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Guideline Summary
Guideline Title
American Academy of Orthopaedic Surgeons clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans.
Bibliographic Source(s)
American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2010 Dec 4. 159 p. [61 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Osteochondritis dissecans (OCD) of the knee (juvenile and adult)

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Orthopedic Surgery
Physical Medicine and Rehabilitation
Radiology
Rheumatology
Sports Medicine
Intended Users
Advanced Practice Nurses
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)
  • To help improve treatment of osteochondritis dissecans (OCD) of the knee based on the current best evidence
  • To serve as an information resource for decision makers and developers of practice guidelines and recommendations
  • To guide qualified physicians through a series of diagnostic decisions in an effort to improve the quality and efficiency of care
Target Population

Skeletally immature and skeletally mature patients with osteochondritis dissecans (OCD) of the knee

Interventions and Practices Considered

Diagnosis/Evaluation

  1. X-ray of the symptomatic knee
  2. Magnetic resonance imaging (MRI)
  3. Repeat history, physical exam, X-ray and/or MRI to assess healing in patients who remain symptomatic after treatment

Treatment/Management

  1. Surgery
  2. Post-operative physical therapy

Note: No recommendations could be made for or against the following interventions: x-rays of the contralateral asymptomatic knee; non-operative treatment (casting, bracing, splinting, unloader brace, electrical or ultrasound bone stimulators, activity restriction alone) for asymptomatic or symptomatic skeletally immature patients; arthroscopic drilling in skeletally immature patients; specific cartilage repair techniques; repeat MRI for asymptomatic skeletally mature patients; physical therapy for patients treated non-operatively; counseling patients on activity modification and weight control

Major Outcomes Considered
  • Sensitivity, specificity, accuracy of diagnostic tests
  • Progression toward healing of lesion
  • Tegner activity, Lysholm, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome (KOOS) and the SF-12 Mental and Physical scores
  • Pain and symptom relief
  • Knee function

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Study Selection Criteria

A priori article inclusion criteria were developed for review. These criteria are the "rules of evidence" and articles that do not meet them are, for the purposes of this guideline, not evidence.

To be included in the systematic reviews (and hence, in this guideline) an article had to be a report of a study that:

  • Investigates osteochondritis dissecans (OCD) of the knee in otherwise healthy children and adults without other conditions that can cause OCD and without comorbid conditions
  • Is not investigating osteochondral fractures or ligament instability
  • Does not combine results of skeletally immature patients with skeletally mature patients
  • Is a full article report of a clinical study (i.e., retrospective case series, medical records review, meeting abstracts, historical articles, editorials, letters, and commentaries are excluded)
  • Articles studying natural history and prognostic factors can be retrospective case series
  • Diagnostic case control studies will be excluded
  • Appears in a peer-reviewed publication
  • Has 10 or more patients per group
  • Is of humans
  • Is published in English
  • Is published in or after 1966
  • Reports results quantitatively
  • Has follow up of at least two years except for when healing or adverse events are the outcome
  • Has ≥50% patient follow-up (if the follow-up is >50% but <80%, the study quality will be downgraded)
  • Is not an in vitro study
  • Is not a biomechanical study
  • Is not performed on cadavers

Inclusion of Studies with Mixed Patient Populations

The work group specified a priori to the literature search that the studies must enroll and report the results of patients with osteochondritis dissecans of the knee. Studies with mixed populations must report the results of patients with osteochondritis dissecans of the knee separately or if the results are combined, 80% of the patient population must be of patients with osteochondritis dissecans of the knee in order to consider the study for inclusion in this guideline.

Best Available Evidence

When examining primary studies, the work group analyzed the best available evidence regardless of study design. They first considered the randomized controlled trials (RCTs) identified by the search strategy. In the absence of two or more RCTs, the work group sequentially searched for prospective controlled trials, prospective comparative studies, retrospective comparative studies, and prospective case-series studies. Only studies of the highest level of available evidence were included, assuming that there were 2 or more studies of that higher level. For example, if there were two Level II studies that addressed the recommendation, Level III and IV studies were not included.

