Nav: Home

Injections for knee osteoarthritis -- 'subtle but significant' impact of revisions in clinical practice guidelines

May 17, 2018

May 17, 2018 - Recent updates in evidence-based recommendations have led to changes in the use of steroid and hyaluronic acid injection for patients with osteoarthritis of the knee, reports a study in the May 16, 2018 issue of The Journal of Bone & Joint Surgery. The journal is published in partnership in the Lippincott portfolio by Wolters Kluwer.

Although guideline revisions based on new evidence have stopped or reversed trends towards increased use of injections for knee osteoarthritis, these treatments remain commonly used, according to the new research by Nicholas A. Bedard, MD, of University of Iowa Hospitals and Clinics, Iowa City, and colleagues.

Guideline Changes Reflect Questions on Injections for Knee Arthritis

The researchers evaluated the impact of updated guidelines for nonsurgical treatment of knee osteoarthritis, issued by the American Academy of Orthopaedic Surgeons (AAOS) in 2008 and 2013. The study focused on two common treatments to reduce knee pain: corticosteroid (steroid) injection, intended to reduce inflammation; and hyaluronic acid, intended to supplement the natural fluids within the knee joint.

Dr. Bedard and colleagues analyzed an insurance database of more than 1 million patients with knee osteoarthritis treated between 2007 and 2015. Overall, about 38 percent of patients received at least one steroid injection and 13 percent had at least one hyaluronic acid injection.

Before the first clinical practice guideline, the rate of steroid injections was rising steadily. In the 2008 guideline, the AAOS suggested that steroid injection could be given for short-term pain relief of knee. After this "Grade B" recommendation - reflecting some limitations of the evidence - the rate of increase in steroid injection slowed significantly.

By 2013, there was new conflicting evidence on effectiveness of steroid injection. In response, the AAOS stated that it could not make any recommendation for or against the use of steroid injection. After this revision, the trend in steroid injection leveled off. Use of steroid injection continued to increase in patients under age 50 - perhaps reflecting attempts to avoid total knee replacement surgery in this younger age group.

Recommendations for injection of hyaluronic acid were also revised during the study period. In 2008, the AAOS stated that there was no evidence on which to base a recommendation on hyaluronic acid injection, either for or against. This recommendation slowed a previous trend toward increased use of hyaluronic acid.

By 2013, there was new evidence showing no benefit of hyaluronic acid compared to inactive placebo, prompting a strong recommendation against the use of this treatment. After this revision, the rate of hyaluronic acid injection declined significantly.

There was a significant decrease in hyaluronic acid injections performed by orthopaedic surgeons and pain specialists - but not by primary care physicians (such as general internal medicine doctors) or non-surgeon musculoskeletal specialists (such as rheumatologists or sports medicine physicians). Overall, orthopaedic surgeons performed two-thirds of hyaluronic acid injections. Trends in steroid injection did not differ by specialty.

Evidence-based guidelines play an important role in ongoing evaluation of medical treatments. The new findings suggest that guideline updates for knee osteoarthritis have had a "subtle but significant" impact on clinical practice. Rates of steroid injection leveled off after the AAOS concluded that no recommendation could be made, while the rate of hyaluronic acid injection decreased in response to a recommendation against this procedure.

Some of the same studies that questioned the effectiveness of these treatments also reported that they account for a large proportion of treatment costs for knee osteoarthritis. Injections given shortly before total knee replacement surgery may even increase the risk of infection. Dr. Bedard comments, "We hope that this project helps to shed light on the important clinical practice guidelines created by AAOS and further encourages providers to follow these recommendations, share them with their patients, and utilize them as a guide to improve the value of care provided to patients with knee osteoarthritis."
-end-
Click here to read "Impact of Clinical Practice Guidelines on Use of Intra-Articular Hyaluronic Acid and Corticosteroid Injections for Knee Osteoarthritis."

DOI: 10.2106/JBJS.17.01045

About The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, The Journal publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal.

About Wolters Kluwer

Wolters Kluwer is a global leader in professional information, software solutions, and services for the health, tax & accounting, finance, risk & compliance, and legal sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with specialized technology and services.

Wolters Kluwer, headquartered in the Netherlands, reported 2017 annual revenues of €4.4 billion. The company serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 19,000 people worldwide.

Wolters Kluwer Health is a leading global provider of trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students with advanced clinical decision support, learning and research and clinical intelligence. For more information about our solutions, visit http://healthclarity.wolterskluwer.com and follow us on LinkedIn and Twitter @WKHealth.

