Treatment of Osteoarthritis of the Knee Guideline

8/12/2019 Treatment of Osteoarthritis of the Knee Guideline

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TREATMENT OF OSTEOARTHRITIS OF THEKNEE

EVIDENCE-BASED GUIDELINE2ND EDITION

Adopted by the American Academy of Orthopaedic SurgeonsBoard of Directors

May 18, 2013


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DisclaimerThis clinical practice guideline was developed by an AAOS work group comprised ofvolunteer physicians and interdisciplinary clinicians as well as staff researchers withexpertise in systematic reviews and statistical methods used to evaluate empiricalevidence. It is an educational tool that integrates the current scientific literature and the

proficiency and sound judgment that physicians typically acquire in clinical practice. Therecommendations that make up this guideline are not intended to be absolute as patientsvary in how they experience symptoms and respond to treatment interventions. Theremay be variability between patients in practice and those who participate in clinical trials.Medical care should always be based on a physicians expertise that is individuallytailored to the patients circumstances, preferences and rights.

Disclosure RequirementIn accordance with AAOS policy, all individuals whose names appear as authors orcontributors to this clinical practice guideline provided full disclosure of and were vettedfor potential conflicts of interest prior to the introductory meeting.

Funding SourceThe American Academy of Orthopaedic Surgeons funded this clinical practice guidelinewithout any financial support from outside commercial sources.

FDA ClearanceSome drugs or medical devices referenced or described in this clinical practice guidelinemay 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.

CopyrightAll rights reserved. No part of this clinical practice guideline may be reproduced orstored in a retrieval system or transmitted in any form or by any means (electronic,mechanical, photocopying, recording, or otherwise) without prior written permissionfrom the AAOS.

Published 2013 by the American Academy of Orthopaedic Surgeons6300 North River RoadRosemont, IL 60018Second EditionCopyright 2013 by the American Academy of Orthopaedic Surgeons


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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 3a........................................................................................................ 1 Recommendation 3b ....................................................................................................... 2 Recommendation 3c........................................................................................................ 2 Recommendation 4 ......................................................................................................... 2 Recommendation 5 ......................................................................................................... 2 Recommendation 6 ......................................................................................................... 3

Pharmacologic Treatments: Recommendation 7 ................................................................ 3 Recommendation 7a........................................................................................................ 3 Recommendation 7b ....................................................................................................... 3

Procedural Treatments: Recommendation 8-11.................................................................. 4 Recommendation 8 ......................................................................................................... 4 Recommendation 9 ......................................................................................................... 4 Recommendation 10 ....................................................................................................... 4 Recommendation 11 ....................................................................................................... 4

Surgical Treatments: Recommendation 12-15 .................................................................... 5 Recommendation 12 ....................................................................................................... 5 Recommendation 13 ....................................................................................................... 5 Recommendation 14 ....................................................................................................... 5 Recommendation 15 ....................................................................................................... 5

Introduction ......................................................................................................................... 6 Overview ......................................................................................................................... 6 Goals and Rationale ........................................................................................................ 6 Intended Users ................................................................................................................ 6 Patient Population ........................................................................................................... 7 Scope ............................................................................................................................... 7 Etiology ........................................................................................................................... 7 Incidence and Prevalence ................................................................................................ 7 Burden of Disease ........................................................................................................... 8 Emotional and Physical Impact ...................................................................................... 8 Potential Benefits, Harm, and Contraindications ............................................................ 8 Differences Between the Present and Previous Guidelines ............................................ 8

Preventing Bias in an AAOS Clinical Practice Guideline ................................................ 10 Methods............................................................................................................................. 13

Formulating Preliminary Recommendations ................................................................ 13 Full Disclosure Information .......................................................................................... 13 Study Selection Criteria ................................................................................................ 13 Best Evidence Synthesis ............................................................................................... 14 Outcomes Considered ................................................................................................... 15


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Literature Searches........................................................................................................ 15 Appraising Evidence Quality and Applicability ........................................................... 15

Quality ....................................................................................................................... 15 Applicability .............................................................................................................. 17

Minimum Clinically Important Improvement .............................................................. 17

Grade of Recommendation ........................................................................................... 18 Defining the Strength of the Recommendations ........................................................... 19 Wording of the Final Recommendations ...................................................................... 19 Consensus Recommendations ....................................................................................... 21 Voting on the Recommendations .................................................................................. 21 Statistical Methods ........................................................................................................ 22

Network Meta-Analysis ............................................................................................ 22 Placebo Data Regression Analysis............................................................................ 23

Inclusion Criteria .................................................................................................. 23 Statistical Analysis ................................................................................................ 23 Results ................................................................................................................... 24

New To Meta-Analysis In This Guideline: Minimal Important Difference (MID)Units .......................................................................................................................... 24 Peer Review .................................................................................................................. 25 Public Comment............................................................................................................ 26 The AAOS Guideline Approval Process ...................................................................... 27 Revision Plans ............................................................................................................... 27 Guideline Dissemination Plans ..................................................................................... 27

AAOS Clinical Guideline on Treating Osteoarthritis of the Knee ................................... 30 Guideline Recommendations ............................................................................................ 30

Recommendation 1 ....................................................................................................... 30 Rationale ................................................................................................................... 30 Supporting Evidence ................................................................................................. 31

Quality................................................................................................................... 31 Applicability ......................................................................................................... 33 Final Strength of Evidence.................................................................................... 34 Results ................................................................................................................... 45

Evidence Tables and Figures .................................................................................... 60 Quality and Applicability ...................................................................................... 60 Findings................................................................................................................. 97

Recommendation 2 ..................................................................................................... 137 Rationale ................................................................................................................. 137 Supporting Evidence ............................................................................................... 137

Quality................................................................................................................. 137 Applicability ....................................................................................................... 138 Final Strength of Evidence.................................................................................. 138 Results ................................................................................................................. 140

Evidence Tables and Figures .................................................................................. 145 Quality and Applicability .................................................................................... 145 Findings............................................................................................................... 151

Recommendation 3a.................................................................................................... 158


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Recommendation 3b ................................................................................................... 158 Recommendation 3c.................................................................................................... 158