Literature Searches

The work group attempted to make the searches for articles comprehensive. Using comprehensive literature searches ensures that the evidence they considered for this guideline is not biased for (or against) any particular point of view.

The work group searched for articles published from January 1966 to March 24, 2010. Four electronic databases were searched: PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials. Strategies for searching electronic databases were constructed by a medical librarian using previously published search strategies to identify relevant studies.

Searches of electronic databases were supplemented with manual screening of the bibliographies of all retrieved publications. The bibliographies of recent systematic reviews and other review articles were also searched for potentially relevant citations. Finally, work group members provided a list of potentially relevant studies that were not identified by the searches. All articles identified were subject to the study selection criteria listed above.

The work group did not include systematic reviews compiled by others or guidelines developed by other organizations. These documents are developed using different inclusion criteria than those specified by the American Academy of Orthopaedic Surgeons (AAOS) work group. Therefore they may include studies that do not meet AAOS inclusion criteria. These documents were recalled, if the abstract suggested they might provide an answer to one of the recommendations, and their bibliographies were searched for additional studies to supplement the systematic review.

The study attrition diagram in Appendix III of the original guideline provides details about the inclusion and exclusion of the studies considered for this guideline. The search strategies used to identify these studies are provided in Appendix IV of the original guideline.

Number of Source Documents

16 articles were included

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for Primary Research Question1

Types of Studies
  Therapeutic Studies
Investigating the results of treatment
Prognostic Studies
Investigating the effects of a patient characteristic on the outcome of disease
Diagnostic Studies
Investigating a diagnostic test
Economic and Decision Analyses
Developing an economic or decision model
Level I
  • High quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals
  • Systematic review2 of Level I randomized controlled trials (RCTs) (and study results were homogenous3)
  • High quality prospective study4 (all patients were enrolled at the same point in their disease with ≥80% follow-up of enrolled patients)
  • Systematic review2 of Level I studies
  • Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard)
  • Systematic review2 of Level I studies
  • Sensible costs and alternatives; values obtained from many studies; with multiway sensitivity analyses
  • Systematic review2 of Level I studies
Level II
  • Lesser quality RCT (e.g., <80% follow-up, no blinding, or improper randomization)
  • Prospective4 comparative study5
  • Systematic review2 of Level II studies or Level I studies with inconsistent results
  • Retrospective study6
  • Untreated controls from an RCT
  • Lesser quality prospective study (e.g., patients enrolled at different points in their disease or <80% follow-up)
  • Systematic review2 of Level II studies
  • Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard)
  • Systematic review2 of Level II studies
  • Sensible costs and alternatives; values obtained from limited studies; with multiway sensitivity analyses
  • Systematic review2 of Level II studies
Level III
  • Case control study7
  • Retrospective6 comparative study5
  • Systematic review2 of Level III studies
  • Case control study7
  • Study of nonconsecutive patients; without consistently applied reference "gold" standard
  • Systematic review2 of Level III studies
  • Analyses based on limited alternatives and costs; and poor estimates
  • Systematic review2 of Level III studies
Level IV
  • Case series8
  • Case series
  • Case-control study
  • Poor reference standard
  • Analyses with no sensitivity analyses
Level V Expert opinion Expert opinion Expert opinion Expert opinion

1 A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
2 A combination of results from two or more prior studies.
3 Studies provided consistent results.
4 Study was started before the first patient enrolled.
5 Patients treated one way (e.g., cemented hip arthroplasty) compared with a group of patients treated in another way (e.g., uncemented hip arthroplasty) at the same institution.
6 The study was started after the first patient enrolled.
7 Patients identified for the study based on their outcome, called "cases"; e.g., failed total hip arthroplasty, are compared to those who did not have outcome, called "controls"; e.g., successful total hip arthroplasty.
8 Patients treated one way with no comparison group of patients treated in another way.

