health care professionals look to their specialty organizations to provide guidelines for treatment of various diseases, illnesses, and conditions. Orthopedic surgeons rely on the American Academy of Orthopaedic Surgeons (AAOS) to provide such guidelines whenever possible.
In this article, we find out that Clinical Practice Guidelines (referred to as CPGs) are now available for a knee problem called osteochondritis dissecans or OCD. The American Academy of Orthopaedic Surgeons has approved the 16 recommendations that make up the CPG.
Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). The problem occurs where the cartilage of the knee attaches to the bone underneath.
The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. A joint surface damaged by OCD doesn’t heal naturally.
Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. That’s why proper treatment (based on evidence of what works and what doesn’t) is so important.
The new guidelines report how the recommendations were developed, reasons why each recommendation was made, and any supporting evidence for each one. The task force in charge of reviewing the research and putting these guidelines together labeled the strength of the evidence for each of the 16 guidelines.
The three main levels of strength of recommendation are: weak, inconclusive, and consensus. As the names suggest, weak evidence has been gathered for the guideline but more research is needed to study the area more completely.
In the case of OCD, there is weak evidence that X-rays and MRIs are two options for examining the damage. Information obtained from these imaging studies may help direct treatment.
Inconclusive evidence may reflect the fact that some studies result in one outcome while other studies on the same topic draw opposite conclusions. There isn’t enough evidence to recommend for or against the item being reviewed.
For example, should treatment be surgical or nonoperative, should the condition be treated if it’s not causing any pain or other symptoms, what type of treatment is advised for someone with OCD with pain versus patients with OCD who don’t have pain. There wasn’t strong evidence to support a clear answer to these questions.
And a consensus strength of recommendation means the group as a whole agreed on a particular guideline when there wasn’t enough reliable evidence for or against the recommendation. There was consensus that surgery is an option for patients with unstable OCD or displaced lesions (piece of bone has detached and shifted).
Another area where there was consensus of opinion based on available research evidence relates to imaging studies. There is consensus that repeat X-rays and MRIs can be used to see if (and how much) healing has taken place. As always, tests of this type aren’t just to satisfy the curiosity of patient, family, and surgeon. They are ordered when the information gained will help direct treatment.
In summary, there isn’t enough high-quality evidence on the treatment of OCD to develop clear treatment protocols. In fact, there really isn’t a high level of evidence to support the types of treatment being used today by many surgeons for this condition.
Patients are advised to modify their activities, use bracing or splinting to immobilize the joint, and even have surgery — all without strong evidence that these common treatments are required or helpful.
The positive value of conducting a task force to develop clinical practice guidelines is that we see clearly what type of research is needed. Having an outline for future research areas helps direct money, time, and resources in ways that will ultimately benefit patients with improved results.