Rationale ................................................................................................................. 158 Supporting Evidence ............................................................................................... 160

Quality................................................................................................................. 160

Applicability ....................................................................................................... 161 Final Strength of Evidence.................................................................................. 161 Results ................................................................................................................. 169



Quality................................................................................................................. 227 Applicability ....................................................................................................... 227

Final Strength of Evidence.................................................................................. 228

Results ................................................................................................................. 229 Evidence Tables and Figures .................................................................................. 233

Quality and Applicability .................................................................................... 233 Findings............................................................................................................... 240







Recommendation 7a.................................................................................................... 341 Recommendation 7b ................................................................................................... 341


Quality................................................................................................................. 342


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Applicability ....................................................................................................... 342 Final Strength of Evidence.................................................................................. 343 Results ................................................................................................................. 428

Evidence Tables and Figures .................................................................................. 440 Quality and Applicability .................................................................................... 440

Findings............................................................................................................... 624 Recommendation 8 ..................................................................................................... 747 Rationale ................................................................................................................. 747 Supporting Evidence ............................................................................................... 747



Recommendation 9 ..................................................................................................... 770




Recommendation 10 ................................................................................................... 854 Rationale ................................................................................................................. 854 Supporting Evidence ............................................................................................... 854







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Quality................................................................................................................. 877 Applicability ....................................................................................................... 877

Final Strength of Evidence.................................................................................. 877 Results ................................................................................................................. 887 Evidence Tables and Figures .................................................................................. 889

Quality and Applicability .................................................................................... 889 Findings............................................................................................................... 913


Quality................................................................................................................. 932 Applicability ....................................................................................................... 932 Final Strength of Evidence.................................................................................. 932

Results ................................................................................................................. 934








Future Research .......................................................................................................... 974 Appendix I .................................................................................................................. 976

Work Group ............................................................................................................ 976 Revision Work Group ............................................................................................. 976 Original Work Group .............................................................................................. 937

Appendix II ................................................................................................................. 939


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Decision-Makers Who Approve This Clinical Practice Guideline ......................... 939 Appendix III ................................................................................................................ 940 Determining Critical Outcomes .................................................................................. 940

Work Group Participation ....................................................................................... 940 Critical Outcomes Form .......................................................................................... 940

Determining Outcomes ....................................................................................... 940 Appendix IV................................................................................................................ 944 Study Attrition Flowchart ....................................................................................... 944

Appendix V ................................................................................................................. 945 Literature Search Strategies .................................................................................... 945

PubMed/MEDLINE ............................................................................................ 945 Embase ................................................................................................................ 947 Cochrane Library (Wiley Interface).................................................................... 949

Appendix VI................................................................................................................ 951 Quality and Applicability Questions ....................................................................... 951 Studies of Interventions .......................................................................................... 951

Quality..................................................................................................................... 951

Applicability ........................................................................................................... 953 Appendix VII .............................................................................................................. 954

Form For Assigning Strength of Recommendation ................................................ 954 Appendix VIII ............................................................................................................. 955

Opinion Based Recommendations .......................................................................... 955 Rules for Making Opinion Based Recommendations ............................................. 955 Checklist For Voting on Opinion Based Recommendations .................................. 956 Voting by the Nominal Group Technique .............................................................. 956

Appendix IX................................................................................................................ 957 Structured Peer Review Form ................................................................................. 957

Appendix X ................................................................................................................. 961 Participating Peer Review Organizations ............................................................... 961

Appendix XI................................................................................................................ 962 Interpreting the Forest Plots .................................................................................... 962 Abbreviations Used In This Report ........................................................................ 962

Appendix XII .............................................................................................................. 964 Conflict of Interest .................................................................................................. 964

Appendix XIII ............................................................................................................. 965 Network Meta Analysis Checks for Consistency ................................................... 965

Appendix XIV ............................................................................................................. 975 Confidence Intervals of Treatment Effects that Range in Statistical and ClinicalSignficance .............................................................................................................. 975

Appendix XV .............................................................................................................. 976 Bibliography ........................................................................................................... 976 Additional References ............................................................................................. 994 Excluded Studies ................................................................................................... 1005


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LIST OF TABLESTable 1. Relationship between Quality and Domain Scores for Interventions ................. 16 Table 2. Relationship between Applicability and Domain Scores for Interventions ........ 17 Table 3. Brief Description of the PRECIS Questions and Domains................................. 17 Table 4. Descriptive Terms for Results with MCII .......................................................... 18 Table 5. AAOS Guideline Language ................................................................................ 19 Table 6. Recommendation Strengths, Descriptions, and Clinical Implications ............... 20 Table 7. Quality and Applicability Summary: Strength Training Versus Control ........... 34 Table 8 Quality and Applicability Summary: Isokinetic Versus Isotonic Versus IsometricStrength Training .............................................................................................................. 35 Table 9. Quality and Applicability Summary: High Versus Low Resistance StrengthTraining ............................................................................................................................. 35 Table 10. Quality and Applicability Summary: Isokinetic Versus Isotonic VersusIsometric Strength Training .............................................................................................. 35 Table 11. Quality and Applicability Summary: Proprioception Versus Control .............. 36 Table 12. Quality and Applicability Summary: Physical Therapy Versus Control .......... 36 Table 13. Quality and Applicability Summary: Kinesthesia Plus Strengthening VersusStrengthening Only ........................................................................................................... 38 Table 14. Quality and Applicability Summary: Agility Plus Perturbation Versus StandardExercise Therapy .............................................................................................................. 38 Table 15. Quality and Applicability Summary: Self-Management Plus Exercise VersusExercise Alone .................................................................................................................. 39 Table 16. Quality and Applicability Summary: Aerobic Exercise Versus Education ...... 39 Table 17. Quality and Applicability Summary: Home-Based Exercise, Self-Management,and Coping Strategies Versus Usual Care ........................................................................ 40 Table 18. Quality and Applicability Summary: Water Versus Land-Based Exercises .... 43 Table 19. Quality and Applicability Summary: Supervised Walking Versus Usual Care 43 Table 20. Quality and Applicability Summary: Yoga Plus Physiotherapy VersusPhysiotherapy Only ........................................................................................................... 44 Table 21. Quality and Applicability Summary: Standardized Consultation Versus UsualCare ................................................................................................................................... 44 Table 22. Quality and Applicability: Strength Training Versus Control .......................... 60 Table 23. Quality and Applicability: High Versus Low Resistance Training .................. 65 Table 24. Quality and Applicability: Isokinetic Versus Isotonic Versus Isometric StrengthTraining ............................................................................................................................. 66 Table 25. Quality and Applicability: Strength Training Versus Education ...................... 67 Table 26. Quality and Applicability: Proprioceptive Versus Control.............................. 68 Table 27. Quality and Applicability: Physical Therapy Versus Control .......................... 69 Table 28. Quality and Applicability: Kinesthesia Plus Strengthening VersusStrengthening Alone ......................................................................................................... 73 Table 29. Quality and Applicability: Agility Plus Perturbation Versus Standard ExerciseTherapy ............................................................................................................................. 74 Table 30. Quality and Applicability: Self-Management Versus Control ......................... 77 Table 31. Quality and Applicability: Supervised Walking Versus Control ...................... 83 Table 32. Quality and Applicability: Water Versus Land-Based Exercise ...................... 84 Table 33. Quality and Applicability: Aerobic Exercise Versus Education ...................... 85