Methods Used to Analyze the Evidence
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Data Extraction

Data elements extracted from studies were defined in consultation with the physician work group. The elements extracted are shown in Appendix V of the original guideline document. Evidence tables were constructed to summarize the best evidence pertaining to each preliminary recommendation. Disagreements about the accuracy of extracted data were resolved by consensus and consulting the work group. Disagreements were resolved by consensus and by consulting the physician work group.

The work group specified a priori to the literature search that data would be stratified by joint but that mixed studies could be accepted and reported as such. When studies did not separate the data by joint, it is not possible to report them separately. If a study with mixed joints reported the data for each joint, they were reported as such. If a study reported mixed joints but had less than 25 patients per joint, the analyst reported only the mixed data.

Judging the Quality of Evidence

Determining the quality of the included evidence is vitally important when preparing any evidence-based work product. Doing so conveys the amount of confidence one can have in any study's results. One has more confidence in high quality evidence than in low quality evidence.

Assigning a level of evidence on the basis of study design plus other quality characteristics ties the levels of evidence reported more closely to quality than levels of evidence based only on study design. Because the work group ties quality to levels of evidence, they are able to characterize the confidence one can have in their results. Accordingly, they characterize the confidence one can have in Level I evidence as high, the confidence one can have in Level II and III evidence as moderate, and the confidence one can have in Level IV and V evidence as low. Similarly, throughout the guideline they refer to Level I evidence as reliable, Level II and III evidence as moderately reliable, and Level IV and V evidence as not reliable.

Diagnostic Studies

In studies investigating a diagnostic test, the work group used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) instrument (Appendix VI in the original guideline document) to identify potential bias and assess variability and the quality of reporting in studies reporting the effectiveness of diagnostic techniques. Studies without any indication of bias are categorized as high quality studies. The quality of a study that has bias in the study design (disease progression, partial verification), index test description, or clinical data was lowered for each bias present. Quality could be further downgraded if greater than 50% of the QUADAS (at least 3 of the 5) questions that assess the quality of reporting determined there was important information missing. Studies that have bias known to affect measures of diagnostic accuracy (i.e., spectrum bias, incorporation bias) were considered very low quality and not considered for analysis.

Treatment Studies

In studies investigating the result of treatment, the work group assessed the quality of the evidence for each outcome at each time point reported in a study. They did not simply assess the overall quality of a study. This approach follows the recommendations of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group as well as others.

Quality was evaluated on a per outcome basis rather than a per study basis because quality is not necessarily the same for all outcomes and all follow-up times reported in a study. For example, a study might report results immediately after patients received a given treatment and after some period of time has passed. Often, nearly all enrolled patients contribute data at early follow-up times but, at much later follow-up times, only a few patients may contribute data. One has more confidence in the earlier data than in the later data. The fact that a higher quality score would be assigned to the earlier results reflects this difference in confidence.

The work group assessed the quality of treatment studies using a two step process. First, they assigned quality to all results reported in a study based solely on that study's design. Accordingly, all data presented in randomized controlled trials were initially categorized as high quality evidence, all results presented in non-randomized controlled trials and other prospective comparative studies were initially categorized as moderate quality, all results presented in retrospective comparative and case-control studies were initially categorized as low quality, and all results presented in prospective case-series reports were initially categorized as low quality. The work group next assessed each outcome at each reported time point using a quality questionnaire and, when quality standards were not met, downgraded the level of evidence (for this outcome at this time point) by one level (see Appendix VI in the original guideline document).

Prognostic Studies

In studies investigating the effect of a characteristic on the outcome of disease, quality was assessed using a two step process including a quality questionnaire (Appendix VI in the original guideline document). The quality questionnaire was developed from previously published literature addressing the use and analysis of prognostic variables. All studies were initially assigned as high quality and when quality standards were not met, as determined by the quality questionnaire, the study quality was lowered. The lowering of study quality was cumulative. Studies with five or more flaws indicated by the quality questionnaire were reduced to very low quality and not considered in our analysis.

