TREATMENT OF OSTEOARTHRITIS OF THE KNEE ......2013/05/18 · TREATMENT OF OSTEOARTHRITIS OF THE KNEE EVIDENCE-BASED GUIDELINE 2 ND EDITION Adopted by the American Academy of Orthopaedic

TREATMENT OF OSTEOARTHRITIS OF THE

KNEE

EVIDENCE-BASED GUIDELINE 2ND EDITION

Adopted by the American Academy of Orthopaedic Surgeons Board of Directors

May 18, 2013

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Disclaimer This clinical practice guideline was developed by an AAOS work group comprised of volunteer physicians and interdisciplinary clinicians as well as staff researchers with expertise in systematic reviews and statistical methods used to evaluate empirical evidence. It is an educational tool that integrates the current scientific literature and the proficiency and sound judgment that physicians typically acquire in clinical practice. The recommendations that make up this guideline are not intended to be absolute as patients vary in how they experience symptoms and respond to treatment interventions. There may be variability between patients in practice and those who participate in clinical trials. Medical care should always be based on a physician’s expertise that is individually tailored to the patient’s circumstances, preferences and rights.

Disclosure Requirement In accordance with AAOS policy, all individuals whose names appear as authors or contributors to this clinical practice guideline provided full disclosure of and were vetted for potential conflicts of interest prior to the introductory meeting.

Funding Source The American Academy of Orthopaedic Surgeons funded this clinical practice guideline without any financial support from outside commercial sources.

FDA Clearance Some drugs or medical devices referenced or described in this clinical practice guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the clearance status of each drug or device prescribed in clinical practice.

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

Published 2013 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018 Second Edition Copyright 2013 by the American Academy of Orthopaedic Surgeons

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

Pharmacologic Treatments: Recommendation 7 ................................................................ 3 Recommendation 7a........................................................................................................ 3 Recommendation 7b ....................................................................................................... 4

Procedural Treatments: Recommendations 8-11 ................................................................ 4 Recommendation 8 ......................................................................................................... 4 Recommendation 9 ......................................................................................................... 4 Recommendation 10 ....................................................................................................... 5 Recommendation 11 ....................................................................................................... 5

Surgical Treatments: Recommendations 12-15 .................................................................. 5 Recommendation 12 ....................................................................................................... 5 Recommendation 13 ....................................................................................................... 5 Recommendation 14 ....................................................................................................... 6 Recommendation 15 ....................................................................................................... 6

Introduction ......................................................................................................................... 7 Overview ......................................................................................................................... 7 Goals and Rationale ........................................................................................................ 7 Intended Users ................................................................................................................ 7 Patient Population ........................................................................................................... 8 Scope ............................................................................................................................... 8 Etiology ........................................................................................................................... 8 Incidence and Prevalence ................................................................................................ 8 Burden of Disease ........................................................................................................... 9 Emotional and Physical Impact ...................................................................................... 9 Potential Benefits, Harm, and Contraindications ............................................................ 9 Differences Between the Present and Previous Guidelines ............................................ 9

Preventing Bias in an AAOS Clinical Practice Guideline ................................................ 11 Methods............................................................................................................................. 14

Formulating Preliminary Recommendations ................................................................ 14 Full Disclosure Information .......................................................................................... 14 Study Selection Criteria ................................................................................................ 14 Best Evidence Synthesis ............................................................................................... 15 Outcomes Considered ................................................................................................... 16

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Literature Searches........................................................................................................ 16 Appraising Evidence Quality and Applicability ........................................................... 16

Quality....................................................................................................................... 16 Applicability .............................................................................................................. 18

Minimum Clinically Important Improvement .............................................................. 18 Grade of Recommendation ........................................................................................... 19 Defining the Strength of the Recommendations ........................................................... 20 Wording of the Final Recommendations ...................................................................... 20 Consensus Recommendations ....................................................................................... 22 Voting on the Recommendations .................................................................................. 22 Statistical Methods ........................................................................................................ 23

