According to the AAOS, therapies that don't make the cut include:
- glucosamine and/or chondroitin (sulfate or hydrochloride)
- needle lavage of the joint
- custom-made foot orthotics
Knee arthritis guidelines: most thorough yet
“Each individual patient is unique, and application of these guidelines needs to be individualized by the practitioner to a given patient.”—John C. Richmond, MD
“The ‘take home’ for an orthopaedic surgeon is that these specific recommendations are evidence-based and therefore are treatments that are supported (or not supported, as the case may be) by the most thorough and scientific review of the literature to date,” said lead author John C. Richmond, MD. Dr. Richmond, who chairs the department of orthopedic surgery at New England Baptist Hospital in Boston, Mass., told MSKreport.com, "Each individual patient is unique, and application of these guidelines needs to be individualized by the practitioner to a given patient.”
Weight loss, Tylenol®, NSAIDs remain first line in knee OA care
The new guidelines oppose performing an arthroscopic lavage if a patient has OA symptoms without mechanical problems like loose bodies or meniscus tears. The guidelines also urge a 5% body weight reduction in patients with a body mass index (BMI) >25. The AAOS also wants knee OA patients to begin or increase low-impact aerobic exercise programs.
For symptomatic knee OA, AAOS recommends acetaminophen (not to exceed 4 grams per day), nonsteroidal anti-inflammatory drugs (NSAIDs) or intra-articular corticosteroids (for short term pain relief). The reviewers concluded that evidence for or against acupuncture and intra-articular hyaluronic acid is inconclusive.
The guidelines recommend against glucosamine and/or chondroitin.
“These [supplements] appear to be of similar efficacy to placebo in the well done studies,” Dr. Richmond said. “As an orthopaedic surgeon who tries to run a completely ‘evidence-based’ practice, I find myself occasionally suggesting a trial of these for a patient. I always inform the patient that the science indicates that they are no better than placebo, but there are occasional patients who feel that they are very beneficial (which is supported by the literature).”
Recommendations graded "inconclusive" may still be an option for certain patients, Dr. Richmond explained. For example, recommendation 16 states, "We cannot recommend for or against the use of intra-articular hyaluronic acid for patients with mild to moderate symptomatic OA of the knee."
But this treatment “may still be indicated for a specific patient, who might not have other alternatives based on a medical condition, such as intolerance of NSAID's in spite of using COX-2's and gastroprotecive agents with nonselective NSAID's, and is also not a candidate for surgical treatment,” Dr. Richmond said.
Similarly, arthroscopy with debridement or lavage might be useful in a young patient who is severely symptomatic, non-responsive to all less invasive treatments, and not a candidate, based on age or activity level for more invasive treatments such as joint replacement. “Frank discussion between the surgeon and patient as to the potential high rate of failure of this treatment would be warranted prior to proceeding with arthroscopic debridement,” Dr. Richmond warned.
Reference
1. AAOS. Guideline on the Treatment of Osteoarthritis (OA) of the Knee. Accessed at: http://www.aaos.org/Research/guidelines/OAKguideline.pdf
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