Statistical Methods

Likelihood ratios, sensitivity, specificity, and 95% confidence intervals were calculated to determine the accuracy of diagnostic modalities based on two by two diagnostic contingency tables extracted from the included studies. When summary values of sensitivity, specificity, or other diagnostic performance measures were reported, estimates of the diagnostic contingency table were used to calculate likelihood ratios.

Likelihood ratios (LR) indicate the magnitude of the change in probability of disease due to a given test result. For example, a positive likelihood ratio of 10 indicates that a positive test result is 10 times more common in patients with disease than in patients without disease. Likelihood ratios are interpreted according to previously published values, as seen in Table 3 of the original guideline document.

Methods Used to Formulate the Recommendations
Expert Consensus (Nominal Group Technique)
Description of Methods Used to Formulate the Recommendations

This guideline and systematic review were prepared by The Diagnosis and Treatment of Osteochondritis Dissecans of the Knee guideline work group with the assistance of the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines Unit in the Department of Research and Scientific Affairs at the AAOS (see Appendix I in the original guideline document).

To develop this guideline, the work group held an introductory meeting to develop the scope of the guideline on April 19, 2009. Upon completion of the systematic review, the work group met again on April 10 and 11, 2010 to write and vote on the final recommendations and associated rationales for each recommendation based on the evidence.

Formulating Preliminary Recommendations

The work group began work on this guideline by constructing a set of preliminary recommendations. These recommendations specify [what] should be done in [whom], [when], [where], and [how often or how long]. They function as questions for the systematic review, not as final recommendations or conclusions. Preliminary recommendations are almost always modified on the basis of the results of the systematic review. Once established, these a priori preliminary recommendations cannot be modified until the final work group meeting, they must be addressed by the systematic review, and the relevant review results must be presented in the final guideline.

Defining the Strength of the Recommendations

Judging the quality of evidence is only a stepping stone towards arriving at the strength of a guideline recommendation. Unlike Levels of Evidence (which apply only to a given result at a given follow-up time in a given study) strength of recommendation takes into account the quality, quantity, and applicability of the available evidence. Strength also takes into account the trade-off between the benefits and harms of a treatment or diagnostic procedure, and the magnitude of a treatment's effect.

Strength of recommendation expresses the degree of confidence one can have in a recommendation. As such, the strength expresses how possible it is that a recommendation will be overturned by future evidence. It is very difficult for future evidence to overturn a recommendation that is based on many high quality randomized controlled trials that show a large effect. It is much more likely that future evidence will overturn recommendations derived from a few small case series. Consequently, recommendations based on the former kind of evidence are given a high strength of recommendation and recommendations based on the latter kind of evidence are given a low strength.

To develop the strength of a recommendation, AAOS staff first assigned a preliminary strength for each recommendation that took only the quality and quantity of the available evidence into account (see "Rating Scheme for the Strength of the Recommendations" field). Work group members then modified the preliminary strength using the "Form for Assigning Strength of Recommendation (Interventions)" shown in Appendix VII of the original guideline document.

Consensus Development

The recommendations and their strength were voted on using a structured voting technique known as the nominal group technique. Details of this technique are presented in Appendix VIII of the original guideline document. Voting on guideline recommendations was conducted using a secret ballot and work group members were blinded to the responses of other members. If disagreement between work group members was significant, there was further discussion to see whether the disagreement(s) could be resolved. Up to three rounds of voting were held to attempt to resolve disagreements. If disagreements were not resolved following three voting rounds, no recommendation was adopted. Lack of agreement is a reason that the strength for some recommendations is labeled "Inconclusive."

Rating Scheme for the Strength of the Recommendations

To develop the strength of a recommendation, American Academy of Orthopaedic Surgeons (AAOS) staff first assigned a preliminary strength for each recommendation that took only the quality and quantity of the available evidence into account (see table below). Work group members then modified the preliminary strength using the "Form for Assigning Strength of Recommendation (Interventions)" shown in Appendix VII of the original guideline document.

