Osteoarthritis Guidelines

Updated: Oct 12, 2020
  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
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Guidelines

Guidelines Summary

Guidelines on osteoarthritis have been issued by the following organizations:

  • American College of Rheumatology (ACR)/Arthritis Foundation – Management of hand, hip, and knee osteoarthritis
  • Osteoarthritis Research Society International (OARSI) – Nonpharmacologic therapies for hip and knee osteoarthritis
  • American Academy of Orthopaedic Surgeons (AAOS) – 1) Nonpharmacologic and pharmacologic therapies and joint replacement for knee osteoarthritis; 2) Surgical management of osteoarthritis of the knee; 3) Management of osteoarthritis of the hip
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Hand Osteoarthritis

For hand osteoarthritis, the American College of Rheumatology (ACR)/Arthritis Foundation recommends the following regarding nonpharmacologic measures [154] :

  • Exercise is strongly recommended
  • Self‐efficacy and self‐management programs are strongly recommended
  • Cognitive behavioral therapy is conditionally recommended
  • For patients with osteoarthritis of the first carpometacarpal joint, hand orthoses are strongly recommended and kinesiotaping is conditionally recommended; hand orthoses are conditionally recommended for patients with osteoarthritis in other joints of the hand.
  • Acupuncture is conditionally recommended
  • Thermal interventions (locally applied heat or cold, including heat therapy with paraffin) are conditionally recommended.
  • Iontophoresis is conditionally recommended against in patients with first carpometacarpal joint osteoarthritis.

For pharmacologic treatment, the ACR/Arthritis Foundation guidelines strongly recommend oral nonsteroidal anti-inflammatory drugs (NSAIDs); however, doses should be as low as possible and treatment should be as short as possible. Conditionally recommended agents include the following [154] :

  • Topical NSAIDs
  • Intra-articular glucocorticoid injections
  • Acetaminophen
  • Duloxetine
  • Tramadol
  • Chondroitin sulfate

The ACR/Arthritis Foundation guidelines conditionally recommend against use of the following for hand osteoarthritis:

  • Topical capsaicin
  • Non‐tramadol opioids (with the recognition that they may be used under certain circumstances, particularly when alternatives have been exhausted)
  • Intra-articular hyaluronic acid injections
  • Colchicine
  • Fish oil
  • Vitamin D

The ACR/Arthritis Foundation guidelines strongly recommend against use of the following for hand osteoarthritis:

  • Bisphosphonates
  • Glucosamine
  • Hydroxychloroquine
  • Methotrexate
  • Tumor necrosis factor inhibitors and interleukin‐1 receptor antagonists

 

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Knee Osteoarthritis

The Osteoarthritis Research Society International (OARSI) guidelines provide separate recommendations for treatment of symptomatic arthritis in one or both knees (knee-only OA) and in the knee(s) in addition to other joints (eg, hip, hand, spine, etc). Separate recommendations are made based on the absence or presence of comorbidities (ie, diabetes; hypertension; cardiovascular disease; kidney failure; gastrointestinal (GI) bleeding; depression; or physical impairment limiting activity, including obesity). The following nonpharmacologic recommendations apply to all subphenotypes [70] :

  • Biomechanical interventions such as knee braces, knee sleeves, and foot orthoses as directed by an appropriate specialist
  • Land-based exercise and strength training
  • Aquatic exercise
  • Self-management and education
  • Weight management

The OARSI recommmends use of a cane in knee-only OA to diminish pain and improve function and some aspects of quality of life. However, there was a lack of evidence for benefit in mutiple-joint OA. The guidelines noted that cane use could be inappropriate for some patients because relieving knee pain may require an increase in the weight-bearing load on other affected joints (eg, contralateral hand and hip joints). [70]

For multiple-joint OA with comorbidities, balneotherapy (defined as the use of baths containing thermal mineral waters) is recommended and includes practices such as Dead Sea salt or mineral baths, sulfur baths, and radon-carbon dioxide baths. [70]  