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Table 34. Quality and Applicability: Weight Bearing and Non-Weight Bearing ExercisePrograms ........................................................................................................................... 87 Table 35. Quality and Applicability: Home and Class-Based Exercise Programs ........... 89 Table 36. Quality and Applicability: Standardized Structured Physician ConsultationProgram (Education) Versus Control ................................................................................ 92

Table 37. Quality and Applicability: Integrated Exercise, Self-Management, and CopingStrategies Versus Usual Care ............................................................................................ 93 Table 38. Quality and Applicability: Yoga Plus Physiotherapy Versus PhysiotherapyOnly................................................................................................................................... 95 Table 39. Strength Training Compared to Control: Pain Outcomes ................................. 97 Table 40. Isokinetic Versus Isotonic Versus Isometric Exercise: Pain ............................ 98 Table 41. Strength Training Versus Control: Functional Measure ................................... 99 Table 42. Strengthening Versus Control: WOMAC Total ............................................. 102 Table 43. High Versus Low Resistance Training: Function ........................................... 103 Table 44. Resistance Strength Training Versus Health Education ................................ 103 Table 45. Physical Therapy Versus Control: Pain Measures .......................................... 104

Table 46. Physical Therapy Versus Control: Functional Measures ............................... 105

Table 47. Exercise Plus Manual Physical Therapy Versus Non-Therapeutic IntensityUltrasound ....................................................................................................................... 107 Table 48. Proprioceptive Training Versus Control: Pain Measures ............................... 108 Table 49. Proprioceptive Training Versus No Exercise: Function ................................. 108 Table 50. Agility and Perturbation Training Plus Usual Exercise Versus Exercise Only(Fitzgerald 2011) ............................................................................................................. 108 Table 51. Agility and Perturbation Training Plus Usual Exercise Versus Exercise Only:Odds of Improvement From Baseline for WOMAC Functional Tasks (Teixeira 2011) 109 Table 52. Kinesthesia Plus Strength Training Versus Strength Training: Function ....... 111 Table 53. Weight Bearing and Non-Weight Bearing Exercise ....................................... 112 Table 54. Water Versus Land-Based Exercise: Pain ...................................................... 114 Table 55. Water Versus Land-Based Exercise: Lequesne Index .................................... 115 Table 56. Home-Based and Hospital-Based Exercise Programs .................................... 116 Table 57. Aerobic Exercise Versus Control: Function ................................................... 119 Table 58. Aerobic Exercise Versus Control: Functional Task ....................................... 120 Table 59. Supervised Walking Versus Usual Care: Pain ................................................ 120 Table 60. Supervised Walking Versus Usual Care: Function......................................... 121 Table 61. Supervised Walking Versus Control: Arthritis Impact Measurement Scale(Medications Use) ........................................................................................................... 121 Table 62. Self-Management Versus Waitlist Control ..................................................... 122 Table 63. Self-Management Plus Exercise Versus Usual Care: Pain ............................. 128 Table 64. Self-Management Plus Exercise Versus Usual Care: Function ...................... 128 Table 65. Structured Consultation Versus Control: Function ........................................ 129 Table 66. Integrated Exercise, Self-Management, and Coping Strategies Versus UsualCare (Hurley 2007) ......................................................................................................... 131 Table 67. Yoga Plus Physiotherapy Versus Physiotherapy Only (Ebenezer 2011) ....... 134 Table 68. Quality and Applicability Summary: Weight Loss Versus Education ........... 138 Table 69. Quality and Applicability Summary: Low Energy Diet Versus ConventionalDiet .................................................................................................................................. 139


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Table 70. Quality and Applicability Summary: Diet Versus Exercise ........................... 140 Table 71. Quality and Applicability: Exercise-Based Weight Loss Program Versus HealthEducation ........................................................................................................................ 145 Table 72. Quality and Applicability: Weight Loss Versus Education Programs ........... 146 Table 73. Quality and Applicability: Low Energy Diet Versus Control Diet ................ 148

Table 74. Quality and Applicability: Diet Versus Exercise ............................................ 150 Table 75. Weight Loss-Exercise Only Versus Control: Function .................................. 151 Table 76. Weight Loss-Exercise Only Versus Control: Functional Task ....................... 151 Table 77. Dietary Weight Loss (With and Without Exercise) Versus Education Control......................................................................................................................................... 152 Table 78. Low Energy Diet Versus Control Diet ........................................................... 154 Table 79. Diet Versus Exercise ....................................................................................... 156 Table 80. Quality and Applicability Summary: Acupuncture Versus Control ............... 161 Table 81. Quality and Applicability Summary: Periosteal Stimulation Therapy ........... 165 Table 82. Quality and Applicability Summary: Pulsed Electrical Stimulation .............. 165 Table 83. Quality and Applicability Summary: Pulsed Electromagnetic Therapy ......... 167

Table 84. Quality and Applicability Summary: Swedish Massage Therapy .................. 167