Strength of Recommendation

Guideline Language Strength of Recommendation Description of Evidence
The work group recommends Strong Level I evidence from more than one study with consistent findings for recommending for or against the intervention or diagnostic.
The work group suggests Moderate Level II or III evidence from more than one study with consistent findings, or Level I evidence from a single study for recommending for or against the intervention or diagnostic.
Treatment X is an option Weak Level IV or V evidence from more than one study with consistent findings, or Level II or III evidence from a single study for recommending for or against the intervention or diagnostic.
The work group is unable to recommend for or against Treatment X Inconclusive The evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention or diagnostic.
In the absence of reliable evidence, it is the opinion of the work group…* Consensus* There is no supporting evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion considering the known harms and benefits associated with the treatment.

*Consensus based recommendations are made according to specific criteria. These criteria can be found in Appendix VI of the original guideline document.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Peer Review

The draft of the guideline and evidence report was peer reviewed by an expert, outside advisory panel that was nominated a priori by the physician work group prior to the development of the guideline. The physician members of the American Academy of Orthopaedic Surgeons (AAOS) Guidelines and Technology Oversight Committee, the Evidence Based Practice Committee, and the Occupational Health and Workers' Compensation Committee also provided peer review of the draft document. Peer review was accomplished using a structured peer review form (see Appendix IX in the original guideline document). The draft guideline was sent to a total of 11 reviewers and 6 returned reviews (see Appendix X in the original guideline). The disposition of all non-editorial peer review comments was documented and accompanied this guideline through the public commentary and the AAOS guideline approval process. The peer reviewer comments, the responses and the final guideline are posted to the AAOS website upon approval of the AAOS Board of Directors.

Public Commentary

After modifying the draft in response to peer review, the guideline was distributed for a thirty-day period of "Public Commentary." Commentators consist of members of the AAOS Board of Directors (BOD), members of the Council on Research, Quality Assessment, and Technology (CORQAT), members of the Board of Councilors (BOC), and members of the Board of Specialty Societies (BOS). Based on these bodies, up to 185 commentators had the opportunity to provide input concerning the content of this guideline and the AAOS guideline development process. Of these, 2 returned public comments.

The AAOS Guideline Approval Process

Following public commentary, the work group and clinical practice guidelines unit edited the draft if public comments indicated changes were necessary based on the evidence. This final guideline draft, peer review comments and the responses as well as a summary of all changes made during the review process were then forwarded into the approval process. The guideline draft was sequentially approved by the AAOS Guidelines Oversight Committee, the AAOS Evidence-Based Practice Committee, the AAOS Council on Research, Quality Assessment, and Technology, and the AAOS Board of Directors. Descriptions of these bodies are provided in Appendix II of the original guideline document. No changes to the draft may occur during the approval process; all entities vote to approve or reject the document.

Recommendations

Major Recommendations

Definitions of the strength of recommendations (Strong, Moderate, Weak, Inconclusive, and Consensus) are provided at the end of the "Major Recommendations" field.

Note from the American Academy of Orthopaedic Surgeons (AAOS): The following is a summary of the recommendations in the AAOS clinical practice guideline, The Diagnosis and Treatment of Osteochondritis Dissecans (OCD) of the Knee. The scope of this guideline is specifically limited to osteochondritis dissecans of the knee. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. The work group is confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners.

  1. In a patient with knee symptoms (pain, swelling, locking, catching, popping, giving way) and/or signs (tenderness, effusion, loss of motion, crepitus), x-rays (including anteroposterior [AP], lateral, sunrise/Merchant, and tunnel views) are an option.

    Strength of Recommendation: Weak

  2. The work group is unable to recommend for or against x-rays on the contralateral asymptomatic knee in patients with confirmed OCD of one knee.

