The newly revised 2013 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for knee osteoarthritis (OA) has become a focus for discussion in both the orthopedic and general health care community.
The most significant changes from the 2008 clinical practice guideline is a strong recommendation AGAINST the use of the following treatments/procedures:
- Intraarticular Hyaluronic Acid (HA) injections a.k.a. “viscosupplementation.”
- the use of Acupuncture.
- the use of Glucosamine and Chondroitin sulfate.
- Arthroscopy with lavage for primary knee OA. (simply “scoping” the joint and washing/sucking out particulate matter, absent any actual repair/reconstruction)
The new guidelines also reduced the maximum dosage for acetaminophen from 4000 to 3000 mg/day. Interestingly, it does not recommend for or against the use of acetaminophen, opioids, or pain patches because evidence of effectiveness remains inconclusive.
The AAOS Committee on Evidence-Based Quality and Value, which oversees the development of clinical practice guidelines. reviewed 14 studies assessing the effectiveness of injections of Hyaluronic Acid (HA) into the knee joint. 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 for recommendation.
The new AAOS guidelines do recommend non-steroidal anti-inflammatory drugs (NSAIDs) and Tramadol (a semi-synthetic pain medicine) for patients with symptomatic OA of the knee. Again, the AAOS guidelines were “unable to recommend for or against the use of acetaminophen, opioids, or pain patches” because of inconclusive evidence. (Of the 15 areas addressed by the AAOS work group, 7 were judged to have inconclusive evidence for or against the specific treatment considered.)
In regard to acetaminophen, some critics of the new guidelines point out that none of the published studies look at combination acetaminophen therapy, which is often how the drug is used in actual practice. For example, acetaminophen in combination with tramadol is said by some to be more effective than tramadol alone for joint pain.
Other key recommendations in the new guidelines 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.
It should be kept in mind that virtually all guidelines include a caveat that the practice of medicine involves the individual patient and that, for the practitioner, guidelines are only suggestions. The problem with guidelines usually arise when third-party payers (insurance companies) decide to use the guidelines simply to justify what are basically economic decisions. It remains to be seen to what extent the insurance industry will use these new guidelines to assert itself in treatment decisions between patient and doctor.
The information above is provided for general information purposes only and should not be construed, under any circumstances, as treatment advice. The reader is advised to seek the counsel of his/her personal health care provider for specific treatment advice.