Table 85. Quality and Applicability Summary: Ultrasound ........................................... 168 Table 86. Quality and Applicability: Acupuncture Versus Control ............................... 176 Table 87. Quality and Applicability: Periosteal Stimulation Therapy ............................ 187 Table 88. Quality and Applicability: Pulsed Electrical and Electromagnetic Therapy .. 188 Table 89. Quality and Applicability: TENS, Interferential Current, and Short WaveDiathermy ....................................................................................................................... 191 Table 90. Swedish Massage Therapy Versus Usual Care............................................... 196 Table 91. Ultrasonic Wave Plus Exercise Versus Exercise Alone ................................. 198 Table 92. Acupuncture Versus Control: Pain ................................................................. 200 Table 93. Acupuncture Versus Control: Function .......................................................... 201 Table 94. Acupuncture Versus Usual Care: Hospital Anxiety and Depression Score ... 206 Table 95. Acupuncture Versus Control: Lequesne Index ............................................... 207 Table 96. Acupuncture Versus Control: Consumption of Concomitant Medication ...... 208 Table 97. Periosteal Stimulation Therapy Versus Regular Acupuncture (Weiner 2007) 208 Table 98. TENS, Interferential Current, and Short Wave Diathermy Versus Sham(Atamaz et al., 2012) ....................................................................................................... 210 Table 99. Swedish Massage Therapy Versus Usual Care (Perlman 2006)..................... 215 Table 100. Ultrasound Versus Control ........................................................................... 217 Table 101. Pulsed Electrical and Electromagnetic Therapy ........................................... 219 Table 102. Quality and Applicability Summary: Brace Versus Usual Care ................... 228 Table 103. Quality and Applicability Summary: Brace Versus Sleeve .......................... 229 Table 104. Quality and Applicability Summary: Brace Versus Insoles ......................... 229 Table 105. Quality and Applicability: Brace Versus Usual Care ................................... 233 Table 106. Quality and Applicability: Unloader Brace Versus Neoprene Sleeve .......... 237 Table 107. Quality and Applicability: Braces Versus Insoles ........................................ 239 Table 108. Brace Plus Usual Care Versus Usual Care: Pain .......................................... 240 Table 109. Brace Plus Usual Care Versus Usual Care: Functional Tasks ...................... 242 Table 110. Brace Plus Usual Care Versus Usual Care: Function ................................... 243 Table 111. Brace plus Usual Care Versus Usual Care: Other Outcomes ....................... 244


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Table 112. Brace Versus Neoprene Sleeve ..................................................................... 245 Table 113. Braces Versus Insoles ................................................................................... 247 Table 114. Quality and Applicability Summary: Lateral Wedge Insole ........................ 249 Table 115. Quality and Applicability Summary: Rubber Versus Urethane Insole ......... 250 Table 116. Quality and Applicability: Lateral Wedge Insole ......................................... 252

Table 117 Quality and Applicability: Rubber versus Urethane Insoles ......................... 254 Table 118. Lateral Wedge versus Neutral Insoles: Critical Outcomes ........................... 255 Table 119. Lateral Wedge versus Neutral Insoles: other outcomes................................ 255 Table 120. Urethane Versus Rubber Insole (Both With Subtalar Strapping) ................. 257 Table 121. Quality and Applicability Summary: Dietary Supplements ......................... 263 Table 122. Quality And Applicability: Glucosamine Versus Control ............................ 278 Table 123. Quality and Applicability: Chondroitin ........................................................ 288 Table 124. Glucosamine Versus Placebo: Pain .............................................................. 305 Table 125. Glucosamine Versus Placebo: Function ....................................................... 306 Table 126. Glucosamine Versus Placebo: WOMAC Stiffness ....................................... 307 Table 127. Glucosamine Versus Placebo: WOMAC Total ............................................ 308

Table 128. Glucosamine Versus Placebo: Other Outcomes ........................................... 309

Table 129 Glucosamine HCL Plus Sodium Chondroitin Plus Manganese AscorbateVersus Placebo: Patient Global Assessment ................................................................... 311 Table 130. Glucosamine Versus Placebo: NSAID Consumption ................................... 311 Table 131. Glucosamine Versus Placebo: Adverse Events ............................................ 312 Table 132. Glucosamine Versus Reparagen: Pain .......................................................... 313 Table 133. Glucosamine Versus Enzymatic Hydrolyzed Collagen ................................ 314 Table 134. Chondroitin Sulfate Versus Placebo: Pain .................................................... 315 Table 135. Chondroitin Sulfate Versus Placebo: Function ............................................. 317 Table 136. Chondroitin Sulfate Versus Placebo: WOMAC Stiffness ............................ 318 Table 137. Chondroitin Sulfate Versus Placebo: WOMAC Total .................................. 318 Table 138. Chondroitin Sulfate Versus Placebo: Lequesne Index ................................. 319 Table 139. Chondroitin Versus Placebo: Additional Analgesic Use .............................. 321 Table 140. Chondroitin Sulfate Versus Placebo: Other Outcomes................................. 321 Table 141. Chondroitin Sulfate Plus Glucosamine Versus Placebo ............................... 323 Table 142. Chondroitin Sulfate Plus Glucosamine: Stratified By Severity (Clegg 2006)......................................................................................................................................... 324 Table 143. Piascledine Versus Chondroitin Sulfate ....................................................... 325 Table 144. Quality and Applicability Summary: Analgesics ......................................... 343 Table 145. Network Meta-Analysis: Statistically Significant Treatment Comparisons . 437 Table 146. Results Summary: Drug Treatments Versus Placebo (Patient and PhysicianAssessments) ................................................................................................................... 438 Table 147. Statistically Significant Active Treatment Comparisons: Global Assessments......................................................................................................................................... 439 Table 148. Quality and Applicability: Cox-2 ................................................................. 440 Table 149. Quality and Applicability: NSAIDs Versus Control .................................... 513 Table 150. Quality and Applicability: Cox-2s Versus NSAIDs ..................................... 570 Table 151. Quality and Applicability: Acetaminophen Versus Control ......................... 603 Table 152. Quality and Applicability: Interleukin Versus Control ................................. 617 Table 153. Quality and Applicability: Tramadol Versus Control ................................... 632