    Strength of Recommendation: Inconclusive

  3. In a patient with a known OCD lesion on x-ray, a magnetic resonance imaging (MRI) of the knee is an option to characterize the OCD lesion or when concomitant knee pathology is suspected such as meniscal pathology, anterior cruciate ligament (ACL) injury, or articular cartilage injury.

    Strength of Recommendation: Weak

  4. The work group is unable to recommend for or against non-operative treatment (casting, bracing, splinting, unloader brace, electrical or ultrasound bone stimulators, or activity restriction alone) for asymptomatic skeletally immature patients with OCD.

    Strength of Recommendation: Inconclusive

  5. The work group is unable to recommend for or against a specific non-operative treatment (casting, bracing, splinting, unloader brace, electrical or ultrasound bone stimulators, or activity restriction alone) for symptomatic skeletally immature patients with OCD.

    Strength of Recommendation: Inconclusive

  6. The work group is unable to recommend for or against arthroscopic drilling in symptomatic skeletally immature patients with a stable lesion(s) who have failed to heal with non operative treatment for at least three months.

    Strength of Recommendation: Inconclusive

  7. In the absence of reliable evidence, it is the opinion of the work group that symptomatic skeletally immature patients with salvageable unstable or displaced OCD lesions be offered the option of surgery.

    Strength of Recommendation: Consensus

  8. The work group is unable to recommend for or against a specific cartilage repair technique in symptomatic skeletally immature patients with unsalvageable fragment.

    Strength of Recommendation: Inconclusive

  9. The work group is unable to recommend for or against repeat MRI for asymptomatic skeletally mature patients.

    Strength of Recommendation: Inconclusive

  10. The work group is unable to recommend for or against treating asymptomatic skeletally mature patients with OCD progression (as identified by X-ray or MRI) like symptomatic patients.

    Strength of Recommendation: Inconclusive

  11. In the absence of reliable evidence, it is the opinion of the work group that symptomatic skeletally mature patients with salvageable unstable or displaced OCD lesions be offered the option of surgery.

    Strength of Recommendation: Consensus

  12. The work group is unable to recommend for or against a specific cartilage repair technique in symptomatic skeletally mature patients with an unsalvageable OCD lesions.

    Strength of Recommendation: Inconclusive

  13. In the absence of reliable evidence, it is the opinion of the work group that patients who remain symptomatic after treatment for OCD have a history and physical examination, x-rays and/or MRI to assess healing.

    Strength of Recommendation: Consensus

  14. The work group is unable to recommend for or against physical therapy for patients with OCD treated non-operatively.

    Strength of Recommendation: Inconclusive

  15. In the absence of reliable evidence, it is the opinion of the work group that patients who have received surgical treatment of OCD be offered post-operative physical therapy.

    Strength of Recommendation: Consensus

  16. The work group is unable to recommend for or against counseling patients about whether activity modification and weight control prevents onset and progression of OCD to osteoarthritis (osteoarthrosis).

    Strength of Recommendation: Inconclusive

Definitions:

Levels of Evidence: See the "Rating Scheme for the Strength of the Evidence" field.

Strength of Recommendation

Guideline Language Strength of Recommendation Description of Evidence
The work group recommends Strong Level I evidence from more than one study with consistent findings for recommending for or against the intervention or diagnostic.
The work group suggests Moderate Level II or III evidence from more than one study with consistent findings, or Level I evidence from a single study for recommending for or against the intervention or diagnostic.
Treatment X is an option Weak Level IV or V evidence from more than one study with consistent findings, or Level II or III evidence from a single study for recommending for or against the intervention or diagnostic.
The work group is unable to recommend for or against Treatment X Inconclusive The evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention or diagnostic.
In the absence of reliable evidence, it is the opinion of the work group…* Consensus* There is no supporting evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion considering the known harms and benefits associated with the treatment.

*Consensus based recommendations are made according to specific criteria. These criteria can be found in Appendix VI of the original guideline document.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

The aim of treatment is pain relief, improved knee function, and potentially altering the degenerative joint process.

