New Guidelines for Treatment of Knee Osteoarthritis

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The American Academy of Orthopaedic Surgeons (AAOS) released its recommendations in December 2008 for "best" practice guidelines. In looking at the commonly used treatments for osteoarthritis (OA), they underscored that many lack support from scientific evidence.

The AAOS guideline targets treatment for patients with OA of the knee whose disease has not progressed to the point of needing joint replacement surgery. It offers 22 treatment recommendations. The guideline is aimed at primary care physicians as well as orthopedic surgeons.

The guideline points to the importance of patient education and lifestyle modifications that have clear benefits. It recommends exercise (strength, flexibility, and aerobic). It recommends weight loss for patients with a body mass index greater than 25. Acetaminophen and nonsteroidal anti-inflammatory medications are recommended for pain relief.

In its new guideline on treating OA of the knee, the American Academy of Orthopaedic Surgeons recommends

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* Reduction of at least 5% of body weight in patients with OA of the knee and a body mass index greater than 25
* Low-impact aerobic fitness exercises
* Quadriceps strengthening
* Acetaminophen (not to exceed 4 g/d) or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. In addition, topical NSAIDs, oral NSAIDs with a gastroprotective agent, or cyclooxygenase 2 inhibitors are recommended for patients with OA of the knee who are at increased risk of gastrointestinal upset
* Intra-articular corticosteroids for short-term pain relief
* Arthroscopy as an option for patients with OA of the knee who also have a torn meniscus and/or a loose body, but is not useful if those complicating factors are not present.
* Patellar taping for short-term pain relief

Based on the evidence, the guideline does not recommend these treatments for OAof the knee:

* Needle lavage
* Glucosamine and/or chondroitin sulfate or hydrochloride
* Custom foot orthotics
* Arthroscopy with debridement or lavage in patients who do not have loose bodies and/or meniscal tears

As a consequence of inconclusive evidence, the guideline does not recommend for or against the following:

* Intra-articular hyaluronic acid for patients with mild to moderate symptoms of OA of the knee
* Bracing
* Acupuncture

Sources
Treatment of Osteoarthritis of the Knee (Non-arthroplasty). American Academy of Orthopaedic Surgeons; December 6, 2008.
Guideline Provides Evidence-Based Advice for Treating Osteoarthritis of the Knee; JAMA. 2009;301(5):475-476; Rebecca Voelker

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