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Table 154. Quality and Applicability: Orgotein Versus Control .................................... 638 Table 155. Cox-2s Versus Placebo ................................................................................. 624 Table 156. Cox-2s Versus Cox-2s .................................................................................. 640 Table 157. NSAIDs Versus Placebo ............................................................................... 657 Table 158. NSAIDs Versus NSAIDs .............................................................................. 661

Table 159. Cox-2s Versus NSAIDs ................................................................................ 675 Table 160. Topical NSAIDs Versus Control .................................................................. 680 Table 161. Interleukin Versus Control............................................................................ 685 Table 162. Acetaminophen Versus Control .................................................................... 692 Table 163. Tramadol Versus Control .............................................................................. 694 Table 164. Active Treatments Versus Placebo: Patient and Physician Global Assessments......................................................................................................................................... 697 Table 165. Active Treatment Comparison: Patient and Physician Global Assessments 702 Table 166. Quality and Applicability Summary: IA Corticosteroids Versus Placebo ... 748 Table 167. Quality and Applicability Summary: IA Corticosteroids Versus HyaluronicAcid ................................................................................................................................. 750

Table 168. Quality and Applicability Summary: IA Corticosteroids Versus NeedleLavage ............................................................................................................................. 751 Table 169. Quality and Applicability: IA Corticosteroids Versus Placebo .................... 754 Table 170. Quality and Applicability: IA Corticosteroids Versus Hyaluronic Acid ...... 758 Table 171. Quality and Applicability: Needle Lavage Versus IA Corticosteroids ......... 761 Table 172. IA Corticosteroids Versus Placebo .............................................................. 762 Table 173. IA Corticosteroids Versus Hyaluronic Acid (Caborn et al., 2004) ............... 766 Table 174. Needle Lavage Versus Corticosteroids ......................................................... 768 Table 175. Quality and Applicability Summary: Hyaluronic Acid Versus Control ....... 772 Table 176. Quality and Applicability Summary: High Versus Low Molecular WeightHyaluronic Acid .............................................................................................................. 780 Table 177. Quality and Applicability: Hyaluronic Acid Versus Control ....................... 789 Table 178. Quality and Applicability: High Versus Low Molecular Weight HyaluronicAcid ................................................................................................................................. 807 Table 179. Hyaluronic Acid Versus Control: Pain ......................................................... 813 Table 180. High Versus Low Molecular Weight: Pain ................................................... 821 Table 181. Hyaluronic Acid Versus Control: Function .................................................. 829 Table 182. High Versus Low Molecular Weight: WOMAC Function ........................... 833 Table 183. Hyaluronic Acid Versus Control: WOMAC Stiffness ................................. 834 Table 184. High Versus Low Molecular Weight: WOMAC Stiffness ........................... 836 Table 185. Hyaluronic Acid Versus Conventional Treatment: WOMAC Total (Kahan etal., 2003) ......................................................................................................................... 837 Table 186. High Versus Low Molecular Weight: WOMAC Total (Juni et al., 2007) ... 838 Table 187. Hyaluronic Acid Versus Control: Lequesne Index ....................................... 839 Table 188. High Versus Low Molecular Weight: Other Outcomes ............................... 841 Table 189. High Versus Low Molecular Weight Hyaluronic Acid: Adverse Events ..... 845 Table 190. Quality and Applicability Summary: Growth Factor and Platelet Rich Plasma......................................................................................................................................... 855 Table 191. Quality and Applicability: Platelet Rich Plasma and Growth Factor Injections......................................................................................................................................... 857


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Table 192. Growth Factor Injections Versus Hyaluronic Acid (Sanchez et al., 2008 andSanchez et al., 2012) ....................................................................................................... 860 Table 193. Platelet Rich Plasma (PRP) Versus Hyaluronic Acid (Spakova et al., 2012)......................................................................................................................................... 862 Table 194. Quality and Applicability Summary: Needle Lavage ................................... 864

Table 195. Quality and Applicability Summary: Needle Lavage Versus Corticosteroids......................................................................................................................................... 865 Table 196. Results Summary: Needle Lavage Versus Sham .......................................... 866 Table 197. Quality and Applicability: Needle Lavage Versus Control .......................... 867 Table 198. Quality and Applicability: Needle Lavage Versus IA Corticosteroid .......... 870 Table 199. Needle Lavage Versus Control: WOMAC Pain ........................................... 871 Table 200. Needle Lavage Versus Sham: Function ........................................................ 872 Table 201. Needle Lavage Versus Sham: Quality of Well-Being Score ........................ 873 Table 202. Needle Lavage Versus Sham: Acetaminophen Consumption ...................... 874 Table 203. Needle Lavage Versus Corticosteroids ......................................................... 875 Table 204. Quality and Applicability Summary: Arthroscopy with Lavage and/or

Debridement .................................................................................................................... 878

Table 205. Quality and Applicability: Arthroscopy with Lavage and/or Debridement . 889 Table 206. Debridement Versus Placebo: Pain............................................................... 913 Table 207. Debridement Versus Placebo: Function ....................................................... 914 Table 208. Debridement Versus Lavage: Pain ............................................................... 916 Table 209. Debridement Versus Lavage: Function ........................................................ 918 Table 210. Arthroscopic Lavage Versus Placebo: Pain .................................................. 921 Table 211. Arthroscopic Lavage Versus Placebo: Function ........................................... 922 Table 212. Arthroscopic Surgery with Lavage and Debridement Versus Usual Care: Pain......................................................................................................................................... 924 Table 213. Arthroscopic Surgery with Lavage and Debridement Versus Usual Care:Function .......................................................................................................................... 926 Table 214. Arthroscopic Surgery with Lavage and Debridement Versus Usual Care:Arthritis Self-Efficacy Score (Other Arthritis Related Symptoms) ................................ 930 Table 215. Full Versus Minimal Irrigation at One Year ................................................. 931 Table 216. Quality and Applicability Summary: Arthroscopic Partial Meniscectomy .. 933 Table 217. Quality and Applicability: Partial Meniscectomy with Exercise VersusExercise Only .................................................................................................................. 935 Table 218. Exercise and Meniscectomy Versus Exercise Only (Herrlin et al., 2007) ... 937 Table 219. Quality and Applicability Summary: Osteotomy ......................................... 940 Table 220. Quality and Applicability Summary: Lateral Closing Wedge Versus MedialOpen Wedge with Puddu Plate ....................................................................................... 944 Table 221. Quality and Applicability: Osteotomy .......................................................... 946 Table 222. Quality and Applicability: Closing Wedge Versus Open Wedge Osteotomy......................................................................................................................................... 953 Table 223. High Tibial Osteotomy: Other Outcomes ..................................................... 959 Table 224. Osteotomy: Adverse Events.......................................................................... 959 Table 225. Open Versus Closed Wedge Osteotomy ....................................................... 965 Table 226. iBalance HTO Versus Control HTO (Getgood et al., 2011) ........................ 967 Table 227. Quality and Applicability Summary: Free-floating Interpositional Device . 970