Wolters Kluwer Health

Related Osteoarthritis Articles:

Cross-species links identified for osteoarthritis
New research from the University of Liverpool, published today in the journal NPJ Systems Biology and Applications, has identified 'cell messages' that could help identify the early stages of osteoarthritis.
Findings do not support steroid injections for knee osteoarthritis
Among patients with knee osteoarthritis, an injection of a corticosteroid every three months over two years resulted in significantly greater cartilage volume loss and no significant difference in knee pain compared to patients who received a placebo injection, according to a study published by JAMA.
Osteoarthritis could be prevented with good diet and exercise
Osteoarthritis can potentially be prevented with a good diet and regular exercise, a new expert review published in the Nature Reviews Rheumatology reports.
Hand osteoarthritis is a common condition
A new study estimates that the lifetime risk of symptomatic hand osteoarthritis is 40 percent, and nearly one in two women and one in four men will develop the condition, which affects hand strength and function and causes disability in activities of daily living.
Noisy knees may be an early sign of knee osteoarthritis
A new study using data from the Osteoarthritis Initiative, a multi-center observational study of nearly 3500 participants, indicates that people who hear grating, cracking, or popping sounds in or around their knee joint may be at increased risk of developing knee osteoarthritis.
Improvements in ACL surgery may help prevent knee osteoarthritis
Injury to the anterior cruciate ligament (ACL) in the knee frequently leads to early-onset osteoarthritis, a painful condition that can occur even if the patient has undergone ACL reconstruction to prevent its onset.
Clinical trial for new innovative osteoarthritis drug
The University of Liverpool, in partnership with AKL Research and Development Ltd, is to lead on a clinical trial to test a potential new drug treatment for osteoarthritis.
Blood test for early osteoarthritis diagnosis unveiled
Patients could soon be diagnosed with early-stage arthritis several years before the onset of physical and irreversible symptoms, thanks to a new test developed by researchers at the University of Warwick.
Osteoarthritis just as severe as rheumatoid arthritis
Rheumatologists more likely to underestimate clinical status of their OA patients than their RA patients
Tissue fluid flow can reveal onset of osteoarthritis
Reflecting the overall structural alterations in the tissue, changes in the flow of interstitial fluid in articular cartilage could be an indicator revealing the onset of osteoarthritis, according to a new study from the University of Eastern Finland.

Related Osteoarthritis Reading:

Osteoarthritis: Preventing and Healing Without Drugs
by Peter Bales (Author)

Osteoarthritis affects over 20 million Americans and is the most common degenerative disorder in the United States. It causes more disability than any other degenerative disease and is occurring in epidemic proportions in our country.

In this novel approach to understanding and treating osteoarthritis, orthopedic surgeon Peter Bales highlights the nutritional connection to this painful and debilitating condition. Dr. Bales focuses on new genetic research, which shows that the same poor nutrition responsible for causing increased inflammation in our bodies, along with epidemic rates of... View Details


HIP Osteoarthritis CAN be Cured: Treating OA with Physical Therapy
by Susan Westlake (Author)

Drawing on the latest research and guidelines on arthritis diagnosis and care published by one of the world's leading health bodies, this essential resource explodes long-standing myths surrounding osteoarthritis in general, and hip OA in particular. It explores the role of muscle imbalance in OA symptoms and reveals that with appropriate self-administered physiotherapy, your prognosis can be far brighter than you ever imagined.

Chapter by chapter you will learn:

how easily OA can be (mis)diagnosed; what a muscle imbalance is and how it can develop; how complex muscle... View Details


The Arthritis Cure: The Medical Miracle That Can Halt, Reverse, And May Even Cure Osteoarthritis
by Jason Theodosakis (Author), Sheila Buff (Author), Barry Fox (Author)

Since its original publication in 1996, The Arthritis Cure has swept the nation, providing amazing relief for the millions who suffer chronic arthritis pain. By outlining a nine-point program that includes a new effective supplement, ASU, The Arthritis Cure Revised Edition describes a program that can halt, reverse, and possibly even cure degenerative osteoarthritis.

Based on the most recent and cutting-edge medical research, this invaluable resource promises readers:
--The latest research indicating that prescription arthritis drugs are not only expensive but can... View Details


Osteoarthritis: Everything you need to know to diagnose and treat your arthritis and how to maintain a healthy body
by Luka Je

Osteoarthritis: Everything you need to know to diagnose and treat your arthritis and how to maintain a healthy body
Read on your PC, Mac, smart phone, tablet or Kindle device.

