AAOS updates clinical practice guidelines for knee OA management
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The American Academy of Orthopaedic Surgeons issued an update to the clinical practice guideline for management of osteoarthritis of the knee.
Developed to include only treatments which are less invasive than knee replacement surgery to provide pain relief and improve patient function, the third edition of the clinical practice guideline updates 19 of the 29 evidence-based recommendations included in the previous guideline.
“Knee osteoarthritis is a highly prevalent, disabling joint disease commonly associated with aging and obesity,” Robert Brophy, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value, said in an AAOS release. “Considering the rising prevalence of knee osteoarthritis in the U.S. population, the AAOS felt it was important to update the guidelines in terms of the best evidence on how to manage these patients, particularly when they have early stages of the disease. The update represents a substantial investment by the AAOS over nearly 3 years to develop consensus around the latest research and offer recommendations regarding various treatment options for patients with knee osteoarthritis.”
According to the release, the guidelines suggest that patients with symptomatic OA of the knee receive acetaminophen that does not exceed 3,000 mg per day, intra-articular corticosteroids or oral anti-inflammatory drugs for pain relief unless contraindicated to the treatment. The release also noted that custom made lateral wedge insoles, glucosamine and/or chondroitin sulfate or hydrochloride and needle lavage and/or debridement are either not recommended or have inconsistent or limited evidence to support their use.
“We know that treatment for osteoarthritis is not a one-size-fits-all approach, and fortunately there are a number of treatment options for orthopedic surgeons to consider with their patients to help alleviate pain and increase mobility,” Brophy said. “The updated guideline includes recommendations for patients across the spectrum of disease severity, regarding a variety of nonsurgical treatments based on the current evidence. It is important for both surgeons and patients to remember that these are guiding principles, not prescriptions, on how to care for symptomatic knee osteoarthritis.”
Perspective
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The AAOS clinical practice guideline (CPG) process is frustrating. The statistical methodology for determining whether a particular treatment modality is useful is primarily based upon evaluation of level 1 studies, which unfortunately do not tell the entire story as to whether a particular modality is helpful in the treatment of a disease that has no cure. Furthermore, there is significant debate as to the committee’s interpretation of minimal clinical important improvement (MCII) and minimum clinically important difference (MCID) as it applies to the chosen literature that was reviewed by the CPG committee.
Unfortunately, insurers will justify their lack of coverage on any conclusion drawn by an AAOS CPG recommendation. This was exemplified in 2013 by the loss of reimbursement of hyaluronic acid reimbursement in more than 35 states by commercial insurers. The problem for the practicing orthopedic surgeon is this approach results in the loss of yet another tool in the orthopedic surgeons “toolbox” for a disease that has no cure.
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