Network Meta-Analysis ............................................................................................ 23 Placebo Data Regression Analysis............................................................................ 24

Inclusion Criteria .................................................................................................. 24 Statistical Analysis ................................................................................................ 24 Results ................................................................................................................... 25

New To Meta-Analysis In This Guideline: Minimal Important Difference (MID) Units .......................................................................................................................... 25

Peer Review .................................................................................................................. 26 Public Comment............................................................................................................ 27 The AAOS Guideline Approval Process ...................................................................... 28 Revision Plans ............................................................................................................... 28 Guideline Dissemination Plans ..................................................................................... 28

AAOS Clinical Guideline on Treating Osteoarthritis of the Knee ................................... 31 Guideline Recommendations ............................................................................................ 31

Recommendation 1 ....................................................................................................... 31 Rationale ................................................................................................................... 31 Supporting Evidence ................................................................................................. 32

Quality................................................................................................................... 32 Applicability ......................................................................................................... 34 Final Strength of Evidence.................................................................................... 35 Results ................................................................................................................... 46

Evidence Tables and Figures .................................................................................... 61 Quality and Applicability ...................................................................................... 61 Findings................................................................................................................. 98

Recommendation 2 ..................................................................................................... 138 Rationale ................................................................................................................. 138 Supporting Evidence ............................................................................................... 138

Quality................................................................................................................. 138 Applicability ....................................................................................................... 139 Final Strength of Evidence.................................................................................. 139 Results ................................................................................................................. 141

Evidence Tables and Figures .................................................................................. 146 Quality and Applicability .................................................................................... 146 Findings............................................................................................................... 152

Recommendation 3a.................................................................................................... 159

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Recommendation 3b ................................................................................................... 159 Recommendation 3c.................................................................................................... 159

Rationale ................................................................................................................. 159 Supporting Evidence ............................................................................................... 161












Recommendation 7a.................................................................................................... 342 Recommendation 7b ................................................................................................... 342

Rationale ................................................................................................................. 342 Supporting Evidence ............................................................................................... 343

Quality................................................................................................................. 343

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Applicability ....................................................................................................... 343 Final Strength of Evidence.................................................................................. 344 Results ................................................................................................................. 429








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






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

Work Group ............................................................................................................ 976 Revision Work Group ............................................................................................. 976 Original Work Group .............................................................................................. 978

Appendix II ................................................................................................................. 980

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Decision-Makers Who Approve This Clinical Practice Guideline ......................... 980 Appendix III ................................................................................................................ 981 Determining Critical Outcomes .................................................................................. 981

Work Group Participation ....................................................................................... 981 Critical Outcomes Form .......................................................................................... 981

Determining Outcomes ....................................................................................... 981 Appendix IV................................................................................................................ 985

Study Attrition Flowchart ....................................................................................... 985 Appendix V ................................................................................................................. 986

Literature Search Strategies .................................................................................... 986 PubMed/MEDLINE ............................................................................................ 986 Embase ................................................................................................................ 988 Cochrane Library (Wiley Interface).................................................................... 990

Appendix VI................................................................................................................ 992 Quality and Applicability Appraisal ....................................................................... 992 Quality..................................................................................................................... 992 Applicability ........................................................................................................... 997

Appendix VII ............................................................................................................ 1000 Form For Assigning Strength of Recommendation .............................................. 1000

Appendix VIII ........................................................................................................... 1001 Opinion Based Recommendations ........................................................................ 1001 Rules for Making Opinion Based Recommendations ........................................... 1001 Checklist For Voting on Opinion Based Recommendations ................................ 1002 Voting by the Nominal Group Technique ............................................................ 1002

Appendix IX.............................................................................................................. 1003 Structured Peer Review Form ............................................................................... 1003

Appendix X ............................................................................................................... 1007 Participating Peer Review Organizations ............................................................. 1007

Appendix XI.............................................................................................................. 1008 Interpreting the Forest Plots .................................................................................. 1008 Abbreviations Used In This Report ...................................................................... 1008