Updated and expanded OARSI guidelines provide the following recommendations on treatment of patients with knee OA [155] :

  • Core treatments include arthritis education and structured land-based exercise programs with or without dietary weight management.
  • Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are strongly recommended.
  • For individuals with gastrointestinal comorbidities, the use of cyclooxygenase (COX)-2 inhibitors or NSAIDs with proton pump inhibitors (PPIs) is recommended.
  • For individuals with cardiovascular comorbidities or frailty, the use of any oral NSAID is not recommended.
  • Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise are recommended, depending upon comorbidity status.
  • The use of acetaminophen (paracetamol) is conditionally not recommended.
  • The use of oral and transdermal opioids is strongly not recommended.

For knee osteoarthritis, the American College of Rheumatology (ACR)/Arthritis Foundation recommends the following regarding nonpharmacologic measures [154] :

  • Exercise is strongly recommended; balance exercises are conditionally recommended
  • Weight loss is strongly recommended for patients who are overweight or obese
  • Self‐efficacy and self‐management programs are strongly recommended
  • Tai chi is strongly recommended
  • Yoga is conditionally recommended
  • Cognitive behavioral therapy is conditionally recommended
  • Cane use is strongly recommended for patients in whom disease in 1 or more joints is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device
  • Tibiofemoral knee braces are strongly recommended for patients in whom disease in 1 or both knees is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device, and who are able to tolerate the associated inconvenience and burden associated with bracing
  • Patellofemoral braces are conditionally recommended for patients with patellofemoral knee OA in whom disease in 1 or both knees is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device.
  • Kinesiotaping is conditionally recommended
  • Modified shoes and lateral and medial wedged insoles are conditionally recommended  against
  • Acupuncture is conditionally recommended
  • Thermal interventions (locally applied heat or cold) are conditionally recommended
  • Radiofrequency ablation is conditionally recommended
  • Massage therapy is conditionally recommended  against
  • Manual therapy with exercise is conditionally recommended  against over exercise alone
  • Pulsed vibration therapy is conditionally recommended  against 
  • Transcutaneous electrical stimulation (TENS) is strongly recommended  against

For pharmacologic treatment of knee osteoarthritis, the ACR/Arthritis Foundation guidelines strongly recommend the following [154]

  • Topical NSAIDs; should be considered prior to use of oral NSAIDs
  • Oral NSAIDs; however, doses should be as low as possible and treatment should be as short as possible
  • Intra-articular glucocorticoid injections

Conditionally recommended agents include the following [154] :

  • Topical capsaicin
  • Acetaminophen
  • Duloxetine
  • Tramadol

The ACR/Arthritis Foundation guidelines conditionally recommend against use of the following for knee osteoarthritis:

  • Non‐tramadol opioids (with the recognition that they may be used under certain circumstances, particularly when alternatives have been exhausted)
  • Intra-articular hyaluronic acid injections
  • Intra-articular botulinum toxin injections
  • Colchicine
  • Fish oil
  • Vitamin D
  • Prolotherapy

The ACR/Arthritis Foundation guidelines strongly recommend against use of the following for knee osteoarthritis:

  • Platelet‐rich plasma treatment
  • Stem cell injections
  • Bisphosphonates
  • Glucosamine
  • Chondroitin sulfate
  • Hydroxychloroquine
  • Methotrexate
  • Tumor necrosis factor inhibitors and interleukin‐1 receptor antagonists

An American Academy of Orthopaedic Surgeons (AAOS) guideline suggests encouraging patients with knee osteoarthritis to participate in self-management educational programs such as those conducted by the Arthritis Foundation and to incorporate activity modifications into their lifestyle (eg, walking instead of running or engaging in alternative activities).