Potential Harms

Surgical treatments are associated with some known risks such as infection, bleeding, venous thromboembolic events and persistent pain, although arthroscopic approaches have relatively low risk compared to more invasive surgeries.

Contraindications

Contraindications

Contraindications vary widely based on the treatment administered. Therefore, discussion of available treatments and procedures applicable to the individual patient rely on mutual communication between the patient and physician, weighing the potential risks and benefits for that patient.

Qualifying Statements

Qualifying Statements
  • An American Academy of Orthopaedic Surgeons (AAOS) physician volunteer Work Group developed this clinical practice guideline based on a systematic review of the current scientific and clinical information as well as accepted approaches to treatment and/or diagnosis. This clinical practice guideline is not intended to be used as a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician's independent medical judgment, given the individual patient's clinical circumstances.
  • Some drugs or medical devices referenced or described in this clinical practice guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice.
  • This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners.
  • This guideline should not be construed as including all proper methods of care or excluding methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

Implementation of the Guideline

Description of Implementation Strategy

Guideline Dissemination Plans

This document is also posted on the American Academy of Orthopaedic Surgeons (AAOS) website at http://www.aaos.org/research/guidelines/guide.asp External Web Site Policy.

Shorter versions of the guideline are available in other venues. Publication of most guidelines is announced by an Academy press release, articles authored by the work group and published in the Journal of the American Academy of Orthopaedic Surgeons, and articles published in AAOS Now. Most guidelines are also distributed at the AAOS Annual Meeting in various venues such as on Academy Row and at Committee Scientific Exhibits.

Selected guidelines are disseminated by webinar, an Online Module for the Orthopaedic Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing them at relevant Continuing Medical Education (CME) courses and at the AAOS Resource Center.

Other dissemination efforts outside of the AAOS will include submitting the guideline to the National Guideline Clearinghouse and distributing the guideline at other medical specialty societies' meetings.

Implementation Tools
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2010 Dec 4. 159 p. [61 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Dec 4
Guideline Developer(s)
American Academy of Orthopaedic Surgeons (AAOS) - Medical Specialty Society
Source(s) of Funding

American Academy of Orthopaedic Surgeons

Guideline Committee

Diagnosis and Treatment of Osteochondritis Dissecans Work Group

Composition of Group That Authored the Guideline

Work Group Members: Henry G. Chambers, MD, Chair; Kevin G. Shea, MD, Vice-Chair; Allen F. Anderson MD; Tommy J. (JoJo) Brunelle, PT, DPT; James L. Carey, MD; Theodore J. Ganley, MD; Mark Paterno, DPT, MS, MBA; Jennifer M. Weiss, MD

Attending Oversight Chair: James O. Sanders, MD

Guidelines and Technology Oversight Chair: William C. Watters III, MD

Guidelines and Technology Oversight Vice-Chair: Michael J. Goldberg, MD

Evidence Based Practice Committee Chair: Michael W. Keith, MD

American Academy of Orthopaedic Surgeons (AAOS) Staff: Charles M. Turkelson, PhD, Director of Research and Scientific Affairs; Janet L. Wies, MPH, AAOS Clinical Practice Guideline Manager; Laura Raymond, MA, AAOS Lead Research Analyst; Kevin M. Boyer, AAOS Research Analyst; Kristin Hitchcock, MLS, AAOS Medical Librarian

AAOS Research Analysts: Sara Anderson, MPH; Patrick Sluka, MPH

Graduate Interns: Catherine Boone, BS; Nilay Patel, MA

Financial Disclosures/Conflicts of Interest

In accordance with American Academy of Orthopaedic Surgeons (AAOS) policy, all individuals whose names appear as authors or contributors to this clinical practice guideline filed a disclosure statement as part of the submission process. All panel members provided full disclosure of potential conflicts of interest prior to voting on the recommendations contained within this clinical practice guideline.

All members of the AAOS work group disclosed any conflicts of interest prior to the development of the recommendations for this guideline. Conflicts of interest are disclosed in writing with the American Academy of Orthopaedic Surgeons via a private on-line reporting database and also verbally at the recommendation approval meeting.