Appendix XII ............................................................................................................ 1010 Conflict of Interest ................................................................................................ 1010

Appendix XIII ........................................................................................................... 1012 Network Meta Analysis Checks for Consistency ................................................. 1012

Appendix XIV ........................................................................................................... 1022 Confidence Intervals of Treatment Effects that Range in Statistical and Clinical Signficance ............................................................................................................ 1022

Appendix XV ............................................................................................................ 1023 Bibliography ......................................................................................................... 1023 Additional References ........................................................................................... 1040 Excluded Studies ................................................................................................... 1051

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LIST OF TABLES Table 1. Relationship between Quality and Domain Scores for Treatment Studies ......... 17 Table 2. Relationship between Applicability and Domain Scores for Treatment Studies 18 Table 3. Brief Description of the PRECIS Questions and Domains................................. 18 Table 4. Descriptive Terms for Results with MCII .......................................................... 19 Table 5. AAOS Guideline Language ................................................................................ 20 Table 6. Recommendation Strengths, Descriptions, and Clinical Implications ............... 21 Table 7. Quality and Applicability Summary: Strength Training Versus Control ........... 35 Table 8 Quality and Applicability Summary: Isokinetic Versus Isotonic Versus Isometric Strength Training .............................................................................................................. 36 Table 9. Quality and Applicability Summary: High Versus Low Resistance Strength Training ............................................................................................................................. 36 Table 10. Quality and Applicability Summary: Isokinetic Versus Isotonic Versus Isometric Strength Training .............................................................................................. 37 Table 11. Quality and Applicability Summary: Proprioception Versus Control .............. 37 Table 12. Quality and Applicability Summary: Physical Therapy Versus Control .......... 37 Table 13. Quality and Applicability Summary: Kinesthesia Plus Strengthening Versus Strengthening Only ........................................................................................................... 39 Table 14. Quality and Applicability Summary: Agility Plus Perturbation Versus Standard Exercise Therapy .............................................................................................................. 39 Table 15. Quality and Applicability Summary: Self-Management Plus Exercise Versus Exercise Alone .................................................................................................................. 40 Table 16. Quality and Applicability Summary: Aerobic Exercise Versus Education ...... 40 Table 17. Quality and Applicability Summary: Home-Based Exercise, Self-Management, and Coping Strategies Versus Usual Care ........................................................................ 41 Table 18. Quality and Applicability Summary: Water Versus Land-Based Exercises .... 44 Table 19. Quality and Applicability Summary: Supervised Walking Versus Usual Care 44 Table 20. Quality and Applicability Summary: Yoga Plus Physiotherapy Versus Physiotherapy Only ........................................................................................................... 45 Table 21. Quality and Applicability Summary: Standardized Consultation Versus Usual Care ................................................................................................................................... 45 Table 22. Quality and Applicability: Strength Training Versus Control .................. 61 Table 23. Quality and Applicability: High Versus Low Resistance Training ........... 66 Table 24. Quality and Applicability: Isokinetic Versus Isotonic Versus Isometric Strength Training............................................................................................................ 67 Table 25. Quality and Applicability: Strength Training Versus Education ............. 68 Table 26. Quality and Applicability: Proprioceptive Versus Control ...................... 69 Table 27. Quality and Applicability: Physical Therapy Versus Control ................... 70 Table 28. Quality and Applicability: Kinesthesia Plus Strengthening Versus Strengthening Alone ....................................................................................................... 74 Table 29. Quality and Applicability: Agility Plus Perturbation Versus Standard Exercise Therapy ............................................................................................................ 75 Table 30. Quality and Applicability: Self-Management Versus Control................... 78 Table 31. Quality and Applicability: Supervised Walking Versus Control .............. 84 Table 32. Quality and Applicability: Water Versus Land-Based Exercise ............... 85 Table 33. Quality and Applicability: Aerobic Exercise Versus Education................ 86

