New research has looked into how the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines have affected the use of hyaluronic acid and corticosteroid injections for knee osteoarthritis (OA).
Lower Rates of Knee Injections per AAOS Guidelines
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#osteoarthritisSecondary#knee#corticosteroids
The study, “Impact of Clinical Practice Guidelines on Use of Intra-Articular Hyaluronic Acid and Corticosteroid Injections for Knee Osteoarthritis,” was published in the May 16, 2018 edition of The Journal of Bone and Joint Surgery.
Co-author Nicholas Bedard, M.D. is with the Department of Orthopaedics & Rehabilitation at the University of Iowa Hospitals and Clinics. He commented to OTW, “We are particularly interested in improving the value of care provided to patients and wanted to know whether interventions such as clinical practice guidelines are helping to improve care for patients with knee osteoarthritis.”
The authors wrote, “Of 1,065,175 patients with knee osteoarthritis, 405,101 (38.0%) received a corticosteroid injection and 137,005 (12.9%) received a hyaluronic acid injection.”
“The rate of increase in hyaluronic acid use, per 100 patients with knee osteoarthritis, decreased from 0.15 to 0.07 injection per quarter year after the first clinical practice guidelines, and the increase changed to a decrease at a rate of -0.12 injection per quarter after the second clinical practice guideline.”
“After the first clinical practice guideline, the rate of increase in utilization of corticosteroids, per 100 patients with knee osteoarthritis, significantly lessened to 0.12 injections per quarter, and after the second clinical practice guideline, corticosteroid injection use plateaued.”
“The trend in use of hyaluronic acid injections by orthopaedic surgeons and pain specialists decreased with time following the second-edition clinical practice guideline but did not change for primary care physicians or nonoperative musculoskeletal providers.”
Dr. Bedard commented to OTW “There have been subtle but significant changes in the use of hyaluronic acid and corticosteroid injections in response to published clinical practice guidelines. However, overall these injections remain in relatively common use.”
“We hope that this project helps to shed light on the important clinical practice guidelines created by AAOS and further encourages providers to follow these recommendations, share them with their patients, and utilize them as a guide to improve the value of care provided to patients with knee osteoarthritis.”
The logical next question is, how did the rate of self-medication or knee surgery change following AAOS’ clinical practice guidelines? If injections declined, did something else increase?
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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