After nearly a decade, the American Academy of Orthopaedic Surgeons has updated its guidance on nonoperative treatment for knee osteoarthritis.
Dr. Robert Brophy
The clinical practice guidelines, released Sept. 13, 2021, is the third edition of the orthopedic society’s clinical practice recommendations.
According to Robert Brophy, MD, FAAOS, an orthopedic surgeon at Washington University, St. Louis, and cochair of the AAOS clinical practice guideline work group, the AAOS guidelines are a “living document” that needs periodic updating as new research comes to light.
“The methodology for maintaining the AAOS guidelines aims to update guideline documents at least every 10 years,” Dr. Brophy said in an interview. “Since the last edition was from 2013, it was time to provide an updated guideline on this very important topic that affects such a high percentage of our patients and providers.”
The guidelines work group, composed of 12 medical doctors and 1 physical therapist, evaluated the evidence for 29 areas of treatment.
A rating scale based on available evidence and the strength of related medical studies labeled each treatment area as demonstrating strong, moderate, or limited evidence.
Eight treatment modalities weighed in with strong evidence for or against their use: lateral wedge insoles, topical or oral NSAIDs, exercise (supervised or unsupervised), self-management programs, patient education programs, oral acetaminophen, and oral opioids.
According to Dr. Brophy, many of the recommendations assigned a strong evidence base were similar to the prior edition of the guidelines.
Oral medications
NSAIDs and acetaminophen still remain steadfast options for the treatment of knee pain secondary to OA.
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The most notable change was that opioids, which have a long history of being used to treat pain, are strongly recommended not to be used for arthritis.
“Reflecting the growing awareness of and emphasis on the opioid epidemic, one of the strongest changes between the current and prior guidelines centers on the use of opioid medications,” Dr. Brophy said. “In the prior guideline, a strong recommendation was made in favor of tramadol with an inconclusive recommendation made regarding other opioid medications. The updated guideline demonstrates clearly the evidence does not support the use of opioid medications – including tramadol – to treat knee osteoarthritis.”
This may require some education for both patients and doctors to buy in that knee pain can be treated adequately with NSAIDs and acetaminophen.
Patients may not understand that anti-inflammatory drugs treat the pain they are experiencing. They may equate an opioid with a “pain pill” and may need education from their doctor that NSAIDs and acetaminophen not only can relieve their pain, but also avoid potential adverse events prior to or after surgery should they progress to knee replacement surgery.
Furthermore, primary care physicians may not be looking at the long-term picture. Solving a short-term pain problem with opioids may limit the medication’s ability to provide pain relief after surgery should a patient develop a tolerance to the medication’s effects.