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Table 34. Quality and Applicability: Weight Bearing and Non-Weight Bearing Exercise Programs .......................................................................................................... 88 Table 35. Quality and Applicability: Home and Class-Based Exercise Programs ... 90 Table 36. Quality and Applicability: Standardized Structured Physician Consultation Program (Education) Versus Control .................................................... 93 Table 37. Quality and Applicability: Integrated Exercise, Self-Management, and Coping Strategies Versus Usual Care ........................................................................... 94 Table 38. Quality and Applicability: Yoga Plus Physiotherapy Versus Physiotherapy Only ........................................................................................................ 96 Table 39. Strength Training Compared to Control: Pain Outcomes ......................... 98 Table 40. Isokinetic Versus Isotonic Versus Isometric Exercise: Pain ...................... 99 Table 41. Strength Training Versus Control: Functional Measure ......................... 100 Table 42. Strengthening Versus Control: WOMAC Total ....................................... 103 Table 43. High Versus Low Resistance Training: Function ..................................... 104 Table 44. Resistance Strength Training Versus Health Education ......................... 104 Table 45. Physical Therapy Versus Control: Pain Measures ................................... 105 Table 46. Physical Therapy Versus Control: Functional Measures........................ 106 Table 47. Exercise Plus Manual Physical Therapy Versus Non-Therapeutic Intensity Ultrasound ..................................................................................................... 108 Table 48. Proprioceptive Training Versus Control: Pain Measures ........................ 109 Table 49. Proprioceptive Training Versus No Exercise: Function........................... 109 Table 50. Agility and Perturbation Training Plus Usual Exercise Versus Exercise Only (Fitzgerald 2011) .................................................................................................. 109 Table 51. Agility and Perturbation Training Plus Usual Exercise Versus Exercise Only: Odds of Improvement From Baseline for WOMAC Functional Tasks (Teixeira 2011) ............................................................................................................... 110 Table 52. Kinesthesia Plus Strength Training Versus Strength Training: Function......................................................................................................................................... 112 Table 53. Weight Bearing and Non-Weight Bearing Exercise ................................. 113 Table 54. Water Versus Land-Based Exercise: Pain ................................................. 115 Table 55. Water Versus Land-Based Exercise: Lequesne Index .............................. 116 Table 56. Home-Based and Hospital-Based Exercise Programs .............................. 117 Table 57. Aerobic Exercise Versus Control: Function .............................................. 120 Table 58. Aerobic Exercise Versus Control: Functional Task ................................. 121 Table 59. Supervised Walking Versus Usual Care: Pain .......................................... 121 Table 60. Supervised Walking Versus Usual Care: Function .................................. 122 Table 61. Supervised Walking Versus Control: Arthritis Impact Measurement Scale (Medications Use) .......................................................................................................... 122 Table 62. Self-Management Versus Waitlist Control ................................................ 123 Table 63. Self-Management Plus Exercise Versus Usual Care: Pain ....................... 129 Table 64. Self-Management Plus Exercise Versus Usual Care: Function ............... 129 Table 65. Structured Consultation Versus Control: Function ................................ 130 Table 66. Integrated Exercise, Self-Management, and Coping Strategies Versus Usual Care (Hurley 2007) ............................................................................................. 132 Table 67. Yoga Plus Physiotherapy Versus Physiotherapy Only (Ebenezer 2011) 135 Table 68. Quality and Applicability Summary: Weight Loss Versus Education ... 139