Allen F. Anderson, MD: 3B (orthopediatrics); 7 (Am J Sports Med); 8 (Am J Sports Med); 9 (American Orthopaedic Society for Sports Medicine); Submitted on: 06/15/2010 and last confirmed as accurate on 10/05/2010.

Tommy J. (JoJo) Brunelle, PT, DPT: (n). Submitted on: 03/04/2009 at 09:14 PM.

James L. Carey, MD: (n) Submitted on: 04/24/2010 and last confirmed as accurate on 10/08/2010.

Henry G. Chambers, MD: 3B (Allergan Corporation); 8 (Gait and Posture); 9 (American Academy for Cerebral Palsy and Developmental Medicine; Pediatric Orthopaedic Society of North America); Submitted on: 09/29/2010.

Theodore J. Ganley, MD: 3B (OrthoPediatrics Corp); Submitted on: 03/11/2010 and last confirmed as accurate on 09/10/2010.

Mark Paterno, PT: (n) Submitted on: 04/09/2010 and last confirmed as accurate on 05/27/2010.

James O. Sanders, MD: 3C (Orthopediatrics); 4 (Abbott; Hospira); 5 (Medtronic Sofamor Danek); 9 (AAOS; American Orthopaedic Association; Pediatric Orthopaedic Society of North America; Scoliosis Research Society); Submitted on: 05/20/2010 and last confirmed as accurate on 09/14/2010.

Kevin G. Shea, MD: 9 (AAOS; American Orthopaedic Society for Sports Medicine; Pediatric Orthopaedic Society of North America); Submitted on: 08/31/2010 and last confirmed as accurate on 10/19/2010.

Jennifer M. Weiss, MD: 9 (Pediatric Orthopaedic Society of North America); Submitted on: 08/09/2010 and last confirmed as accurate on 09/10/2010.

Michael J. Goldberg, MD: 8 (Journal Children's Orthopaedics; Journal of Pediatric Orthopedics); 9 (AAOS); Submitted on: 04/05/2010 and last confirmed as accurate on 10/16/2010.

William Charles Watters III, MD: 3B (Stryker); 4 (Intrinsic Orthopedics); 8 (Official Disability Guidelines; Spine; The Spine Journal); 9 (American Board of Spine Surgery; North American Spine Society); Submitted on: 05/26/2010 and last confirmed as accurate on 09/14/2010.

Disclosure Items Answered: (n) = Respondent answered 'No' to all items indicating no conflicts. 1 = Royalties from a company or supplier; 2 = Speakers bureau/paid presentations for a company or supplier; 3A = Paid employee for a company or supplier; 3B = Paid consultant for a company or supplier; 3C = Unpaid consultant for a company or supplier; 4 = Stock or stock options in a company or supplier; 5 = Research support from a company or supplier as a PI; 6 = Other financial or material support from a company or supplier; 7 = Royalties, financial or material support from publishers; 8 = Medical/orthopaedic publications editorial/governing board; 9 = Board member/committee appointments for a society.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Academy of Orthopaedic Surgeons Web site External Web Site Policy.

Print copies: Available from the American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL 60018-4262. Telephone: (800) 626-6726 (800 346-AAOS); Fax: (847) 823-8125; Web site: www.aaos.org External Web Site Policy.

Availability of Companion Documents

The following is available:

  • The diagnosis and treatment of osteochondritis dissecans. Summary of recommendations. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2010 Dec. 3 p. Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Orthopaedic Surgeons (AAOS) Web site External Web Site Policy.

Print copies: Available from the American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL 60018-4262. Telephone: (800) 626-6726 (800 346-AAOS); Fax: (847) 823-8125; Web site: www.aaos.org External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 21, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact AAOS Department of Research and Scientific Affairs, 6300 North River Road, Rosemont, IL 60018; Phone: (847) 823-7186; Fax: (847) 823-8125.

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