Guidelines for evidence based medicine for osteoarthritis of the knee (Second Edition)

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Evidence based medicine guidelines for osteoarthritis of the knee (Second Edition), based on a systematic review of current scientific and c

Content

Evidence based medicine guidelines for osteoarthritis of the knee (Second Edition), based on a systematic review of current scientific and clinical research. This guide includes only 15 recommendations, compared with the 2008 AAOS clinical practice guidelines, two different analysis methods summary of evidence, second edition of the guide to re evaluate the first edition of the guide to follow the evidence 5 years ago.

This edition does not support replacement therapy with viscoelastic (viscosupplementation) (such as sodium hyaluronate, editor's note) for the treatment of knee osteoarthritis, in addition, the working group formulated the guidelines for the scientific research emphasizes the definitive treatment of knee osteoarthritis need better.

General

According to the American College of Rheumatology, the American Academy of family physicians and the American Society for physical therapy, the American Association of Department of orthopedics physicians (AAOS) recently issued the second edition of evidence-based medicine for osteoarthritis of the knee. Different from the 2008 AAOS clinical practice guidelines is including 15 recommendations, this is because the two edition of the guide analysis summary evidence is different, second edition of the guide to re evaluate the first edition of the guide to follow the evidence 5 years ago.

The first edition of the AAOS guidelines evidence comes from three aspects: the U.S. healthcare research and quality administration evidence -- report of primary and secondary osteoarthritis treatment guidelines, international guidelines and Cochrane database system Osteoarthritis Research Association in retrospect. As noted by many AAOS members and other industry representatives, the original guidelines differ from the AAOS's independent analysis of existing evidence.

AAOS is no longer dependent on previous systematic reviews of evidence, because there are significant differences in the results of the study, which can increase the potential bias, and there are differences in the scope of clinical application of these systems evaluation. Sharma et al. Highlighted the phenomenon in Meta analysis of joint replacement. For these reasons, the AAOS director has authorized an update on the relevant guidelines.

The current working group uses the medical subject headings (Mesh) recommended by the 2008 guidelines for systematic review. There are obvious differences between the inclusion criteria and the first edition. First of all, the inclusion of the study requires at least 30 samples, which can eliminate the small sample, low effect of clinical research, but also can reduce the publication bias. In addition, the study was followed up for at least 4 weeks, and those who reported potential clinical outcomes after treatment for up to two weeks were not included in this systematic review.

This study reviewed more than 10000 independent literatures, AAOS uses the best evidence synthesis of evidence-based medicine analysis, which refers to all eligible studies were carefully read, only those who can study effective evidence-based medicine into the highest level meta network analysis and meta analysis.

After completing the above system analysis, the first edition of the second edition of the knee osteoarthritis clinical practice guideline (CPG) was established, and the AAOS clinical practice guidelines (CPG) were formed after the most extensive peer review. Represents 16 peer reviewers in various specialties are strict in demands gave some suggestions on the manuscript, according to the construction of professional advice on their guidelines for major modification.

For example, for a sample treatment only pointed out the clinical effectiveness, and did not analyze whether can be harmful. The original guidelines for some treatment advice is "not recommended", but in fact "not recommended" may imply "harmful"". The working group adopted the proposal after the re organization of language, this guide includes four "recommended" (3A, 6, 9 and 12 recommended) and two "not recommended" (fifth and 11, it is recommended) implies that the terms of clinical validity evidence.

The biggest difference between the 2013 edition and the 2008 edition is that it does not support the use of viscosity supplements in the treatment of knee osteoarthritis. In the 2008 edition, it is considered that the efficacy of hyaluronic acid treatment is uncertain, and the new version is strongly recommended not to use hyaluronic acid (recommended by ninth), which is the reason why AAOS is so quick to update the clinical treatment guidelines.

In the second edition of the terms "wrote for symptomatic knee osteoarthritis patients, we do not recommend the use of hyaluronic acid, the working group to understand the recommendations brought by the clinical impact of evidence-based medicine concept, but the evidence does not support viscosupplemetation therapy.

Although many studies have shown that, compared with the control group, the effect of the use of high molecular weight hyaluronic acid in the treatment of OA had significant difference, but the difference did not reach the minimum value (MCII) changes and clinical significance of the standard, so there is no clinical difference. AAOS believes that the minimum clinical significance of the change of value is the best way to evaluate this kind of research, so we analyzed 14 articles by the minimum value of the changes and clinical significance of high quality, to measure the viscosity of supplementary therapy, the treatment has found no clinically significant difference.

To sum up, like other systems review stressed that research does not support the viscosity of complementary therapy than those in support of viscosity complementary therapy is more difficult, so the research on the viscosity of supplementary treatment method has obvious deviation.

Although there is a significant publication bias for positive results, the current study does not suggest that intra-articular injection of hyaluronic acid (HA) is effective if the minimum clinical significance (MCII) is the standard. Given that the results of this study have strong clinical implications, some support for the use of hyaluronic acid (HA) may be caused by peer dissatisfaction.

