Recently, the American Academy of Orthopaedic Surgery (AAOS) updated their Clinical Practice Guidelines (CPGs) for the treatment of osteoarthritis of the knee. In general, the CPG’s are recommendations from the AAOS on the treatment of certain diseases which are based on the published clinical research. The published literature is evaluated to find the best studies which help to determine the ability of a treatment to add some therapeutic value to the patient’s disease process. In layman’s terms – will this treatment help someone get better? With this as a basis, the AAOS will then assign a group of physicians to interpret the literature and make recommendations, based on the cumulative findings of the studies reviewed. The current set of guidelines (2013) was updated from the most recent review, done in 2008.
The only real change in the CPG’s this time regards the use of viscosupplementation in the patient with symptomatic knee osteoarthritis. Viscosupplementation is the use of injections, comprised mainly of Hylauronic acid, with brand names, such as Supartz, Hyalgen, Synvisc, etc., used specifically for the treatment of advanced arthritis of the knee joint. The treatment recommendation was changed from “inconclusive” to “cannot recommend”. This change has created quite a stir among patients and physicians. Obviously, there are good reasons for and against the use of viscosupplementation in the knee. The AAOS review is based on literature that has been published in peer-reviewed journals, providing strong support for their recommendations. However; speaking as an Orthopaedic physician, I have had patients (as have my practice colleagues) that have seen tremendous results from the use of viscosupplementation, to the point that they were able to postpone knee replacement for several years.
As the CPG’s are guidelines for treatment and not absolute algorithms, there is some room for individual physician interpretation and patient modification. The balance comes with the clinical evaluation of the patients that are being treated. Patient selection is the most important criteria for the success of any treatment, including that with viscosupplementation. Knowing which patients will get better with a specific treatment is truly the art of medicine. The application of medical knowledge to the treatment options available allows the physician and patient to come together with a treatment plan and expected results.
We know that patients with painful bone-to-bone arthritis will need a knee replacement surgery. Most patients are reluctant to proceed with surgery when they are being evaluated for the first time and rightly so. The other treatment options may delay the inevitable, and give the patient some time to wrap their head around the need for surgery, but they are not a cure for the arthritis. Injections of cortisone, viscosupplementation injections, anti-inflammatory medications and pain medications may all provide some improvement in the symptoms of arthritis, but will not change the course of the disease. The range of treatments should be discussed with patients to ensure they understand the expectations, risks and benefits of each treatment. The informed patient can then participate in the development of a treatment plan, with a clear view of the outcomes related to each treatment option.
Dr. Jeffrey R. Carlson is a Harvard Orthopaedic/Neurosurgical Spine Fellow and is Chief-of-Surgery at Bon Secours Mary Immaculate Hospital in Newport News, VA. He is the Managing Partner of Orthopaedic and Spine Center in Newport News, VA. For more information or for an appointment, contact OSC at 757-596-1900 or go to www.osc-ortho.com.