Recommendations on hip and foot alignment interventions
When it comes to alignment and joint stresses, the knee is sometimes considered the innocent bystander of hip and foot alignment.
Insoles. How the hip and foot align with each can determine the amount of weight that passes through the medial (inner) or lateral (outer) compartment of the knee. To that end, lateral foot insoles have been used in the past for unloading parts of the knee.
Nevertheless, recent evidence has failed to demonstrate a significant benefit for insoles in the setting of OA knee pain, earning the practice a strong recommendation against its use.
High-tibial osteotomy (HTO). The weight-bearing axis of the lower-extremity axis can also be realigned with HTO. The procedure shifts the body’s weight slightly to the opposite side of the knee.
Newer research has led the practice to be downgraded one level in the new guideline, from moderate to limited, despite its widespread use.
It will, however, likely continue to be used as an alternative to total knee replacement in younger patients and to shift weight away from an area of the knee where cartilage is being restored with a concomitant surgical procedure, according to the work group. They noted that additional research studies on the long-term efficacy of the procedure are still needed.
Topical treatments. The guideline authors gave these a strong recommendation. Gels with anti-inflammatory medication have long been available but were prescription only or of considerable cost. Now several affordable over-the-counter options with the same prescription strength can be found in pharmacies and supermarkets.
What makes these medications unique is that they have an NSAID medication in the formulation, which the vast majority of topical treatments found on shelves do not. They also benefit patients who are unable to tolerate oral NSAIDs because of gastrointestinal side effects.
Comparison with 2019 OARSI recommendations
In 2019, the Osteoarthritis Research Society International also published guidelines for the management of OA of the hand, hip, and knee.
Dr. Thomas Trojian
Thomas Trojian, MD, a family medicine physician with expertise in sports medicine in York, Pa., and member of both the AAOS and OARSI recommendation committees, noted that the OARSI guidelines are meant to be practical guidelines of stepwise nonoperative treatment.
He said in an interview that “the OARSI guidelines recommend dietary weight management, education, and land-based [exercise] therapy, next topical NSAIDs, then injection therapy.”
Intra-articular steroids and viscosupplementation injection therapy in the form of hyaluronic acid derivatives continue to be a mainstay of treatment for both groups.
The AAOS group notably gave a moderate strength recommendation for intra-articular steroid injections with the caveat that the effects typically only last for 3 months. They also included newer extended-release steroid injections in the recommendation, stating that the evidence moderately suggests they provide more benefit than traditional short-acting steroid injections.
Methodology differs between guidelines
In the areas where the guidelines don’t fully line up, it is important to remember the methodology of each group often drives the guidelines and recommendations.
Dr. Yale Fillingham
According to Yale Fillingham, MD, an orthopedic surgeon in group private practice in the greater Philadelphia area and the other cochair of the AAOS guidelines committee, the biggest difference between the AAOS and OARSI guidelines is that, although the OARSI guidelines are also grounded in the literature, the recommendation level was based on voting among panel members.
“The AAOS methodology requires the recommendation and strength of the recommendation to be dictated primarily by the best available evidence in the literature and much less on the expertise and opinion of the voting panel,” Dr. Fillingham said in an interview.
He pointed out that the AAOS voting panel can alter the guideline by adjusting the strength of the recommendation but noted it was only in very clearly defined situations. Therefore, the differences in methodology between the groups make it difficult to directly compare the two guidelines.
Multiple guidelines do, however, point to the importance of the issue. Dr. Fillingham commented: “The numerous organizations that have produced guidelines on the treatment of knee osteoarthritis are a testament to the widespread and profound impact of knee osteoarthritis on our health care system and society.”
As a member of both recommendation groups, Dr. Trojian finds both guidelines reveal the importance of understanding that knee OA is a chronic illness. “There are ways we can manage knee OA and reduce the morbidity. ... The core skills of motivational interviewing are important. Open-ended questions, affirmation, reflection, and summarizing are needed to help patients find and remove roadblocks to promote lifestyle changes.”
Dr. Brophy, Dr. Trojian, and Dr. Fillingham have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.