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Table 228. Quality and Applicability: Free-Floating Interpositional Device ................. 971 Table 229. Network Meta-Analysis Consistency Check: WOMAC Pain ...................... 965 Table 230. Network Meta-Analysis Consistency Check: WOMAC Function ............... 967 Table 231. Network Meta-Analysis Consistency Check: WOMAC Stiffness ............... 969 Table 232. Network Meta-Analysis Consistency Check: WOMAC Total ..................... 971

Table 233. Network Meta-Analysis Consistency Check: Adverse Events ..................... 972

LIST OF FIGURESFigure 1. AAOS Clinical Practice Guidelines Development Process............................... 29 Figure 2. Results Summary: Strength Training Versus Control ....................................... 49 Figure 3. Results Summary: Physical Therapy ................................................................. 50 Figure 4. Results Summary: Proprioception Versus Control............................................ 51 Figure 5. Results Summary: Agility and Perturbation Training Plus Usual ExerciseVersus Exercise Only ........................................................................................................ 52 Figure 6. Results Summary: Kinesthesia Versus Control ................................................. 53 Figure 7. Results Summary: Exercise Versus Control...................................................... 54 Figure 8. Self-Management and Structured Consultation Versus Control ....................... 55 Figure 9. Results Summary: Integrated Exercise, Self-Management, and CopingStrategies Versus Usual Care ............................................................................................ 57 Figure 10. Results Summary: Water Versus Land-Based Exercise .................................. 58 Figure 11. Results Summary: Yoga Versus Control ......................................................... 59 Figure 12. Strength Training Versus Control: Pain ........................................................ 136 Figure 13. Summary of Results: Diet, Exercise, and Weight Loss ................................. 142 Figure 14. Results Summary: Low Energy Diet Versus Conventional Diet .................. 143 Figure 15. Results Summary: Diet Versus Exercise ....................................................... 144 Figure 16. Results Summary: Acupuncture Versus Control ........................................... 171 Figure 17. Results Summary: Electro-acupuncture Versus Control ............................... 172 Figure 18. Results Summary: Swedish Massage Therapy and Ultrasound Versus Control......................................................................................................................................... 173 Figure 19. Results Summary: Pulsed Electrical Stimulation .......................................... 174 Figure 20. Results Summary: Electromagnetic Fields .................................................... 175 Figure 21. Acupuncture: WOMAC pain in MID Units .................................................. 223 Figure 22. Acupuncture: WOMAC Function in MID Units ........................................... 224 Figure 23. Acupuncture Versus Placebo: WOMAC Pain (1999) ................................... 225 Figure 24. Acupuncture Versus Control: WOMAC Function ........................................ 226 Figure 25. Results Summary: Brace Versus Usual Care ................................................ 230 Figure 26. Results Summary: Brace vs. Sleeve and Insoles ........................................... 232

Figure 27. Results Summary: Foot Orthotics ................................................................. 251 Figure 28. Lateral Wedge Insole Versus Neutral Insoles: Critical Outcomes ................ 258 Figure 29. Lateral Wedge Insoles Versus Neutral Insoles: Other Outcomes ................. 259 Figure 30. Urethane Versus Rubber Insoles .................................................................. 260 Figure 31. Results Summary: Glucosamine Versus Placebo .......................................... 274 Figure 32. Results Summary: Chondroitin Sulfate Versus Placebo ............................... 276 Figure 33. Chondroitin Sulfate Versus Placebo: VAS Pain ........................................... 332 Figure 34. Glucosamine Versus Placebo: WOMAC Pain in MID Units ........................ 333


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Figure 35. Glucosamine Versus Placebo: WOMAC Function in MID Units................. 334 Figure 36. Glucosamine Versus Placebo: WOMAC Stiffness in MID Units ................. 335 Figure 37. Glucosamine Versus Placebo: WOMAC Total in MID Units ...................... 336 Figure 38. Glucosamine Versus Placebo: WOMAC Pain .............................................. 337 Figure 39. Glucosamine Versus Placebo: WOMAC Function ...................................... 338

Figure 40. Glucosamine Versus Placebo: WOMAC Stiffness ....................................... 339 Figure 41. Glucosamine Versus Placebo: WOMAC Total ............................................. 340 Figure 42. Network Meta-Analysis Model: Pain ............................................................ 432 Figure 43. Network Meta-Analysis Model: WOMAC Function .................................... 433 Figure 44. Network Meta-Analysis Model: WOMAC Stiffness .................................... 434 Figure 45. Network Meta-Analysis Model: WOMAC Total .......................................... 435 Events Figure 46. Network Meta-Analysis Model: Adverse Events .............................. 436 Figure 47. Network Meta-Analysis: Analgesics Versus Placebo (Pain) ........................ 713 Figure 48. Network Meta-Analysis: Cox-2 Versus NSAIDS (Pain) .............................. 714 Figure 49. Network Meta-Analysis: Cox-2 Versus Cox-2 (Pain)................................... 715 Figure 50. Network Meta-Analysis: NSAID Versus NSAID (Pain) .............................. 716

