AAOS Revises Knee Osteoarthritis Treatment Guidelines

The American Academy of Orthopedic Surgeons (AAOS) has revised its clinical practice guideline (CPG) on the treatment of osteoarthritis (OA) of the knee, making two key changes. The first major change is the recommended dose for acetaminophen was reduced from 4,000 mg to 3,000 mg a day. The second is that intra-articular hyaluronic acid is no longer recommended as a method of treatment. This is the second edition of the guidance titled “Treatment of Osteoarthritis of the Knee.”

The changed recommended dose of acetaminophen is based on the U.S. Food and Drug Administration guidance released in 2009, which is applicable to all patients, not only those who have OA of the knee. Besides acetaminophen, the new CPG suggests intra-articular corticosteroids for short-term pain relief or non-steroidal anti-inflammatory drugs, provided there are no contraindications to this treatment.

The work group that compiled the new CPG cannot recommend custom-made lateral wedge insoles; glucosamine, chondroitin sulfate, or hydrochloride; or needle lavage (aspiration of the joint with injection of saline) for OA pain relief. The group also made clear that although acupuncture is growing in popularity, there is no clinical evidence supporting its efficacy for pain relief.

“There are many treatment options for osteoarthritis of the knee,” said David S. Jevsevar, M.D., MBA, chair of the Committee on Evidence-Based Quality and Value, which oversees the development of clinical practice guidelines. “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 orthopedic surgeon to develop the best course of treatment for you.”

AAOS’ guidance on intra-articular hyaluronic acid was unclear in 2009, so this new articulation clarifies the recommendation.

“Fourteen studies assessed intra-articular hyaluronic acid injections,” said Jevsevar, who also is an orthopedic surgeon in St. George, Utah. “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.”

The new CPG also recommends that 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 greater than 25 should lose a minimum of 5 percent of their body weight; and 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 Jevsevar. “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.”