Acupuncture for knee osteoarthritis

Guidelines from different groups offer a range of recommendations regarding the use of acupuncture for knee osteoarthritis, as follows:

  • The ACR conditionally recommends traditional Chinese acupuncture for patients with chronic moderate-to-severe pain who would be candidates for total knee arthroplasty but who either do not want it or have contraindications to it. [129]
  • The OARSI guidelines find the efficacy of acupuncture to be uncertain. [70]
  • The AAOS strongly recommends against the use of acupuncture for symptomatic knee osteoarthritis. [138]

Pharmacologic therapy

The OARSI recommmends intra-articular corticosteroid injections and oral nonselective NSAIDS for treatment of all subphenotypes. COX-2 selective oral NSAIDs were deemed apporpriate for individulals without comorbidities and mutiple-joint OA with moderate co-morbidity risk. Proton-pump inhibitor (PPI) co-prescription with oral NSAIDs is not recommended for those with no co-morbidity risk. For those with moderate or high co-morbidity risk receiving oral non-selective NSAIDs, PPI co-prescription is recommended. No recommendation was made for individuals taking  COX-2 selective oral NSAIDs at moderate mobidy risk. Use of oral NSAIDs is stongly advised against for individuals with high co-morbidity risk. [70]  

Duloxetine is recommended for most subphenotypes, however, associated adverse events and availability of more targeted therapies predicated uncertain appropriateness for individuals with knee-only OA and co-morbidities. [70]

Additional recommendations include [70] :

  • Acetaminophen for patients without co-morbidities
  • Topical capsaicin for knee-only OA without co-morbidities; uncertain for multiple-joint OA and in patients with co-morbidities
  • Topical NSAIDs for knee-only OA

For knee osteoarthritis, the ACR conditionally recommends using one of the following: 

  • Acetaminophen
  • Oral NSAIDs
  • Topical NSAIDs
  • Tramadol
  • Intra-articular corticosteroid injections

The ACR conditionally recommends against using chondroitin sulfate, glucosamine, or topical capsaicin for knee osteoarthritis. The ACR has no recommendations regarding the use of intra-articular hyaluronates, duloxetine, and opioid analgesics.

American Academy of Orthopaedic Surgeons guidelines

A 2013 clinical practice guideline from the American Academy of Orthopaedic Surgeons (AAOS) recommends the following pharmacologic treatments for symptomatic osteoarthritis of the knee [138] :

  • Oral NSAIDs
  • Topical NSAIDs
  • Tramadol

The AAOS was unable to recommend for or against the use of the following for symptomatic knee osteoarthritis:

  • Acetaminophen
  • Opioids
  • Pain patches
  • Intra-articular corticosteroid injections
  • Growth factor injections and/or platelet rich plasma

The recommendation on acetaminophen is a downgrade from the previous AAOS guideline, and reflects the use of new criteria that resulted in the selection of only one study, which found no statistical significance or minimum clinically important improvement with acetaminophen compared with placebo.

The AAOS does not recommend treatment with any of the following:

  • Intra-articular hyaluronic acid
  • Glucosamine and/or chondroitin sulfate or hydrochloride

Knee replacement

A 2016 guideline on surgical management of knee osteoarthritis from the American Academy of Orthopaedic Surgeons (AAOS) includes the following recommendations regarding total knee arthroplasty (TKA) [156] :

