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Treatment of Osteoarthritis of the Knee –2nd EditionEvidence-Based Clinical Practice GuidelineAdopted by:The American Academy of Orthopaedic Surgeons Board of DirectorsMay 18, 2013Please cite this guideline as:American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee – 2nd EditionEvidence-Based Clinical Practice Guideline. uideline.pdf.Published May 18, 2013.
DisclaimerThis clinical practice guideline was developed by an AAOS work group comprised ofvolunteer physicians and interdisciplinary clinicians as well as staff researchers withexpertise in systematic reviews and statistical methods used to evaluate empiricalevidence. It is an educational tool that integrates the current scientific literature and theproficiency and sound judgment that physicians typically acquire in clinical practice. Therecommendations that make up this guideline are not intended to be absolute as patientsvary in how they experience symptoms and respond to treatment interventions. Theremay be variability between patients in practice and those who participate in clinical trials.Medical care should always be based on a physician’s expertise that is individuallytailored to the patient’s circumstances, preferences and rights.Disclosure RequirementIn accordance with AAOS policy, all individuals whose names appear as authors orcontributors to this clinical practice guideline provided full disclosure of and were vettedfor potential conflicts of interest prior to the introductory meeting.Funding SourceThe American Academy of Orthopaedic Surgeons funded this clinical practice guidelinewithout any financial support from outside commercial sources.FDA ClearanceSome drugs or medical devices referenced or described in this clinical practice guidelinemay not have been cleared by the Food and Drug Administration (FDA) or may havebeen cleared for a specific use only. The FDA has stated that it is the responsibility of thephysician to determine the clearance status of each drug or device prescribed in clinicalpractice.CopyrightAll rights reserved. No part of this clinical practice guideline may be reproduced orstored in a retrieval system or transmitted in any form or by any means (electronic,mechanical, photocopying, recording, or otherwise) without prior written permissionfrom the AAOS.Published 2013 by the American Academy of Orthopaedic Surgeons6300 North River RoadRosemont, IL 60018Second EditionCopyright 2013 by the American Academy of Orthopaedic Surgeonsii
TABLE OF CONTENTSTable of Contents . iiiList of Tables . ixList of Figures . xvSummary of Recommendations . 1Conservative Treatments: Recommendations 1-6 . 1Recommendation 1 . 1Recommendation 2 . 1Recommendation 3a. 2Recommendation 3b . 2Recommendation 3c. 2Recommendation 4 . 2Recommendation 5 . 3Recommendation 6 . 3Pharmacologic Treatments: Recommendation 7 . 3Recommendation 7a. 3Recommendation 7b . 4Procedural Treatments: Recommendations 8-11 . 4Recommendation 8 . 4Recommendation 9 . 4Recommendation 10 . 5Recommendation 11 . 5Surgical Treatments: Recommendations 12-15 . 5Recommendation 12 . 5Recommendation 13 . 5Recommendation 14 . 6Recommendation 15 . 6Introduction . 7Overview . 7Goals and Rationale . 7Intended Users . 7Patient Population . 8Scope . 8Etiology . 8Incidence and Prevalence . 8Burden of Disease . 9Emotional and Physical Impact . 9Potential Benefits, Harm, and Contraindications . 9Differences Between the Present and Previous Guidelines . 9Preventing Bias in an AAOS Clinical Practice Guideline . 11Methods. 14Formulating Preliminary Recommendations . 14Full Disclosure Information . 14Study Selection Criteria . 14Best Evidence Synthesis . 15Outcomes Considered . 16iii