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Table 69. Quality and Applicability Summary: Low Energy Diet Versus Conventional Diet.......................................................................................................... 140 Table 70. Quality and Applicability Summary: Diet Versus Exercise ..................... 141 Table 71. Quality and Applicability: Exercise-Based Weight Loss Program Versus Health Education .......................................................................................................... 146 Table 72. Quality and Applicability: Weight Loss Versus Education Programs ... 147 Table 73. Quality and Applicability: Low Energy Diet Versus Control Diet.......... 149 Table 74. Quality and Applicability: Diet Versus Exercise ...................................... 151 Table 75. Weight Loss-Exercise Only Versus Control: Function............................. 152 Table 76. Weight Loss-Exercise Only Versus Control: Functional Task ................ 152 Table 77. Dietary Weight Loss (With and Without Exercise) Versus Education Control ........................................................................................................................... 153 Table 78. Low Energy Diet Versus Control Diet ....................................................... 155 Table 79. Diet Versus Exercise .................................................................................... 157 Table 80. Quality and Applicability Summary: Acupuncture Versus Control ...... 162 Table 81. Quality and Applicability Summary: Periosteal Stimulation Therapy .. 166 Table 82. Quality and Applicability Summary: Pulsed Electrical Stimulation ...... 166 Table 83. Quality and Applicability Summary: Pulsed Electromagnetic Therapy 168 Table 84. Quality and Applicability Summary: Swedish Massage Therapy ........... 168 Table 85. Quality and Applicability Summary: Ultrasound ..................................... 169 Table 86. Quality and Applicability: Acupuncture Versus Control ........................ 177 Table 87. Quality and Applicability: Periosteal Stimulation Therapy .................... 188 Table 88. Quality and Applicability: Pulsed Electrical and Electromagnetic Therapy......................................................................................................................................... 189 Table 89. Quality and Applicability: TENS, Interferential Current, and Short Wave Diathermy ...................................................................................................................... 192 Table 90. Swedish Massage Therapy Versus Usual Care ......................................... 197 Table 91. Ultrasonic Wave Plus Exercise Versus Exercise Alone ............................ 199 Table 92. Acupuncture Versus Control: Pain ............................................................ 201 Table 93. Acupuncture Versus Control: Function .................................................... 202 Table 94. Acupuncture Versus Usual Care: Hospital Anxiety and Depression Score......................................................................................................................................... 207 Table 95. Acupuncture Versus Control: Lequesne Index ......................................... 208 Table 96. Acupuncture Versus Control: Consumption of Concomitant Medication......................................................................................................................................... 209 Table 97. Periosteal Stimulation Therapy Versus Regular Acupuncture (Weiner 2007) ............................................................................................................................... 209 Table 98. TENS, Interferential Current, and Short Wave Diathermy Versus Sham (Atamaz et al., 2012) ..................................................................................................... 211 Table 99. Swedish Massage Therapy Versus Usual Care (Perlman 2006) .............. 216 Table 100. Ultrasound Versus Control ....................................................................... 218 Table 101. Pulsed Electrical and Electromagnetic Therapy ..................................... 220 Table 102. Quality and Applicability Summary: Brace Versus Usual Care ........... 229 Table 103. Quality and Applicability Summary: Brace Versus Sleeve.................... 230 Table 104. Quality and Applicability Summary: Brace Versus Insoles .................. 230 Table 105. Quality and Applicability: Brace Versus Usual Care ............................. 234

