The American Academy of Orthopaedic Surgeons (AAOS) has issued an update on clinical practice guidelines for the management of osteoarthritis of the knee (non-arthroplasty). This article presents salient recommendations from the update that will be helpful for practitioners to be better equipped in their clinical practice.

Clinical practice guidelines supported by research

As the second-most prevalent rheumatologic condition, osteoarthritis is the most common joint illness in India, with a frequency ranging from 22 per cent to 39 per cent. Women are more likely than males to suffer from OA. 70% of those over 65 years of age have OA radiological evidence, and over 45% are afflicted by symptoms, according to the National Institute on Aging (NIA).

As the population ages, and other risk factors including obesity and a sedentary lifestyle come into play, the possibility of OA increases. Physical impairment due to pain and diminished functional capability worsens health and makes patients more vulnerable to future illness. A balanced diet and regular exercise should be prioritised above highly effective medical treatment in the absence of other options.

An extensive evaluation of published research on non-arthroplasty therapy for osteoarthritis of the knee in adults led to the development of this clinical practice recommendation. As a result of its suggestions, practitioners will be better equipped to incorporate current knowledge into clinical practice, and research gaps will be highlighted. Physicians and professionals with adequate training who treat knee osteoarthritis should follow this recommendation.

The AAOS Osteoarthritis of the Knee Guideline physician development group (clinical experts) worked with the AAOS Clinical Quality and Value (CQV) department to create this clinical practise guideline (methodologists).

Salient recommendations

1. Lateral wedge insoles: They are not recommended for patients with knee osteoarthritis.
2. Canes: They could be used to improve pain and function in patients with knee osteoarthritis.
3. Braces: Brace treatment could be used to improve function, pain, and quality of life in patients with knee osteoarthritis.
4. Oral/dietary supplements: The following supplements may be helpful in reducing pain and improving function for patients with mild to moderate knee osteoarthritis; however, the evidence is inconsistent/limited and additional research clarifying the efficacy of each supplement is needed.
   1. Turmeric
   2. Ginger extract
   3. Glucosamine
   4. Chondroitin
   5. Vitamin D
5. Topical treatments: Topical NSAIDs should be used to improve function and quality of life for the treatment of osteoarthritis of the knee, when not contraindicated.
6. Supervised exercise: Supervised exercise, unsupervised exercise, and/or aquatic exercise are recommended over no exercise to improve pain and function for the treatment of knee osteoarthritis
7. Neuromuscular training: Neuromuscular training (i.e. balance, agility, coordination) programs in combination with traditional exercise could be used to improve performance-based function and walking speed for the treatment of knee osteoarthritis.
8. Self-management programs: They are recommended to improve pain and function for patients with knee osteoarthritis.
9. Patient education: Patient education programs are recommended to improve pain in patients with knee osteoarthritis.
10. Weight loss intervention: Sustained weight loss is recommended to improve pain and function in overweight and obese patients with knee osteoarthritis.
11. Manual therapy: Manual therapy in addition to an exercise program may be used to improve pain and function in patients with knee osteoarthritis.
12. Massage: It may be used in addition to usual care to improve pain and function in patients with knee osteoarthritis.
13. Laser treatment: FDA-approved laser treatment may be used to improve pain and function in patients with knee osteoarthritis.
14. Acupuncture: It may improve pain and function in patients with knee osteoarthritis.
15. Transcutaneous electrical nerve stimulation: Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include:
    1. Transcutaneous electrical nerve stimulation (pain)
    2. Strength of recommendation: Limited
16. Percutaneous electrical nerve stimulation/ pulsed electromagnetic field therapy: Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include:
    1. Percutaneous electrical nerve stimulation (pain and function)
    2. Pulsed electromagnetic field therapy (pain)
17. Extracorporeal shockwave therapy: It may be used to improve pain and function for the treatment of osteoarthritis of the knee.
18. Oral NSAIDs: They are recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.
19. Oral acetaminophen: It is recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated.
20. Oral narcotics: These medications, including tramadol, result in a significant increase of adverse events and are not effective at improving pain or function for the treatment of osteoarthritis of the knee.
21. Hyaluronic Acid: Intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee.
22. Intra-articular corticosteroids: They could provide short-term relief for patients with symptomatic osteoarthritis of the knee.
23. Platelet-rich plasma: It may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.
24. Denervation therapy: It may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee.
25. Lavage/debridement: Arthroscopy with lavage and/or debridement in patients with a primary diagnosis of knee osteoarthritis is not recommended.
26. Partial meniscectomy: Arthroscopic partial meniscectomy can be used for the treatment of meniscal tears in patients with concomitant mild to moderate osteoarthritis who have failed physical therapy or other nonsurgical treatments.
27. Tibial osteotomy: High tibial osteotomy may be considered to improve pain and function in properly indicated patients with unicompartmental knee osteoarthritis.
28. Dry needling: In the absence of reliable evidence, it is the opinion of the workgroup that the utility/efficacy of dry needling is unclear and requires additional evidence.
29. Free-floating interpositional devices: In the absence of reliable or new evidence, it is the opinion of the work group not to use free-floating (un-fixed) interpositional devices in patients with symptomatic medial compartment osteoarthritis of the knee.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.