  • Obese patients have less improvement in outcomes (strong supporting evidence)
  • Patients with diabetes are at higher risk for complications (moderate evidence)
  • Patients with select chronic pain conditions have less improvement in patient-reported outcomes (moderate)
  • Patients with depression and/or anxiety symptoms have less improvement in patient-reported outcomes (limited)
  • Patients with cirrhosis or hepatitis C are at higher risk for complications (limited)
  • An 8-month delay to TKA does not worsen outcomes (moderate)
  • Supervised exercise before TKA might improve pain and physical function after surgery (limited)
  • Compared with placebo, peri-articular local anesthetic infiltration in TKA decreases pain and opioid use (strong)
  • Compared with general anesthesia, neuraxial anesthesia can improve select perioperative outcomes and complication rates (moderate)
  • Use of a tourniquet in TKA decreases intraoperative blood loss (moderate) but increases short-term postoperative pain (strong) and decreases short- term postoperative function (limited)
  • In patients with no known contraindications, treatment with tranexamic acid decreases postoperative blood loss and reduces the necessity of postoperative transfusions (strong)
  • Routine use of antibiotics in the cement for primary TKA is not recommended (limited)
  • Outcomes and complications are no different with posterior-stabilized versus posterior cruciate–retaining arthroplasty designs
  • Outcomes are no different with either all-polyethylene or modular tibial components (strong)
  • Use of patellar resurfacing makes no difference in pain or function (strong), but could decrease cumulative reoperations after 5 years (moderate)
  • Cemented or cementless tibial component fixation provides similar functional outcomes and rates of complications and reoperations (strong)
  • Use of either cemented or cementless femoral and tibial components results in similar rates of complications and reoperations (moderate)
  • Either cementing all components or using hybrid fixation (cementless femur) results in similar functional outcomes and rates of complications and reoperations. (moderate)
  • Use of either all cementless components or hybrid fixation (cementless femur) results in similar rates of complications and reoperations (limited)
  • Simultaneous bilateral TKA can be performed in patients aged 70 or younger or with American Society of Anesthesiologists (ASA) status 1-2, because there are no increased complications (limited)
  • In patients with medial compartment osteoarthritis, revision surgery risk could be lower with TKA than with (moderate); however, risk of deep venous thrombosis and manipulation under anesthesia may be higher with TKA) than with unicompartmental knee arthroplasty (limited)
  • In patients with medial compartment knee osteoarthritis, there is no difference in outcome and complications with unicompartmental knee arthroplasty versus valgus-producing proximal tibial osteotomy (moderate)
  • Using intraoperative navigation makes no difference in outcomes or complications (strong)
  • Compared with conventional instrumentation, use of patient-specific instrumentation for TKA makes no difference in pain or functional outcomes (strong) or in transfusions or complications (moderate)
  • Use of a drain with TKA makes no difference in complications or outcomes (strong)
  • Use of cryotherapy devices after TKA does not improve outcomes (moderate)
  • Postoperative continuous passive motion (CPM) does not improve outcomes (strong)
  • Rehabilitation started on the day of surgery reduces length of hospital stay (strong), and reduces pain and improves function compared with rehabilitation started on postoperative day 1 (moderate)
  • A supervised exercise program during the first 2 months after TKA improves physical function (moderate) and may decrease pain (limited)
  • Selected patients might be referred to an intensive supervised exercise program during late-stage post-TKA to improve physical function (limited)
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Hip Osteoarthritis

In the 2019 Osteoarthritis Research Society International (OARSI) guidelines, the only hip osteoarthritis (OA) interventions considered eligible for Core Treatment designation (treatments deemed appropriate for use by the majority of patients in nearly any scenario and deemed safe for use in conjunction with first-line and second-line treatments) were arthritis education and structured land-based exercise programs (Type 1 –  strengthening and/or cardio and/or balance training/neuromuscular). [155]

Conditional OARSI recommendations for hip arthritis include the following:

  • Mind-body exercise (tai chi or yoga), despite despite a lack of direct evidence, because its favorable efficacy and safety profile in patients with knee OA was considered generalizable to hip OA.
  • Self-management programs
  • Cognitive behavioral therapy for patients with widespread pain and/or depression.
  • The use of gait aids, except in patients with widespread pain and/or depression
  • Use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) for hip OA patients without comorbidities and for patients with widespread pain and/or depression.
  • For patients with GI comorbidities, oral NSAID therapy should be restricted to selective COX-2 inhibitors or non-selective NSAIDs in combination with a proton pump inhibitor.
  • NSAIDs with more favorable safety profiles may be used in high-risk patients (including patients with frailty) at the lowest possible dose, for the shortest possible treatment duration, for symptomatic relief.

