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Revised Clinical Practice Guideline for Knee OA

Viscosupplementation questioned (June 4)

The American Academy of Orthopaedic Surgeons (AAOS), with input from the American College of Rheumatology, the American Academy of Family Practice, and the American Physical Therapy Association, has published a collaborative clinical practice guideline (CPG) on the Treatment of Osteoarthritis (OA) of the Knee (Non-Arthroplasty) — 2nd Edition. This evidence-based guideline replaces the 2008 AAOS CPG.

The 2013 OA knee-treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an “inconclusive” recommendation regarding the use of intra-articular hyaluronic acid (HA) injections.

The second-edition CPG recommendation reads: “We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee,” with a “strong” rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria.

Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement.

Changes in the strength of the new CPG’s recommendations were based on their supporting evidence. For example, the recommendation on the use of intra-articular corticosteroid injections went from “We suggest …” to “We are unable to recommend for or against the use of …” Although some reviewers expressed concern about this change to a lower rating, intra-articular corticosteroid injections remain supported in clinical practice.

In addition, the recommendation on arthroscopic meniscectomy increased in strength from a consensus to an inconclusive recommendation, which is now supported by evidence and is no longer based solely on expert opinion. The current inconclusive recommendation helps the AAOS to support this procedure in patients with knee OA.

Sources: AAOS; June 4, 2013; and OA Guideline; May 18, 2013.

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