A global panel of over 40 orthopedic-related experts has published the first-ever Consensus Document that outlines guidelines for active, older less active, and younger knee osteoarthritis (OA) patients. The recommendations define approaches for diagnosis, conservative treatment—comprised of core treatment, biomechanical, pharmaceutical, orthobiologic, and alternative treatments—and surgical options, as specified by patients’ characteristics and expectations.
Consensus Recommendations, Active Knee OA Patients: For these patients, during the initial 6-week acute phase, the panel recommended a long leg standing x-ray and physical examination; water-based, land-based, and strength training exercises; and counseling the patient on self-education and weight management strategies. The panel also recommended the use of oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol/acetaminophen, as well as physiotherapy, RICE (rest, ice, compression, elevation)/cryotherapy and psychological support. Finally, during the acute phase, the consensus was to use orthotic insoles and a biomechanical unloading brace.
For patients in the subacute and ongoing phases who remained non-responsive, the panel recommended additional diagnostic imaging as well as medical interventions such as dynamic taping, steroid injections, hyaluronic acid (HA), or platelet-rich plasma (PRP) injections.
Consensus Recommendations, Older, Less Active Knee OA Patients: For the elderly, less active patient population, the importance of initial clinical and functional investigations was emphasized during the initial 6-week acute phase to identify the root cause of referred pain, as well as specific muscle strengthening exercises, assessments of appropriate footwear use, and gait analysis and retraining to correct any limb misalignment. The panel also recommended short-term use of oral or topical NSAIDs as well as HA and PRP injections.
Beyond the acute phase, unloader bracing was recommended, as was continued HA injections with the intention of maintaining cartilage preservation. If HA alone was unsuccessful, clinicians should switch between PRP and HA injections every 4 months according to patient response. The panel also considered optional treatments, such as paracetamol/acetaminophen, corticosteroid injections, supplements including capsaicin, glucosamine-chondroitin sulfate, and alternatives such as oral collagen, adipocytes, placental derivatives, and stem cells. Other optional conservative treatments included yoga, tai chi, cold therapy, shockwave, induction therapy, acupuncture, and quad stimulation. Also recommended were weak opioids with a designated end-date and a maximum of 2 corticosteroid injections. The panel also recommended osteotomy, cartilage repair, and arthroplasty procedures for patients who remained non-responsive over the longer term.
Consensus Recommendations, Younger Knee OA Patients: For addressing the needs of younger patients with knee OA, which represents a rapidly growing subset of the knee OA patient community, the panel recommended clinical and functional inspection and x-rays, including a long leg x-ray for patients with varus or valgus misalignment. Diagnostic imaging such as ultrasound and MRI were considered optional. Ultrasound was indicated in cases of swelling, particularly in patients who remained symptomatic 4 months or longer. In the acute phase following diagnosis, the panel recommended short-term use of oral or topical NSAIDs, patient education, weight management strategies, exercise, counseling, and appropriate footwear. Patients who were non-responsive to these practices were also recommended functional insoles and/or an unloader knee brace to assist with pain and enhance mobility. The panel considered a variety of other, optional treatment approaches, including paracetamol/acetaminophen, steroidal injections, kinesiology tape, ablation of the genicular nerve, and ice compression. They also deemed supplements, such as capsaicin, oral collagen, adipocytes, placental derivatives, and stem cells, as optional.
For this patient population whose OA progressed into the subacute and ongoing phases, the administration of glucosamine-chondroitin sulfate was recommended on an ongoing basis. HA injections with the intention of maintaining cartilage preservation was recommended in non-responsive patients after the acute phase, as well as for patients who were responding to the recommended protocol, beyond the 3-month mark. The panel also suggested that if HA therapy was unsuccessful, HA injections should be alternated with PRP injections. For patients who remained non-responsive longer term, corticosteroid injections and surgical procedures, including osteotomy, arthroscopy, and arthroplasty should be considered.
To access the Consensus Document, visit https://res.cloudinary.com/ossur/image/upload/v1583828848/documents/unloader/London-2019-Expert-Consensus-Knee-OA_Reduce_Pain_Maintain_Cartilage_Improve_Activity_Level.pdf.