Literature Searches. 16Appraising Evidence Quality and Applicability . 16Quality. 16Applicability . 18Minimum Clinically Important Improvement . 18Grade of Recommendation . 19Defining the Strength of the Recommendations . 20Wording of the Final Recommendations . 20Consensus Recommendations. 22Voting on the Recommendations . 22Statistical Methods . 23Network Meta-Analysis . 23Placebo Data Regression Analysis. 24Inclusion Criteria . 24Statistical Analysis . 24Results . 25New To Meta-Analysis In This Guideline: Minimal Important Difference (MID)Units . 25Peer Review . 26Public Comment. 27The AAOS Guideline Approval Process . 28Revision Plans. 28Guideline Dissemination Plans . 28AAOS Clinical Guideline on Treating Osteoarthritis of the Knee . 31Guideline Recommendations . 31Recommendation 1 . 31Rationale . 31Supporting Evidence . 32Quality. 32Applicability . 34Final Strength of Evidence. 35Results . 46Evidence Tables and Figures . 61Quality and Applicability. 61Findings. 98Recommendation 2 . 138Rationale . 138Supporting Evidence . 138Quality. 138Applicability . 139Final Strength of Evidence. 139Results . 141Evidence Tables and Figures . 146Quality and Applicability. 146Findings. 152Recommendation 3a. 159iv
Recommendation 3b . 159Recommendation 3c. 159Rationale . 159Supporting Evidence . 161Quality. 161Applicability . 162Final Strength of Evidence. 162Results . 170Evidence Tables and Figures . 177Quality and Applicability. 177Findings. 201Recommendation 4 . 228Rationale . 228Supporting Evidence . 228Quality. 228Applicability . 228Final Strength of Evidence. 229Results . 230Evidence Tables and Figures . 234Quality and Applicability. 234Findings. 241Recommendation 5 . 249Rationale . 249Supporting Evidence . 249Quality. 249Applicability . 249Final Strength of Evidence. 250Results . 251Evidence Tables and Figures . 253Quality and Applicability. 253Findings. 256Recommendation 6 . 262Rationale . 262Supporting Evidence . 263Quality. 263Applicability . 263Final Strength of Evidence. 263Results . 273Evidence Tables and Figures . 279Quality and Applicability. 279Findings. 306Recommendation 7a. 342Recommendation 7b . 342Rationale . 342Supporting Evidence . 343Quality. 343v
Applicability . 343Final Strength of Evidence. 344Results . 429Evidence Tables and Figures . 441Quality and Applicability. 441Findings. 624Recommendation 8 . 747Rationale . 747Supporting Evidence . 747Quality. 747Applicability . 748Final Strength of Evidence. 748Results . 752Evidence Tables and Figures . 754Quality and Applicability. 754Findings. 762Recommendation 9 . 770Rationale . 770Supporting Evidence . 771Quality. 771Applicability . 771Final Strength of Evidence. 772Results . 783Evidence Tables and Figures . 789Quality and Applicability. 789Findings. 813Recommendation 10 . 854Rationale . 854Supporting Evidence . 854Quality. 854Applicability . 854Final Strength of Evidence. 855Results . 856Evidence Tables and Figures . 857Quality and Applicability. 857Findings. 860Recommendation 11 . 863Rationale . 863Supporting Evidence . 863Quality. 863Applicability . 864Final Strength of Evidence. 864Results . 865Evidence Tables and Figures . 867Quality and Applicability. 867Findings. 871vi
Recommendation 12 . 876Rationale . 876Supporting Evidence . 877Quality. 877Applicability . 877Final Strength of Evidence. 877Results . 887Evidence Tables and Figures . 889Quality and Applicability. 889Findings. 913Recommendation 13 . 932Rationale . 932Supporting Evidence . 932Quality. 932Applicability . 932Final Strength of Evidence. 932Results . 934Evidence Tables and Figures . 935Quality and Applicability. 935Findings. 937Recommendation 14 . 939Rationale . 939Supporting Evidence . 939Quality. 939Applicability . 939Final Strength of Evidence. 940Results . 945Evidence Tables and Figures . 946Quality and Applicability. 946Findings. 956Recommendation 15 . 969Rationale . 969Supporting Evidence . 969Quality. 969Applicability . 969Final Strength of Evidence. 970Results . 970Evidence Tables and Figures . 971Quality and Applicability. 971Findings. 972Future Research . 974Appendix I . 976Work Group . 976Revision Work Group . 976Origin
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.
