AAOS Changes Two Practice Guidelines

The American Academy of Orthopaedic Surgeons (AAOS) is recommending two revised clinical practice guidelines (CPG) for treatment of osteoarthritis of the knee. One is a reduction from 4, 000 mg of acetaminophen to 3, 000 mg a day, based on a change made by the FDA in 2009 for any individuals—not necessarily just those with osteoarthritis—who use the drug. The second change is the withdrawal of a recommendation for the use of intra-articular hyaluronic acid as a method of treatment for patients with osteoarthritis of the knee. Previous guidelines were inconclusive regarding this treatment.

“Fourteen studies assessed intra-articular hyaluronic acid injections, ” 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. “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 guidelines, according to the news release, are not meant to be stand alone documents but as points of reference and an educational tool for physicians and orthopaedic surgeons. Other 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 greater than 25 should lose a minimum of 5% of their body weight.
• Patients should begin or increase their participation in low-impact aerobic exercise.
• The AAOS work group suggests that patients with symptomatic OA of the knee receive one of the following analgesics for pain:
  • Acetaminophen (not to exceed 3, 000 mg per day)
  • Intra-articular corticosteroids
  • Non-steroidal anti inflammatory drugs
• Treatments that the AAOS Work Group does not recommend are:
  • Custom made lateral wedge insoles
  • Glucosamine and/or chondroitin sulfate or hydrochloride
  • Needle lavage (aspiration of the joint with injection of saline)

Although acupuncture continues to grow in popularity, the work group found that evidence did not support its use in patients with OA of the knee. The group is also 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 Jevsevar. “However, not all are effective. There needs to be more and better testing, since results are still inconclusive.”