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AAOS Releases Revised Clinical Practice Guideline for
Osteoarthritis of the Knee - Intra-articular hyaluronic acid no
longer recommended, while recommended dosage of acetaminophen
reduced
June 04, 2013
Rosemont, Ill. - The American Academy of Orthopaedic Surgeons (AAOS)
recently released its revised clinical practice guideline (CPG) on
the treatment of osteoarthritis of the knee, addressing two key
changes. Most of the remaining recommendations provided in the 2009
CPG go unchanged. CPGs are not meant to be stand-alone documents,
but rather serve as a point of reference and educational tool for
both primary care physicians and orthopaedic surgeons.
The original guideline, as well as this revised version, was
developed to include only treatments which are less invasive than
knee replacement surgery. Osteoarthritis (OA) is a common condition
that can affect any joint in the body particularly after years of
use. It is also known as "wear and tear" arthritis and most commonly
occurs in people who are 65 years of age or older. Some 33 million
Americans are affected by osteoarthritis, and it is the leading
cause of physical disability.
The two primary changes recommended in the 2013 guidelines that
differ from the 2009 CPG include:
• Acetaminophen: The recommended dosage was reduced from 4,000 mg to
3,000 mg a day. This is not a change made by AAOS specifically for
OA patients, but an overall change made by the FDA since 2009 for
individuals who use acetaminophen.
• Intra-articular Hyaluronic Acid (HA): Intra-articular hyaluronic
acid is no longer recommended as a method of treatment for patients
with symptomatic osteoarthritis of the knee. The 2009 guidelines
review was inconclusive regarding this treatment method.
"Fourteen studies assessed intra-articular hyaluronic acid
injections," said David S. Jevsevar, MD, MBA, chair of the AAOS
Evidence Based Practice Committee which oversees the development of
clinical practice guidelines. "Although a few individual studies
found statistically significant treatment effects, when combined
together in a meta-analysis the evidence did not meet the minimum
clinically important improvement thresholds."
Other important recommendations that remain in the revised guideline
include:
- Patients who only display symptoms of osteoarthritis and no
other problems, such as loose bodies or meniscus tears, should
not be treated with arthroscopic lavage.
- Patients with a Body Mass Index (or BMI) greater than 25
should lose a minimum of five percent of their body weight.
- Patients should begin or increase their participation in
low-impact aerobic exercise.
"One of the best ways for a patient to reduce his or her pain and
realize better health is to be proactive," said Dr. Jevsevar, who
also is an orthopaedic surgeon in St. George, Utah. "For instance,
if a patient is overweight, losing weight is probably the best thing
he or she can do to slow the progression of osteoarthritis of the
knee."
The AAOS work group suggests that patients with symptomatic OA of
the knee receive one of the following analgesics for pain (unless
there are contraindications to this treatment):
• Acetaminophen (not to exceed 3,000 mg per day)
• For short-term pain relief, intra-articular corticosteroids
• Non-steroidal anti inflammatory drugs (NSAIDs)
The AAOS work group cannot recommend the following treatments:
• Custom made lateral wedge insoles
• Glucosamine and/or chondroitin sulfate or hydrochloride
• Needle lavage (aspiration of the joint with injection of saline)
In addition, although acupuncture continues to grow in popularity,
the evidence did not support its use in patients with OA of the
knee.
Due to a lack of available research, the CPG is unable to recommend
for or against the use of bracing, growth factor injections and/or
platelet rich plasma.
"There are many treatment options for osteoarthritis of the knee,"
said Dr. Jevsevar. "However, not all are effective. There needs to
be more and better testing, since results are still inconclusive.
Therefore, if you are experiencing knee problems, the best advice is
to work closely with your physician and orthopaedic surgeon to
develop the best course of treatment for you."
The full guideline along with all supporting documentation and
workgroup disclosures is available on the AAOS website: http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp
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