We reviewed the systematic reviews of the use of hyaluronic acid (HA) and found that they had made many mistakes in the analysis of evidence. Most of these studies did not exclude publication bias and heterogeneity between studies, and did not assess the clinical efficacy of the treatment when the final recommendations were given. In addition, many researchers who use the minimal clinical significance change as a criterion to assess the difference in clinical efficacy have made some fundamental errors.

From the beginning of the drafting of AAOS clinical practice guidelines, the working group has been to minimize the clinical significance of changes of value as the standard to evaluate the effectiveness of clinical treatment, so you can determine a really effective clinical treatment, and not just because of a little improvement and was effective.

The guidelines are applied to the other two measure of treatment effect of strength, a patient acceptable symptom score, he represents the absolute score of patient satisfaction, another is the IMMPACT score, he represents the percentage of patients satisfied with treatment.

Relative to the AAOS clinical practice guidelines for the analysis of evidence requirements, these two methods have a certain method of logic is not enough. Therefore, higher quality research is still needed to carry out the objective evaluation. The methods of the research should have a higher quality of the method logic, and it is necessary to carry on the thorough analysis to the related subgroup.

Other recommendations are based on the strength of evidence based medicine. For example, many reviewers recommended recommended levels of intra-articular injection of glucocorticoid downgrade, though clinical some patients still use intra-articular injection of glucocorticoid in the treatment of knee osteoarthritis, but evidence-based medicine has not support such treatment.

Whether in patients with knee osteoarthritis underwent arthroscopic meniscal resection in the treatment of this problem, although experts to recommend, but the evidence of this guide will be recommended based on the level from "agreed" to "uncertain", but in fact these recommended levels for the clinical treatment of uncertainty in terms of knee the OA does have its merits.

In the compilation of the second edition of the clinical practice guidelines for knee osteoarthritis, special attention was paid to the methodological errors made in the first edition of the analysis of evidence. In the participation of experts under the guidance of our sample and evidence-based analysis of critical evaluation, and ultimately benefit a lot, then we will also adhere to this way. Like all other AAOS clinical practice guidelines, this guideline does not count as a tool to cover all clinical decisions. AAOS still hopes that the guidelines are properly interpreted and used to better serve patients and doctors.

Although the current guidelines are still in the process of defining the effectiveness of a drug, an intervention, or a diagnostic test, we will develop appropriate application criteria (AUC) in the future. Appropriate use of the standard will further standardize the use of appropriate drugs, surgical intervention and diagnostic tests, "the appropriate patient" and "the best period". Appropriate guidelines for the use of this guideline are currently being developed, which will further define the clinical pathway for patients with knee osteoarthritis.

The working group emphasized the need to design more rigorous clinical trials in order to obtain a higher level of evidence-based evidence for the treatment of knee OA, and to improve the methodology to identify whether the treatment is truly clinically effective. No evidence of evidence-based medicine is sufficient to make important clinical decisions, regardless of whether they are strongly recommended or not.

Personal values and preferences in clinical research must be balanced to ensure that clinical evidence is best shared, and evidence-based medicine is not a "one size fits all" approach. We need to be clear about the integration of evidence-based medicine, including three elements: scientific evidence, physician experience and patient opinion, no single factor can not be used as a basis for clinical decision-making.

Recommend

This article is a streamlined version of evidence-based guidelines for the second edition of AAOS treatment of knee osteoarthritis, including list of recommended drug treatment, evidence-based physical therapy and surgical treatment, but not including knee arthroplasty. The full version of the guide includes how each recommendation is formed and the relevant complete evidence-based medical reports, which can be found in http://www.aaos.org/guidelines.

We encourage readers to consult the full version of the guide to fully understand the relevant research. Evidence of evidence-based medicine used in the development of this guideline is subject to strict control bias, increased transparency, and enhanced reproducibility.

We do not wish to rely solely on guidelines for clinical practice. A perfect medical activity should take into account the evidence of evidence-based medicine, the professional experience of the physician and the patient's actual situation and preferences. In order to bring benefits to patients in medical activities, clinical decision-making requires the cooperation of patients, doctors and the corresponding health care providers.

This guide "strongly recommended" means to support the treatment of evidence-based quality grade is very high, "moderate recommendation" refers to the treatment of the benefits outweigh the potential damage (if the potential damage is significantly more than the benefit of treatment is not recommended, but moderate) the level of evidence for the former not so high. "Expert consensus" means that although there is no evidence of compliance with the criteria for inclusion in the guidelines, experts say the treatment is beneficial. "Uncertainty" means that there is no evidence to suggest that the benefit ratio of the treatment.

Recommendation 1

For patients with symptomatic osteoarthritis of the knee, it is recommended to participate in self-management programs, including strength training, low intensity aerobic exercise, neuromuscular training, and physical activity in accordance with the national guidelines.

Recommended level: highly recommended

A clinician should follow this advice unless there is a clear and compelling alternative.