In 2011 my mother’s arthritis left her in a height of intolerable pain and discomfort for several months. She had swollen joints, had lost her normal functionality and was also on the verge of insomnia each night. This was her osteoarthritis at work. Fortunate to say she did recover from this spell, and in reflection on this event, I thought it may be of some help to others also suffering if I... View Details


Treat Your Own Hand and Thumb Osteoarthritis
by Jim Johnson (Author)

Drawing from the latest research, Treat Your Own Hand and Thumb Osteoarthritis is a friendly manual that offers a simple, yet effective program for those who suffer from hand and thumb osteoarthritis. Illustrated with over 100 step-by-step photographs, readers will find easy-to-follow exercises that are designed to make their hands less stiff, much stronger, more coordinated, and less painful. Perhaps best of all, the exercises can be done in the privacy of one's home with little cost or equipment - and they take just a few minutes each day to do. View Details


Osteoarthritis (Natural Health Guide) (Alive Natural Health Guides)
by Zoltan P Rona (Author)

Osteoarthritis--the most common form of joint disease--may be reversible! At the very least, the signs and symptoms can be arrested, and the discomforts improved enough to allow better joint function. This valuable book provides information about natural remedies such as glucosamine sulfate, chondroitin sulfate, essential fatty acids, niacinamide, and others. It also outlines the type of diet that can be followed to both prevent and manage osteoarthritis. View Details


Osteoarthritis: Diagnosis and Medical/Surgical Management
by Roland W. Moskowitz MD (Editor), Roy D. Altman MD (Editor), Joseph A. Buckwalter MD (Editor), Victor M. Goldberg (Editor), Marc C. Hochberg MD MPH (Editor)

Written by the foremost experts, this text is a comprehensive clinical reference on osteoarthritis. Chapters review current information on the epidemiology, etiopathogenesis, and pathology of osteoarthritis, the biochemistry and molecular and cell biology of articular cartilage, and experimental models of osteoarthritis. Major sections focus on clinical presentations, roentgenologic and laboratory diagnosis, and treatment, including pharmacologic treatment, intra-articular therapy, surgery, arthroscopy, and complementary and alternative medicine.

The authors discuss the indications,... View Details


Learn All About OSTEOARTHRITIS PAIN Treatment & Prevention: Authentic Medical Facts For Patients
by Dr A Mitra MBBS MD (Author)

Osteoarthritis Pain Treatment & Prevention: Authentic Medical Facts for Patients written by Dr A Mitra, MBBS, MD. Based on current Scientific evidence-based Medical Knowledge about Osteoarthritis (also commonly known as Arthritis). Simple language (without using any medical jargon) based answers to the common questions asked by every patient. The book covers issues related to treatment with Pain Relief Medications, Non-medication treatments, Alternative therapies including Diet & Vitamins, Surgical treatments, Pain Relief Aids, as well as Prevention of Osteoarthritis. View Details


Arthritis Care: Osteoarthritis Symptoms, Prevention, Treatment, Exercise & Diet (inflammation, arthritis diet, anti-inflammation diet, arthritis cure)

Do you, or someone you know, suffer from the pain, inflammation and discomfort due to Osteoarthritis? Or are you just starting to feel the effects of this condition?
Get this book for just $0.99. Read on your PC, Mac, smart phone, tablet or Kindle device.
Osteoarthritis (OA) is the most common form of arthritis. To get an idea of the amount of people suffering, an estimated 12.1 percent in the United States age 25 and older are affected.
When you begin to develop osteoarthritis you may not even notice any symptoms, however, the condition does eventually progress causing... View Details


Arthritis in knee, osteoarthritis in knee. Knee arthritis types, knee exercises and stretches, treatments, home remedies, knee replacements and knee braces all covered.
by Robert Rymore (Author)

Arthritis in knee. Knee arthritis types, knee exercises and stretches, treatments, home remedies, knee replacements and knee braces all covered. Millions of people are suffering from knee arthritis. This is another very informative book by Robert Rymore. He continues with his interest in writing medical educational guides. This guide is intended to be a tool, one that will give you information and hopefully some pain relief. Readers will surely find much contribution by this book, to relief their pain or even to create a pain free healthy lifestyle. The book is written in an easy to read and... View Details

Best Science Podcasts 2018

We have hand picked the best science podcasts for 2018. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

Inspire To Action
What motivates us to take up a cause, follow a leader, or create change? This hour, TED speakers explore stories of inspirational leadership, and what makes some movements more successful than others. Guests include high school history teacher Diane Wolk-Rogers, writer and behavioral researcher Simon Sinek, 2016 Icelandic presidential candidate Halla Tómasdóttir, professor of leadership Jochen Menges, and writer and activist Naomi Klein.
Now Playing: Science for the People

#474 Appearance Matters
This week we talk about appearance, bodies, and body image. Why does what we look like affect our headspace so much? And how do we even begin to research a topic as personal and subjective as body image? To try and find out, we speak with some of the researchers at the Centre for Appearance Research (CAR) at the University of the West of England in Bristol. Psychology Professor Phillippa Diedrichs walks us through body image research, what we know so far, and how we know what we know. Professor of Appearance and Health Psychology Diana Harcourt talks about visible...