Nonsurgical management of hip and knee osteoarthritis

New osteoarthritis treatment guidelines for hip and knee cite strong evidence for the benefits of exercise and physical therapy, according to Joseph A. O’Daniel Jr. , M.D., a hip and knee specialist with Norton Orthopedic Institute.

New osteoarthritis treatment guidelines for hip and knee cite strong evidence for the benefits of exercise and physical therapy.

Moderate evidence also supports weight loss for knee pain, though the same evidence doesn’t exist for hip pain, based on the new guidance from the American Academy of Orthopaedic Surgeons (AAOS).

“Even in patients with symptomatic osteoarthritis, there is strong evidence showing physical therapy benefits can last up to nine months after treatment is stopped,” said Joseph A. O’Daniel Jr., M.D., a hip and knee specialist with Norton Orthopedic Institute. “While there isn’t evidence to support weight loss as a treatment of osteoarthritis of the hip, the AAOS advised that it may be beneficial as a nonsurgical approach to manage pain, function and quality of life.”

The AAOS clinical guidelines strongly favor NSAIDs and acetaminophen for symptom management for hips and knees.

A meta-analysis of oral acetaminophen compared with controls demonstrated a meaningful reduction in pain and improved function. Major clinical guidelines, including the American College of Rheumatology, European Alliance of Associations for Rheumatology (EULAR), Osteoarthritis Research Society International, and the United Kingdom’s National Institute for Health and Care Excellence, recommend acetaminophen as the first choice for mild-to-moderate osteoarthritis-related pain because of its safety and effectiveness.

EULAR guidelines also state that if acetaminophen treatment is successful, it should be used for long-term analgesia. If acetaminophen fails, according to the guidelines, nonsteroidal anti-inflammatory drugs (NSAIDs) should be given at the lowest effective dose to avoid or reduce side effects.

A meta-analysis of nonselective oral NSAIDs compared with controls also demonstrated a meaningful reduction in pain. Studies also have shown nonselective and selective cyclooxygenase-2 (COX-2) oral NSAIDs consistently improved pain and function, compared with  controls.

Narcotics are not recommended; chondroitin and glucosamine don’t appear effective

The AAOC does not recommend narcotics. Narcotic use to treat osteoarthritis of the knee and hip is consistently associated with a significantly high risk of adverse events. Five high-quality and two moderate quality studies also show oral narcotics are not an effective treatment to reduce pain and improve function in osteoarthritis of the knee.

“Given the effective and relatively safe alternatives of oral NSAIDs and acetaminophen, oral narcotics should be avoided when the provider is considering the recommendation of an oral medication,” Dr. O’Daniel said.

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Chondroitin sulfate CPG has shown limited evidence of effectiveness. Chondroitin or glucosamine, alone or in combination, did not have a clinically relevant effect on perceived joint pain or on joint space narrowing.

A pair of studies have shown ginger extract may be used to improve pain in patients with osteoarthritis of the knee, though there was no significant difference in function between ginger extract and control. Other studies have shown those outcomes were not superior to those patients taking Vitamin D supplements

New evidence supporting high molecular cross-linked hyaluronic acid

The AAOC has changed guidance on viscosupplementation/hyaluronic acid injections. The guidelines report statistically significant improvements associated with high molecular cross-linked hyaluronic acid. Approval for this treatment varies by insurer and may require prior authorization. Patients should expect a two- to three-week lead time and injections every six months.

Moderate evidence supports intra-articular steroid injections to treat knee osteoarthritis. Overall pain and function improved with intra-articular corticosteroids, though the benefits typically only last three months. Intra-articular steroid injections are no longer recommended for hip osteoarthritis. A study that looked at 129 injections for osteoarthritis in the hip found a 21% incidence of rapidly destructive osteoarthritis (RDOA).

No evidence supports stem cell therapy for osteoarthritis of the knee or hip. Clinics offering stem cell therapy generally claim a high success rate, but when researchers contacted 317 of these clinics, none had any data to support their claims. In a study presented at the annual meeting of AAOS, the researchers found the cost for stem therapy raged from $1,150 to $12,000, with prices unrelated to the success rate claimed by the clinics.

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