Treatment of Osteoarthritis of the Knee – 2 Edition

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. 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.

2 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. 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. 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.

3 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 .. 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 4 Recommendation 10 .. 5 Recommendation 11 .. 5 Surgical Treatments: Recommendations 12-15 .. 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 .. 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.

5 20 Consensus Recommendations .. 22 Voting on the Recommendations .. 22 Statistical Methods .. 23 Network Meta-Analysis .. 23 Placebo Data Regression 24 Inclusion Criteria .. 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 .. 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.

6 159 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 .. 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 .. 279 306 Recommendation 342 Recommendation 7b .. 342 Rationale .. 342 Supporting Evidence .. 343 343 v Applicability .. 343 Final Strength of 344 Results.

7 429 Evidence Tables and Figures .. 441 Quality and Applicability .. 441 624 Recommendation 8 .. 747 Rationale .. 747 Supporting Evidence .. 747 747 Applicability .. 748 Final Strength of 748 Results .. 752 Evidence Tables and Figures .. 754 Quality and Applicability .. 754 762 Recommendation 9 .. 770 Rationale .. 770 Supporting Evidence .. 771 771 Applicability .. 771 Final Strength of 772 Results .. 783 Evidence Tables and Figures .. 789 Quality and Applicability .. 789 813 Recommendation 10 .. 854 Rationale .. 854 Supporting Evidence .. 854 854 Applicability .. 854 Final Strength of 855 Results .. 856 Evidence Tables and Figures .. 857 Quality and Applicability .. 857 860 Recommendation 11 .. 863 Rationale .. 863 Supporting Evidence .. 863 863 Applicability .. 864 Final Strength of 864 Results .. 865 Evidence Tables and Figures .. 867 Quality and Applicability .. 867 871 vi Recommendation 12 .. 876 Rationale .. 876 Supporting Evidence.

8 877 877 Applicability .. 877 Final Strength of 877 Results .. 887 Evidence Tables and Figures .. 889 Quality and Applicability .. 889 913 Recommendation 13 .. 932 Rationale .. 932 Supporting Evidence .. 932 932 Applicability .. 932 Final Strength of 932 Results .. 934 Evidence Tables and Figures .. 935 Quality and Applicability .. 935 937 Recommendation 14 .. 939 Rationale .. 939 Supporting Evidence .. 939 939 Applicability .. 939 Final Strength of 940 Results .. 945 Evidence Tables and Figures .. 946 Quality and Applicability .. 946 956 Recommendation 15 .. 969 Rationale .. 969 Supporting Evidence .. 969 969 Applicability .. 969 Final Strength of 970 Results .. 970 Evidence Tables and Figures .. 971 Quality and Applicability .. 971 972 Future Research .. 974 Appendix I .. 976 Work Group .. 976 Revision Work Group .. 976 Original Work Group .. 978 Appendix II .. 980 vii Decision-Makers Who Approve This Clinical Practice Guideline .. 980 Appendix III.

9 981 Determining Critical Outcomes .. 981 Work Group Participation .. 981 Critical Outcomes Form .. 981 Determining Outcomes .. 981 Appendix 985 Study Attrition Flowchart .. 985 Appendix V .. 986 Literature Search Strategies .. 986 PubMed/MEDLINE .. 986 Embase .. 988 Cochrane Library (Wiley Interface).. 990 Appendix 992 Quality and Applicability Appraisal .. 992 992 Applicability .. 997 Appendix VII .. 1000 Form For Assigning Strength of Recommendation .. 1000 Appendix VIII .. 1001 Opinion Based Recommendations .. 1001 Rules for Making Opinion Based Recommendations .. 1001 Checklist For Voting on Opinion Based Recommendations .. 1002 Voting by the Nominal Group Technique .. 1002 Appendix 1003 Structured Peer Review Form .. 1003 Appendix X .. 1007 Participating Peer Review Organizations .. 1007 Appendix 1008 Interpreting the Forest Plots .. 1008 Abbreviations Used In This Report .. 1008 Appendix XII .. 1010 Conflict of Interest .. 1010 Appendix XIII .. 1012 Network Meta Analysis Checks for Consistency.

10 1012 Appendix XIV .. 1022 Confidence Intervals of Treatment Effects that Range in Statistical and Clinical Signficance .. 1022 Appendix XV .. 1023 Bibliography .. 1023 Additional References .. 1040 Excluded Studies .. 1051 viii LIST OF TABLES Table 1. Relationship between Quality and Domain Scores for Treatment Studies .. 17 Table 2. Relationship between Applicability and Domain Scores for Treatment Studies 18 Table 3. Brief Description of the PRECIS Questions and 18 Table 4. Descriptive Terms for Results with MCII .. 19 Table 5. AAOS Guideline Language .. 20 Table 6. Recommendation Strengths, Descriptions, and Clinical Implications .. 21 Table 7. Quality and Applicability Summary: Strength Training Versus Control .. 35 Table 8 Quality and Applicability Summary: Isokinetic Versus Isotonic Versus Isometric Strength Training .. 36 Table 9. Quality and Applicability Summary: High Versus Low Resistance Strength Training .. 36 Table 10. Quality and Applicability Summary: Isokinetic Versus Isotonic Versus Isometric Strength Training.