Figure 51. Network Meta-Analysis: Cox-2 and NSAIDS Versus Other Analgesics (Pain)......................................................................................................................................... 717 Figure 52. Network Meta-Analysis: Topical NSAIDS Versus Oral Analgesics (Pain) . 718 Figure 53. Network Meta-Analysis: Analgesics Versus Placebo (WOMAC Function) 719 Figure 54. Network Meta-Analysis: Cox-2 Versus NSAIDS (WOMAC Function) ...... 720 Figure 55. Network Meta-Analysis: NSAID Versus NSAID (WOMAC Function) ...... 721 Figure 56. Network Meta-Analysis: Cox-2 Versus Cox-2 (WOMAC Function) ........... 722 Figure 57. Network Meta-Analysis: Cox-2 and NSAIDS Versus Other Analgesics(WOMAC Function) ....................................................................................................... 723 Figure 58. Network Meta-Analysis: Topical NSAIDS Versus Other Analgesics(WOMAC Function) ....................................................................................................... 724 Figure 59. Network Meta-Analysis: Analgesics Versus Placebo (WOMAC Stiffness) . 725 Figure 60. Network Meta-Analysis: Cox-2 Versus NSAIDS (WOMAC Stiffness) ...... 726 Figure 61. Network Meta-Analysis: NSAIDS Versus NSAIDS (WOMAC Stiffness) .. 727 Figure 62. Network Meta-Analysis: Cox-2 Versus Cox-2 (WOMAC Stiffness) ........... 728 Figure 63. Network Meta-Analysis: Cox-2 and NSAIDS Versus Other Analgesics(WOMAC Stiffness) ....................................................................................................... 729 Figure 64. Network Meta-Analysis: Analgesics Versus Placebo (WOMAC Total) ...... 730 Figure 65. Network Meta-Analysis: NSAIDS Versus Cox-2 (WOMAC Total) ............ 731 Figure 66. Network Meta-Analysis: NSAIDS Versus NSAIDS (WOMAC Total)........ 732 Figure 67. Network Meta-Analysis: Cox-2 Versus Cox-2 (WOMAC Total) ................ 733 Figure 68. Network Meta-Analysis: Cox-2 and NSAIDS Versus Other Analgesics(WOMAC Total) ............................................................................................................. 734 Figure 69. Network Meta-Analysis: Analgesics Versus Placebo (Adverse Events) ...... 735 Figure 70. Network Meta-Analysis: Cox-2 Versus Cox-2 (Adverse Events) ................ 736 Figure 71. Network Meta-Analysis: NSAID Versus NSAID (Adverse Events) ............ 737 Figure 72. Network Meta-Analysis: Cox-2 Versus NSAID (Adverse Events) .............. 738 Figure 73. Network Meta-Analysis: Acetaminophen Versus Cox-2 and NSAIDS(Adverse Events) ............................................................................................................. 739
http://fileshares/RESEARCH$/GUIDELINES/Osteoarthritis%20of%20the%20Knee/2010%20The%20TX%20of%20OA%20Knee%20Complete%20Update/5%20Draft%20Documents/FINAL%20Draft%20OAK%20CPG%20042613%20for%20BOD%20approval.docx%23_Toc356809779http://fileshares/RESEARCH$/GUIDELINES/Osteoarthritis%20of%20the%20Knee/2010%20The%20TX%20of%20OA%20Knee%20Complete%20Update/5%20Draft%20Documents/FINAL%20Draft%20OAK%20CPG%20042613%20for%20BOD%20approval.docx%23_Toc356809779http://fileshares/RESEARCH$/GUIDELINES/Osteoarthritis%20of%20the%20Knee/2010%20The%20TX%20of%20OA%20Knee%20Complete%20Update/5%20Draft%20Documents/FINAL%20Draft%20OAK%20CPG%20042613%20for%20BOD%20approval.docx%23_Toc356809779


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Figure 74. Network Meta-Analysis: Diacerein (Interleukin) Versus Cox-2 Inhibitors and NSAIDS (Adverse Events) ............................................................................................. 740 Figure 75. Network Meta-Analysis: Gastrointestinal Cox-2 Versus NSAIDS (AdverseEvents) ............................................................................................................................ 741 Figure 76. Network Meta-Analysis: Cox-2 Versus NSAID Non-Gastrointestinal (Adverse

Events) ............................................................................................................................ 742 Figure 77. Network Meta-Analysis: Acetaminophen Versus Celecoxib (Adverse Events)......................................................................................................................................... 743 Figure 78. Network Meta-Analysis: Acetaminophen Versus Rofecoxib 12.5 mg (AdverseEvents) ............................................................................................................................ 744 Figure 79. Network Meta-Analysis: Acetaminophen Versus Rofecoxib 25mg (AdverseEvents) ............................................................................................................................ 745 Figure 80. Network Meta-Analysis: Acetaminophen Versus Ibuprofen-Adverse Events(Bradley 1991) ................................................................................................................ 746 Figure 81. Results Summary: IA Corticosteroids ........................................................... 753 Figure 82. Network Meta-Analysis: IA Corticosteroids Versus Placebo (Pain) ............ 769

Figure 83. Results Summary: Intraarticular Hyaluronic Acid Versus Control ............... 785

Figure 84. Results Summary: High Versus Low Molecular Weight Hyaluronic Acid .. 787 Figure 85. Hyaluronic Acid Versus Placebo: Pain in MID Units ................................... 847 Figure 86. Hyaluronic Acid Versus Placebo: WOMAC Function in MID Units ........... 848 Figure 87. Hyaluronic Acid Versus Placebo: WOMAC Stiffness in MID Units ........... 849 Figure 88. Hyaluronic Acid Versus Placebo: WOMAC Pain......................................... 850 Figure 89. Hyaluronic Acid Versus Placebo: VAS Weight Bearing Pain ...................... 851 Figure 90. Hyaluronic Acid Versus Placebo: Function .................................................. 852 Figure 91. Hyaluronic Acid Versus Placebo: WOMAC Stiffness .................................. 853 Figure 92. Results Summary: Arthroscopic Surgery, Lavage, and Debridement VersusControl ............................................................................................................................ 888 Figure 93. Open-Wedge High Tibial Osteotomy: VAS Pain Change from Baseline(Pongsoipetch et al., 2009).............................................................................................. 956 Figure 94. Open Wedge High Tibial Osteotomy with TomoFix Plate: VAS Pain at 3 YearFollow-Up (El-Azab et al., 2011) ................................................................................... 956 Figure 95. Hospital for Special Surgery: Pain and Function (Rudan and Simurda, 1990)......................................................................................................................................... 957 Figure 96. International Knee Documentation Committee Score: Open-Wedge HTO withInternal Fixator Plate (Niemeyer et al., 2010) ................................................................ 957 Figure 97. Open-Wedge High Tibial Osteotomy: Knee Society Score (Pongsoipetch etal., 2009) ......................................................................................................................... 958 Figure 98. High Tibial Osteotomy: International Knee Society Score (Flamme et al.,2003) ............................................................................................................................... 958 Figure 99. Closed Versus Open Osteotomy: VAS Pain (Brouwer et al., 2006) ............. 962 Figure 100. Open Versus Closed Wedge Osteotomy: Mild to Severe Knee Pain on StairClimb (Song et al., 2012) ................................................................................................ 963 Figure 101. Open Versus Closed Wedge Osteotomy (Brouwer et al., 2006) ................. 964 Figure 102. Adverse Events: Open Versus Closed Wedge Osteotomy (Brouwer et al.,2006) ............................................................................................................................... 966