Recommendation 2

For symptomatic knee osteoarthritis patients, if the body mass index of more than 25, it is recommended to lose weight.

Recommended level: moderate recommendation

Meaning: Clinicians should follow the recommendations, but if there are other ways to meet the patient's preferences, you can adjust the treatment plan.

Recommended 3A

For symptomatic knee osteoarthritis, we do not recommend the use of acupuncture therapy.

Recommended level: Although we do not conduct a hazard analysis, we strongly recommend.

A clinician should follow this advice unless there is a clear and compelling alternative.

Recommended 3B

For patients with symptomatic osteoarthritis of the knee, we neither agree nor oppose the use of physical therapy (including electrical stimulation).

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommended 3C

For patients with symptomatic osteoarthritis of the knee, we neither agree nor oppose the use of massage therapy.

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommendation 4

For patients with symptomatic knee osteoarthritis, we neither agree nor oppose the use of valgus stress support (medial compartment).

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommendation 5

For patients with symptomatic osteoarthritis of the knee, it is not recommended to use an external wedge insole.

Recommended level: moderate recommendation

Meaning: Clinicians should follow the recommendations, but if there are other ways to meet the patient's preferences, you can adjust the treatment plan.

Recommendation 6

The symptoms of patients with knee osteoarthritis, we do not recommend the use of glucosamine and chondroitin.

Recommended level: Although we do not conduct a hazard analysis, we strongly recommend.

A clinician should follow this advice unless there is a clear and compelling alternative.

Recommended 7a

The symptoms of patients with knee osteoarthritis, we recommend oral or topical use of nonsteroidal anti-inflammatory drugs or tramadol.

Recommended level: highly recommended.

A clinician should follow this advice unless there is a clear and compelling alternative.

Recommended 7B

For patients with symptomatic knee osteoarthritis, we neither agree nor oppose the use of acetaminophen, opioids, and other analgesics.

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommendation 8

For patients with symptomatic knee osteoarthritis, we neither agree nor oppose the use of intra-articular injections of corticosteroids

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommendation 9

For patients with symptomatic osteoarthritis of the knee, we do not recommend the use of hyaluronic acid.

Recommended level: Although this is not a hazard analysis, it is strongly recommended.

A clinician should follow this advice unless there is a clear and compelling alternative.

Recommendation 10

For patients with symptomatic knee OA, we neither agree nor oppose the use of intra-articular injection of growth factor and / or platelet rich plasma.

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommendation 11

For patients with symptomatic knee osteoarthritis, it is not recommended to use syringe irrigation.

Recommended level: moderate recommendation

Meaning: Clinicians should follow the recommendations, but if there are other ways to meet the patient's preferences, you can adjust the treatment plan.

Recommendation 12

For patients with symptomatic osteoarthritis of the knee, we do not recommend arthroscopic lavage and / or debridement.

Recommended level: Although this is not a hazard analysis, it is strongly recommended.

A clinician should follow this advice unless there is a clear and compelling alternative.

Recommendation 13

For patients with osteoarthritis of the knee joint with rupture of the meniscus, we neither agree nor oppose the partial meniscectomy.

Recommended level: uncertain

Meaning: physicians should decide on their own experience to use the results of the "uncertain" treatment, but should always be concerned about evaluating the benefits of such treatment as a result of recent research to help clinical decision-making. Patient willingness is a key factor in determining treatment.

Recommendation 14

The symptoms of medial knee osteoarthritis patients, the doctor may implement proximal tibial valgus osteotomy.

Recommended level: Limited

Doctors should decide whether to adopt the proposal based on their experience, but should pay close attention to the latest research on the treatment. Patient willingness is a key factor in determining treatment.

Recommendation 15

Because of the lack of reliable evidence, the working group recommends that a floating free (non fixed) interval device be used in patients with symptomatic medial compartment osteoarthritis.

Recommended level: expert consensus

Meaning: although they may be given priority, it is primarily a doctor's decision to follow the advice, but the patient's will is a key factor in determining treatment.

References (see the text, click on the "download the original")

[editor's note]

China continent, there are many hospitals, including many hospitals are still in patients with knee osteoarthritis by intra-articular injection of sodium hyaluronate, arthroscopic lavage cleaning, and in the new guidelines, there is clear evidence (recommendation 9 and 12 above) clearly opposed to treatment. Looks like it's time to change our clinical habits.

As for the patients with knee osteoarthritis with meniscus rupture, should the arthroscopic partial meniscectomy be performed, the guidelines are "uncertain"". In the guidelines released 16 days ago, published a randomized controlled study in the new England Journal of medicine, concluded that "the clinical symptoms and radiographic evidence associated with meniscal tears in patients with osteoarthritis, arthroscopic surgery and physiotherapy are likely to improve function, relieve pain". However, this is a new challenge to the necessity of surgical treatment. Of course, the study is too new, can only be used in the development of the next version of the guide, it can be expected that the next version of the guidelines for this issue should be more clear.

 

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