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Table 106. Quality and Applicability: Unloader Brace Versus Neoprene Sleeve ... 238 Table 107. Quality and Applicability: Braces Versus Insoles ................................... 240 Table 108. Brace Plus Usual Care Versus Usual Care: Pain .................................... 241 Table 109. Brace Plus Usual Care Versus Usual Care: Functional Tasks ...................... 243 Table 110. Brace Plus Usual Care Versus Usual Care: Function ................................... 244 Table 111. Brace plus Usual Care Versus Usual Care: Other Outcomes ....................... 245 Table 112. Brace Versus Neoprene Sleeve .................................................................. 246 Table 113. Braces Versus Insoles ................................................................................. 248 Table 114. Quality and Applicability Summary: Lateral Wedge Insole ........................ 250 Table 115. Quality and Applicability Summary: Rubber Versus Urethane Insole 251 Table 116. Quality and Applicability: Lateral Wedge Insole ................................... 253 Table 117 Quality and Applicability: Rubber versus Urethane Insoles ......................... 255 Table 118. Lateral Wedge versus Neutral Insoles: Critical Outcomes .................... 256 Table 119. Lateral Wedge versus Neutral Insoles: other outcomes................................ 256 Table 120. Urethane Versus Rubber Insole (Both With Subtalar Strapping) ........ 258 Table 121. Quality and Applicability Summary: Dietary Supplements .................. 264 Table 122. Quality And Applicability: Glucosamine Versus Control ...................... 279 Table 123. Quality and Applicability: Chondroitin ................................................... 289 Table 124. Glucosamine Versus Placebo: Pain .......................................................... 306 Table 125. Glucosamine Versus Placebo: Function ................................................... 307 Table 126. Glucosamine Versus Placebo: WOMAC Stiffness .................................. 308 Table 127. Glucosamine Versus Placebo: WOMAC Total ....................................... 309 Table 128. Glucosamine Versus Placebo: Other Outcomes ...................................... 310 Table 129 Glucosamine HCL Plus Sodium Chondroitin Plus Manganese Ascorbate Versus Placebo: Patient Global Assessment ................................................................... 312 Table 130. Glucosamine Versus Placebo: NSAID Consumption.............................. 312 Table 131. Glucosamine Versus Placebo: Adverse Events ....................................... 313 Table 132. Glucosamine Versus Reparagen: Pain ..................................................... 314 Table 133. Glucosamine Versus Enzymatic Hydrolyzed Collagen .......................... 315 Table 134. Chondroitin Sulfate Versus Placebo: Pain .............................................. 316 Table 135. Chondroitin Sulfate Versus Placebo: Function ....................................... 318 Table 136. Chondroitin Sulfate Versus Placebo: WOMAC Stiffness ...................... 319 Table 137. Chondroitin Sulfate Versus Placebo: WOMAC Total ........................... 319 Table 138. Chondroitin Sulfate Versus Placebo: Lequesne Index ........................... 320 Table 139. Chondroitin Versus Placebo: Additional Analgesic Use ........................ 322 Table 140. Chondroitin Sulfate Versus Placebo: Other Outcomes .......................... 322 Table 141. Chondroitin Sulfate Plus Glucosamine Versus Placebo ......................... 324 Table 142. Chondroitin Sulfate Plus Glucosamine: Stratified By Severity (Clegg 2006) ............................................................................................................................... 325 Table 143. Piascledine Versus Chondroitin Sulfate ................................................... 326 Table 144. Quality and Applicability Summary: Analgesics ......................................... 344 Table 145. Network Meta-Analysis: Statistically Significant Treatment Comparisons . 438 Table 146. Results Summary: Drug Treatments Versus Placebo (Patient and Physician Assessments) ................................................................................................................... 439 Table 147. Statistically Significant Active Treatment Comparisons: Global Assessments ................................................................................................................... 440

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Table 148. Quality and Applicability: Cox-2 .............................................................. 441 Table 149. Quality and Applicability: NSAIDs Versus Control ............................... 514 Table 150. Quality and Applicability: Cox-2s Versus NSAIDs ................................ 571 Table 151. Quality and Applicability: Acetaminophen Versus Control .................. 604 Table 152. Quality and Applicability: Interleukin Versus Control ......................... 618 Table 153. Quality and Applicability: Tramadol Versus Control ............................ 633 Table 154. Quality and Applicability: Orgotein Versus Control ............................. 639 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 Hyaluronic Acid ............................................................................................................ 750 Table 168. Quality and Applicability Summary: IA Corticosteroids Versus Needle Lavage ............................................................................................................................ 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 Weight Hyaluronic Acid ............................................................................................... 780 Table 177. Quality and Applicability: Hyaluronic Acid Versus Control ................ 789 Table 178. Quality and Applicability: High Versus Low Molecular Weight Hyaluronic Acid ............................................................................................................ 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

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Table 185. Hyaluronic Acid Versus Conventional Treatment: WOMAC Total (Kahan et al., 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 Table 192. Growth Factor Injections Versus Hyaluronic Acid (Sanchez et al., 2008 and Sanchez 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

