Optimizing the Management of Rotator Cuff Problems’’

Dr. Pedowitz has described some of the issues of the AAOS evidence-based clinical practice guidelines (CPGs) that have concerned a number of Academy members and deserve some clarification. The first issue is the selection of evidence for the AAOS CPGs. In the AAOS guidelines process, there is no restriction of evidence to Level-I studies. All AAOS clinical practice guidelines start with preliminary questions developed by a Work Group composed of clinical expert volunteers from the AAOS and from other medical and surgical professional societies so that all of the interests of the patient may be included. The experts develop the questions, and a complete systematic literature review is performed to address them. To prevent bias when members of the Work Group do not like the answers, questions cannot be changed once they are finalized. The CPG process is guided by the questions posed by theWork Group. Some guidelines have asked more clinically relevant and practice-relevant questions than others. The AAOS is developing a broader and more inclusive method to allow more members and other stakeholders to be involved in the formulation of questions for the guideline process. When answering the questions, the best available evidence is used to find the answers. When high-quality studies are available, lower-quality studies are not used. When higher-quality studies are not available, lower-quality studies are used (with the exception of retrospective noncomparative case series, which are not used in the guideline process). Even prospective, Level-IV case series are included as evidence despite their inherent weaknesses. Even the experts are often surprised that the evidence for some of our cherished treatments is weak or nonexistent. A number of AAOS members have been upset that their favored o