Knee Osteoarthritis Guidelines for Decision Making

The recommendations of the EULAR 2009 Guidelines for the diagnosis of knee osteoarthritis (1) states that diagnosis of osteoarthritis can be made in patients over 40 yrs of age who have all three symptoms (persistent knee pain, morning stiffness, and function limitation) and  also have all three signs (crepitus, restricted movement, and bony enlargement. X-rays, they state are not necessary for diagnosis. If a palpable effusion is present, then it should aspirated and lab studies performed to rule out infection and gout and pseudogout.

The National Insitute for Clinical Excellence (NICE) osteoarthritis care guidelines (2) make a number of useful recommendations.

First, there should be a holistic evaluation of the patient with osteoarthritis. This means basically that effects on the patient of the disease should be assessed in every facet of his or her life. The Knee Injury and Osteoarthritis Outcome Score (KOOS) is an excellent instrument for this purpose and asks the patient detailed questions on knee pain and function and it is available online at http://www.orthopaedicscore.com/scorepages/knee_injury_osteopaedic_outcome_score.html.

Another useful questionnaire to follow knee and/or hip osteoarthritis is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) available online at
http://www.orthopaedicscore.com/scorepages/knee_injury_osteopaedic_outcome_score_womac.html.

Second, all patients need education on the condition, aerobic exercise training and strengthening.

Third, if these interventions are insufficient then acetaminophen and topical NSAIDS are recommended.

Fourth, additional medicines including NSAIDS and intra-articular steroid injection can be considered as well supports and braces, TENS unit, and manipulation and stretching [physical therapy]. If NSAIDS and/or acetaminophen give insufficient relief, then opiods should be considered after careful risk assessment.

Finally, joint surgery should be considered only after the first four steps have been tried.
“Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on
their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain.” [I think the KOOS instrument discussed above can be helpful.]

The American Academy of Orthopedic Surgeons (AAOS) has recommendations for when surgery for osteoarthritis is indicated (these recommendations do not discuss total knee replacement).(3,4)
What follows are some of the recommendations of the AAOS:

Intra-articular steroid injection of the knee is indicated for short term pain relief.

The AAOS has no recommendation for or against the intra-articular injection of hyaluronic acid for patients with mild to moderate osteoarthritis knee pain.

The group recommends against needle lavage of the knee.

The AAOS recommends “against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee.”

The AAOS states that  “Arthroscopic partial meniscectomy or loose body removal is an option in patients with symptomatic OA of the knee who also have primary signs and symptoms of a torn meniscus and/or a loose body.”

Other recommendations include weight loss for those who are overweight (body mass index greater than 25), low impact aerobic exercise, and quadriceps strengthening exercise.

There are  a total of twenty-two AAOS recommendations for the treatment of osteoarthritis of the knee(4) and the full guideline supplies the rationale for the recommendations.(3)

The American College of Radiology has recommendations on the imaging of non-traumatic
knee pain.(5) The document considers a total of 11 clinical variants of non-traumatic knee pain. Some variants are children and adolescents and some for adults.

The document recommends  anteroposterior (AP) and lateral knee x-rays for non-traumatic knee pain.

For patients with anterior knee pain, an axial x-ray called a Merchant view in 45 degrees flexion may be indicated. Anterior knee pain is dull pain or aching located on the sides of the kneecap, below the kneecap, or behind the knee cap.

Finally, evidence suggests that arthroscopic debridement of osteoarthritis of the knee, is no more effective than non-operative treatment (See Ref 6 for details). Note that the American Academy of Orthopedic Surgeons agree with this as noted above. (3,4)

(1) EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis 2009 Recommendations Supplement Online Web Only data available at (click on link View Appendix 1)
http://ard.bmj.com/content/suppl/2010/04/16/ard.2009.113100.DC1.html.

(2) The National Institute for Clinical Excellence (NICE) Osteoarthritis Guideline: The Care and Management of Osteoarthritis in Adults available at
http://www.nice.org.uk/nicemedia/pdf/CG59NICEguideline.pdf’

(3) The American Academy of Orthepedic Surgeons Osteoarthritis Guidelines (complete) are available at http://www.aaos.org/research/guidelines/OAKguideline.pdf’

(4) The AAOS Osteoarthritis Summary of Recommendations only are available at
http://www.aaos.org/research/guidelines/OAKrecommendations.pdf.

(5) The American College of Radiology Appropriateness Criteria [for imaging]: Nontraumatic Knee Pain available at
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/NonTraumaticKneePainDoc15.aspx.

(6) Arthroscopic Surgery for Osteoarthritis of the Knee? Editorial, New England Journal of Medicine, 2008, available at http://www.nejm.org/doi/full/10.1056/NEJMe0804450#t=article.

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