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Table 217. Quality and Applicability: Partial Meniscectomy with Exercise Versus Exercise 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 Medial Open 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 Table 228. Quality and Applicability: Free-Floating Interpositional Device ................. 971 Table 229. Network Meta-Analysis Consistency Check: WOMAC Pain .............. 1012 Table 230. Network Meta-Analysis Consistency Check: WOMAC Function....... 1014 Table 231. Network Meta-Analysis Consistency Check: WOMAC Stiffness ....... 1016 Table 232. Network Meta-Analysis Consistency Check: WOMAC Total ............. 1018 Table 233. Network Meta-Analysis Consistency Check: Adverse Events ............. 1019

LIST OF FIGURES Figure 1. AAOS Clinical Practice Guidelines Development Process............................... 30 Figure 2. Results Summary: Strength Training Versus Control ....................................... 50 Figure 3. Results Summary: Physical Therapy ................................................................. 51 Figure 4. Results Summary: Proprioception Versus Control............................................ 52 Figure 5. Results Summary: Agility and Perturbation Training Plus Usual Exercise Versus Exercise Only ........................................................................................................ 53 Figure 6. Results Summary: Kinesthesia Versus Control ................................................. 54 Figure 7. Results Summary: Exercise Versus Control...................................................... 55 Figure 8. Self-Management and Structured Consultation Versus Control ....................... 56 Figure 9. Results Summary: Integrated Exercise, Self-Management, and Coping Strategies Versus Usual Care ............................................................................................ 58 Figure 10. Results Summary: Water Versus Land-Based Exercise .................................. 59 Figure 11. Results Summary: Yoga Versus Control ......................................................... 60 Figure 12. Strength Training Versus Control: Pain ........................................................ 137 Figure 13. Summary of Results: Diet, Exercise, and Weight Loss ................................. 143 Figure 14. Results Summary: Low Energy Diet Versus Conventional Diet .................. 144 Figure 15. Results Summary: Diet Versus Exercise ....................................................... 145 Figure 16. Results Summary: Acupuncture Versus Control ........................................... 172 Figure 17. Results Summary: Electro-acupuncture Versus Control ............................... 173 Figure 18. Results Summary: Swedish Massage Therapy and Ultrasound Versus Control......................................................................................................................................... 174

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Figure 19. Results Summary: Pulsed Electrical Stimulation .......................................... 175 Figure 20. Results Summary: Electromagnetic Fields .................................................... 176 Figure 21. Acupuncture: WOMAC pain in MID Units .................................................. 224 Figure 22. Acupuncture: WOMAC Function in MID Units ........................................... 225 Figure 23. Acupuncture Versus Placebo: WOMAC Pain (1999) ................................... 226 Figure 24. Acupuncture Versus Control: WOMAC Function ........................................ 227 Figure 25. Results Summary: Brace Versus Usual Care ................................................ 231 Figure 26. Results Summary: Brace vs. Sleeve and Insoles ........................................... 233 Figure 27. Results Summary: Foot Orthotics ................................................................. 252 Figure 28. Lateral Wedge Insole Versus Neutral Insoles: Critical Outcomes ................ 259 Figure 29. Lateral Wedge Insoles Versus Neutral Insoles: Other Outcomes ................. 260 Figure 30. Urethane Versus Rubber Insoles .................................................................. 261 Figure 31. Results Summary: Glucosamine Versus Placebo .......................................... 275 Figure 32. Results Summary: Chondroitin Sulfate Versus Placebo ............................... 277 Figure 33. Chondroitin Sulfate Versus Placebo: VAS Pain ........................................... 333 Figure 34. Glucosamine Versus Placebo: WOMAC Pain in MID Units ........................ 334 Figure 35. Glucosamine Versus Placebo: WOMAC Function in MID Units................. 335 Figure 36. Glucosamine Versus Placebo: WOMAC Stiffness in MID Units ................. 336 Figure 37. Glucosamine Versus Placebo: WOMAC Total in MID Units ...................... 337 Figure 38. Glucosamine Versus Placebo: WOMAC Pain .............................................. 338 Figure 39. Glucosamine Versus Placebo: WOMAC Function ...................................... 339 Figure 40. Glucosamine Versus Placebo: WOMAC Stiffness ....................................... 340 Figure 41. Glucosamine Versus Placebo: WOMAC Total ............................................. 341 Figure 42. Network Meta-Analysis Model: Pain ............................................................ 433 Figure 43. Network Meta-Analysis Model: WOMAC Function .................................... 434 Figure 44. Network Meta-Analysis Model: WOMAC Stiffness .................................... 435 Figure 45. Network Meta-Analysis Model: WOMAC Total .......................................... 436 Events Figure 46. Network Meta-Analysis Model: Adverse Events .............................. 437 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