Dietary weight management was not recommended for patients with hip OA because of lack of direct evidence for its effectiveness specifically for symptoms of Hip OA. However, dietary weight management may be recommended for certain individuals (eg, those with body mass index ≥30 kg/m2) as a part of a healthy lifestyle regimen. [155]

For hip osteoarthritis, the American College of Rheumatology (ACR)/Arthritis Foundation recommends the following regarding nonpharmacologic measures [154] :

  • Exercise is strongly recommended; balance exercises are conditionally recommended
  • Weight loss is strongly recommended for patients who are overweight or obese
  • Self‐efficacy and self‐management programs are strongly recommended
  • Tai chi is strongly recommended
  • Cognitive behavioral therapy is conditionally recommended
  • Cane use is strongly recommended for patients in whom disease in 1 or more joints is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device
  • Modified shoes and lateral and medial wedged insoles are conditionally recommended  against
  • Acupuncture is conditionally recommended
  • Thermal interventions (locally applied heat or cold) are conditionally recommended
  • Massage therapy is conditionally recommended  against
  • Manual therapy with exercise is conditionally recommended  against over exercise alone
  • Transcutaneous electrical stimulation (TENS) is strongly recommended  against

For pharmacologic treatment of hip osteoarthritis, the ACR/Arthritis Foundation guidelines strongly recommend the following [154]

  • Oral nonsteroidal anti-inflammatory drugs (NSAIDs); however, doses should be as low as possible and treatment should be as short as possible
  • Intra-articular glucocorticoid injections
  • Ultrasound guidance for glucocorticoid injections into hip joints

Conditionally recommended agents include the following [154] :

  • Topical capsaicin
  • Acetaminophen
  • Duloxetine
  • Tramadol

The ACR/Arthritis Foundation guidelines conditionally recommend against use of the following for hip osteoarthritis:

  • Non‐tramadol opioids (with the recognition that they may be used under certain circumstances, particularly when alternatives have been exhausted)
  • Intra-articular botulinum toxin injections
  • Colchicine
  • Fish oil
  • Vitamin D
  • Prolotherapy

The ACR/Arthritis Foundation guidelines strongly recommend against use of the following for hip osteoarthritis:

  • Intra-articular hyaluronic acid injections
  • Platelet‐rich plasma treatment
  • Stem cell injections
  • Bisphosphonates
  • Glucosamine
  • Chondroitin sulfate
  • Hydroxychloroquine
  • Methotrexate
  • Tumor necrosis factor inhibitors and interleukin‐1 receptor antagonists

A 2017 guideline on management of hip osteoarthritis from the American Academy of Orthopaedic Surgeons (AAOS) place an emphasis on presurgical treatments to reduce pain and increase mobility and also highlight patient populations who may have greater risk associated with hip replacement surgery. [157] The guidelines found moderate strength evidence for the following risk issues [158] :

  • Practitioners may use risk assessment tools for predicting complications, assessing surgical risks, and educating patients about receiving total hip arthroplasty.

  • Obese patients may have lower absolute outcome scores, but similar levels of satisfaction and improvement in pain and function after total hip replacement compared with nonobese patients.

  • Increased age is associated with lower functional and quality-of-life outcomes after total hip replacement.

  • Mental health disorders, including depression, anxiety, and psychosis, are associated with decreased function, pain relief, and quality of life after total hip replacement.

The AAOS found strong evidence regarding the following management approaches [158] :

  • Nonnarcotic medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) improve short-term pain, function, or both.
  • Corticosteroid injections provide short-term improvements in function and pain.
  • Hyaluronic acid injections are no better than placebo for improving function, stiffness, and pain.
  • Physical therapy improves function and decreases pain in mild to moderate hip osteoarthritis.

There was moderate strength evidence for the following [158] :

  • Postoperative physical therapy improves early function more than no physical therapy.
  • Glucosamine sulfate is no better than placebo for improving function, reducing stiffness, and decreasing pain.
  • Practitioners may use intravenous or topical tranexamic acid to reduce blood loss associated with total hip replacement surgery.
  • There are no clinically significant differences in patient-oriented outcomes for anterior vs posterior approaches in total hip replacement.
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