2 Edition - American Academy of Orthopaedic Surgeons

1 Please cite this guideline as: American Academy of Orthopaedic Surgeons . Treatment of Osteoarthritis of the Knee 2nd Edition Evidence-Based Clinical Practice Guideline. Published May 18, 2013. Treatment of Osteoarthritis of the Knee 2nd Edition Evidence-Based Clinical Practice Guideline Adopted by: The American Academy of Orthopaedic Surgeons Board of Directors May 18, 2013 Disclaimer This clinical practice guideline was developed by an AAOS work group comprised of volunteer physicians and interdisciplinary clinicians as well as staff researchers with expertise in systematic reviews and statistical methods used to evaluate empirical evidence.

2 It is an educational tool that integrates the current scientific literature and the proficiency and sound judgment that physicians typically acquire in clinical practice. The recommendations that make up this guideline are not intended to be absolute as patients vary in how they experience symptoms and respond to treatment interventions. There may be variability between patients in practice and those who participate in clinical trials. Medical care should always be based on a physician s expertise that is individually tailored to the patient s circumstances, preferences and rights.

3 Disclosure Requirement In accordance with AAOS policy, all individuals whose names appear as authors or contributors to this clinical practice guideline provided full disclosure of and were vetted for potential conflicts of interest prior to the introductory meeting. Funding Source The American Academy of Orthopaedic Surgeons funded this clinical practice guideline without any financial support from outside commercial sources. FDA Clearance Some drugs or medical devices referenced or described in this clinical practice guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only.

4 The FDA has stated that it is the responsibility of the physician to determine the clearance status of each drug or device prescribed in clinical practice. Copyright All rights reserved. No part of this clinical practice guideline may be reproduced or stored in a retrieval system or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without prior written permission from the AAOS. Published 2013 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018 Second Edition Copyright 2013 by the American Academy of Orthopaedic Surgeons ii TABLE OF CONTENTS Table of Contents.

5 Iii List of Tables .. ix List of Figures .. xv Summary of Recommendations .. 1 Conservative Treatments: Recommendations 1-6 .. 1 Recommendation 1 .. 1 Recommendation 2 .. 1 Recommendation 2 Recommendation 3b .. 2 Recommendation 2 Recommendation 4 .. 2 Recommendation 5 .. 3 Recommendation 6 .. 3 Pharmacologic Treatments: Recommendation 7 .. 3 Recommendation 3 Recommendation 7b .. 4 Procedural Treatments: Recommendations 8-11 .. 4 Recommendation 8 .. 4 Recommendation 9 .. 4 Recommendation 10 .. 5 Recommendation 11 .. 5 Surgical Treatments: Recommendations 12-15.

6 5 Recommendation 12 .. 5 Recommendation 13 .. 5 Recommendation 14 .. 6 Recommendation 15 .. 6 Introduction .. 7 Overview .. 7 Goals and Rationale .. 7 Intended Users .. 7 Patient Population .. 8 Scope .. 8 Etiology .. 8 Incidence and Prevalence .. 8 Burden of Disease .. 9 Emotional and Physical Impact .. 9 Potential Benefits, Harm, and Contraindications .. 9 Differences Between the Present and Previous Guidelines .. 9 Preventing Bias in an AAOS Clinical Practice Guideline .. 11 14 Formulating Preliminary Recommendations.

7 14 Full Disclosure Information .. 14 Study Selection Criteria .. 14 Best Evidence Synthesis .. 15 Outcomes Considered .. 16 iii Literature 16 Appraising Evidence Quality and Applicability .. 16 16 Applicability .. 18 Minimum Clinically Important Improvement .. 18 Grade of Recommendation .. 19 Defining the Strength of the Recommendations .. 20 Wording of the Final Recommendations .. 20 Consensus Recommendations .. 22 Voting on the Recommendations .. 22 Statistical Methods .. 23 Network Meta-Analysis .. 23 Placebo Data Regression 24 Inclusion Criteria.

8 24 Statistical Analysis .. 24 Results .. 25 New To Meta-Analysis In This Guideline: Minimal Important Difference (MID) Units .. 25 Peer Review .. 26 Public 27 The AAOS Guideline Approval Process .. 28 Revision Plans .. 28 Guideline Dissemination Plans .. 28 AAOS Clinical Guideline on Treating Osteoarthritis of the Knee .. 31 Guideline Recommendations .. 31 Recommendation 1 .. 31 Rationale .. 31 Supporting Evidence .. 32 32 Applicability .. 34 Final Strength of 35 Results .. 46 Evidence Tables and Figures .. 61 Quality and Applicability.

9 61 98 Recommendation 2 .. 138 Rationale .. 138 Supporting Evidence .. 138 138 Applicability .. 139 Final Strength of 139 Results .. 141 Evidence Tables and Figures .. 146 Quality and Applicability .. 146 152 Recommendation 159 iv Recommendation 3b .. 159 Recommendation 159 Rationale .. 159 Supporting Evidence .. 161 161 Applicability .. 162 Final Strength of 162 Results .. 170 Evidence Tables and Figures .. 177 Quality and Applicability .. 177 201 Recommendation 4 .. 228 Rationale .. 228 Supporting Evidence.

10 228 228 Applicability .. 228 Final Strength of 229 Results .. 230 Evidence Tables and Figures .. 234 Quality and Applicability .. 234 241 Recommendation 5 .. 249 Rationale .. 249 Supporting Evidence .. 249 249 Applicability .. 249 Final Strength of 250 Results .. 251 Evidence Tables and Figures .. 253 Quality and Applicability .. 253 256 Recommendation 6 .. 262 Rationale .. 262 Supporting Evidence .. 263 263 Applicability .. 263 Final Strength of 263 Results .. 273 Evidence Tables and Figures .. 279 Quality and Applicability.