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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 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 (Adverse Events) ............................................................................................................................ 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 (Adverse Events) ............................................................................................................................ 744 Figure 79. Network Meta-Analysis: Acetaminophen Versus Rofecoxib 25mg (Adverse Events) ............................................................................................................................ 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 Versus Control ............................................................................................................................ 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 Year Follow-Up (El-Azab et al., 2011) ................................................................................... 956

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Figure 95. Hospital for Special Surgery: Pain and Function (Rudan and Simurda, 1990)......................................................................................................................................... 957 Figure 96. International Knee Documentation Committee Score: Open-Wedge HTO with Internal Fixator Plate (Niemeyer et al., 2010) ................................................................ 957 Figure 97. Open-Wedge High Tibial Osteotomy: Knee Society Score (Pongsoipetch et al., 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 Stair Climb (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 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 RECOMMENDATIONS This summary of the AAOS clinical practice guideline, “Treatment of Osteoarthritis of the Knee” contains a list of the evidence based treatment recommendations and includes only less invasive alternatives to knee replacement. Discussion of how and why each recommendation was developed and the evidence report are contained in the full guideline at www.aaos.org/guidelines. Readers are urged to consult the full guideline for the comprehensive evaluation of the available scientific studies. The recommendations were 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 should always be based on a physician’s expert judgment and the patient’s circumstances, values, preferences and rights. For treatment procedures to provide benefit, mutual collaboration with shared decision-making between patient and physician/allied healthcare provider is essential.

Conservative Treatments: Recommendations 1-6 RECOMMENDATION 1 We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. Strength of Recommendation: Strong Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the benefits of the recommended approach clearly exceed 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 rationale for an alternative approach is present. RECOMMENDATION 2 We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥ 25. Strength of Recommendation: Moderate Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. 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 the quality/applicability of the supporting evidence is not as strong. Implications: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

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RECOMMENDATION 3A We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Strong Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supporting evidence is high. A harms analysis on this recommendation was not performed. Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. RECOMMENDATION 3B We are unable to recommend for or against the use of physical agents (including electrotherapeutic modalities) in patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Inconclusive

Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted 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 to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. RECOMMENDATION 3C We are unable to recommend for or against manual therapy in patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted 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 to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. RECOMMENDATION 4 We 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 Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.

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

Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. 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 the quality/applicability of the supporting evidence is not as strong. Implications: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences. RECOMMENDATION 6 We cannot recommend using glucosamine and chondroitin for patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Strong

Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supporting evidence is high. A harms analysis on this recommendation was not performed. Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. .

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

Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supporting evidence is high. A harms analysis on this recommendation was not performed. Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

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RECOMMENDATION 7B We 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 Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted 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 to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

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

Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted 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 to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. RECOMMENDATION 9 We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Strong

Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supporting evidence is high. A harms analysis on this recommendation was not performed. Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

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RECOMMENDATION 10 We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Inconclusive

Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. Implications: Practitioners should

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TREATMENT OF OSTEOARTHRITIS OF THE KNEE ......2013/05/18 · TREATMENT OF OSTEOARTHRITIS OF THE KNEE EVIDENCE-BASED GUIDELINE 2 ND EDITION Adopted by the American Academy of Orthopaedic