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Figure 103. iBalance HTO Versus Control HTO: Adverse Events (Getgood et al., 2011)......................................................................................................................................... 968 Figure 104. Knee Society Scores (Sisto and Mitchell 2005) .......................................... 972 Figure 105. VAS Pain (Sisto and Mitchell, 2005) .......................................................... 973 Figure 106. Percent Revised to Total Knee Arthroplasty (Sisto and Mitchell, 2005) .... 973


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SUMMARY OF RECOMMENDATIONSThis summary of the AAOS clinical practice guideline, Treatment of Osteoarthritithe Knee contains a list of the evidence based treatment recommendations and inconly less invasive alternatives to knee replacement. Discussion of how and why eachrecommendation was developed and the evidence report are contained in the fullguideline at www.aaos.org/guidelines. Readers are urged to consult the full guideline forthe comprehensive evaluation of the available scientific studies. The recommendationswere established using methods of evidence-based medicine that rigorously control for

bias, enhance transparency, and promote reproducibility.

The summary of recommendations is not intended to stand alone. Medical care shouldalways be ba sed on a physicians expert judgment and the patients circumstances, values, preferences and rights. For treatment procedures to provide benefit, mutualcollaboration with shared decision-making between patient and physician/alliedhealthcare provider is essential.

Conservative Treatments: Recommendations 1-6RECOMMENDATION 1 We recommend that patients with symptomatic osteoarthritis of the knee participate inself-management programs, strengthening, low-impact aerobic exercises, andneuromuscular education; and engage in physical activity consistent with nationalguidelines.Strength of Recommendation: Strong

Description: A Strong recommendation means that the benefits of the recommended approach clearlyexceed the potential harm and/or that the quality of the supporting evidence is high.

Implications: Practitioners should follow a Strong recommendation unless a clear and compellingrationale for an alternative approach is present.

RECOMMENDATION 2We suggest weight loss for patients with symptomatic osteoarthritis of the knee and aBMI 25. Strength of Recommendation: Moderate

Description: A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but thequality/applicability of the supporting evidence is not as strong.

Implications: Practitioners should generally follow a Moderate recommendation but remain alert to newinformation and be sensitive to patient preferences.

RECOMMENDATION 3AWe cannot recommend using acupuncture in patients with symptomatic osteoarthritisof the knee.Strength of Recommendation: Strong


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Description: A Strong recommendation means that the quality of the supporting evidence is high. A harmsanalysis on this recommendation was not performed.

Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationalefor an alternative approach is present.

RECOMMENDATION 3BWe are unable to recommend for or against the use of physical agents (includingelectrotherapeutic modalities) in patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive

Description: An Inconclusive recommendation means that there is a lack of compelling evidence that hasresulted in an unclear balance between benefits and potential harm.

Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps todetermine the balance between benefits and potential harm. Patient preference should have a substantial

influencing role.

RECOMMENDATION 3CWe are unable to recommend for or against manual therapy in patients withsymptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive


Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to

determine the balance between benefits and potential harm. Patient preference should have a substantialinfluencing role.

RECOMMENDATION 4We are unable to recommend for or against the use of a valgus directing force brace(medial compartment unloader) for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive


Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps todetermine the balance between benefits and potential harm. Patient preference should have a substantialinfluencing role.

RECOMMENDATION 5We cannot suggest that lateral wedge insoles be used for patients with symptomaticmedial compartment osteoarthritis of the knee.Strength of Recommendation: Moderate


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Description: A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but thequality/applicability of the supporting evidence is not as strong.

Implications: Practitioners should generally follow a Moderate recommendation but remain alert to newinformation and be sensitive to patient preferences.

RECOMMENDATION 6We cannot recommend using glucosamine and chondroitin for patients with symptomaticosteoarthritis of the knee.Strength of Recommendation: Strong

Description: A Strong recommendation means that the quality of the supporting evidence is high. A harmsanalysis on this recommendation was not performed.

Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationalefor an alternative approach is present..

Pharmacologic Treatments: Recommendation 7RECOMMENDATION 7AWe recommend nonsteroidal anti-inflammatory drugs (NSAIDs; oral or topical) orTramadol for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Strong

Description: A Strong recommendation means that the benefits of the recommended approach clearlyexceed the potential harm and/or that the quality of the supporting evidence is high.

Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationalefor an alternative approach is present.

RECOMMENDATION 7BWe are unable to recommend for or against the use of acetaminophen, opioids, or pain

patches for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive


Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to

determine the balance between benefits and potential harm. Patient preference should have a substantialinfluencing role.


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Procedural Treatments: Recommendation 8-11RECOMMENDATION 8We are unable to recommend for or against the use of intraarticular (IA) corticosteroidsfor patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive


Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps todetermine the balance between benefits and potential harm. Patient preference should have a substantialinfluencing role.

RECOMMENDATION 9We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritisof the knee.

Strength of Recommendation: Strong

Description: A strong recommendation means that the quality of the supporting evidence is high. A harms analysis on this recommendation was not p

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