Guideline Provides Evidence-Based Advice for Treating Osteoarthritis of the Knee

A new practice guideline from the American Academy of Orthopaedic Surgeons (AAOS) underscores recent research showing that some commonly used treatments for osteoarthritis (OA) of the knee lack any strong support from scientific evidence.

The AAOS guideline, released in December, offers 22 treatment recommendations for patients with OA of the knee whose disease has not progressed to the point of needing joint replacement surgery. It supports neither the widely advertised nutritional supplements glucosamine and chondroitin sulfate or hydrochloride nor customized orthotics such as heel wedges. The guideline is aimed at primary care physicians as well as orthopedic surgeons (http://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp).

“It's clear that joint replacement has huge value in treating end-stage osteoarthritis pain,” said John Richmond, MD, chair of the AAOS working group that produced the guideline recommendations. “But the real issue is, how do you treat people short of joint replacement?” He added that of the estimated 33 million individuals in the United States who have OA of the knee, the vast majority do not have disease severe enough to require joint replacement.

AAOS President Tony Rankin, MD, said the new guideline is a “refinement” of existing recommendations that reflects the most up-to-date research on treatment regimens for OA of the knee. The guideline points to the importance of patient education and lifestyle modifications that have clear benefits. It recommends aerobic, strength, and flexibility exercises as well as weight loss for patients with a body mass index greater than 25. Acetaminophen and nonsteroidal anti-inflammatory medications are recommended for pain relief.

The guideline calls arthroscopy “an option” for patients with knee OA who also have meniscal tears or loose bodies in the joint. But the guideline does not support arthroscopy if those complicating factors are not present, reflecting a recent finding that showed arthroscopy provided no more benefit to patients with knee OA than physical and medical therapy (Kirkley A et al. N Engl J Med. 2008;359[11]:1097-1107).

The guideline also concurs with a 2007 report from the Agency for Healthcare Research and Quality (AHRQ) that called the results of clinical trials of viscosupplementation with hyaluronic acid uncertain and unclear. The AAOS makes no recommendation regarding viscosupplementation, a technique the US Food and Drug Administration approved more than a decade ago.

“A number of manufacturers that produce [hyaluronic acid] all had randomized controlled trials to demonstrate that their particular product works,” said Richmond. “The literature that is strongly in favor of viscosupplementation is often industry-supported, and there are some statistical flaws with a number of studies out there.”

Primary care physicians will welcome the new guideline, said Ted Epperly, MD, president of the American Academy of Family Physicians. He described the recommendations as “balanced, fair, and accurate” and noted that the guideline represents a “common-sense approach” to a common disease that primary care physicians should discuss as part of providing a medical home for their patients with OA.

“This really calls into question the need for surgery or intervention in the knee with injections or lavage and arthroscopy,” said Epperly. “It's refreshing that it didn't call for more invasive treatment.”

In its new guideline on treating OA of the knee, the American Academy of Orthopaedic Surgeons recommends

Based on the evidence, the guideline does not recommend these treatments for OAof the knee:

As a consequence of inconclusive evidence, the guideline does not recommend for or against the following:

Source: Treatment of Osteoarthritis of the Knee (Non-arthroplasty). American Academy of Orthopaedic Surgeons; December 6, 2008.