The Journal of Arthroplasty xxx (2019) 1e6

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Adherence to the American Academy of Orthopaedic Surgeons

Clinical Practice Guidelines for Nonoperative Management of Knee
Osteoarthritis
Karthik P. Meiyappan, BS a, Mark P. Cote, DPT b, Kevin J. Bozic, MD, MBA c,
Mohamad J. Halawi, MD b, *
a
University of Miami School of Medicine, Miami, FL
b
Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
c
Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX

a r t i c l e i n f o a b s t r a c t

Article history: Background: The American Academy of Orthopaedic Surgeons (AAOS) has published evidence-based
Received 1 July 2019 Clinical Practice Guidelines (CPGs) for the nonarthroplasty management of knee osteoarthritis (OA).
Received in revised form The purpose of this study is to determine how closely our orthopedic providers adhered to the recom-
10 August 2019
mendations included in those CPGs.
Accepted 23 August 2019
Available online xxx
Methods: We retrospectively reviewed 1096 consecutive ambulatory visits with primary diagnosis of
knee OA at a single center. Demographic, radiographic, and treatment information was collected. The
primary outcome was the frequency of agreement between our treatment recommendations and the
Keywords:
AAOS
AAOS CPGs. A secondary outcome was the associated costs of care.
Clinical Practice Guidelines Results: The total number of interventions generated during the visits was 1955. Adherence to the AAOS
knee guidelines was 65% (362/557), 60% (226/377), and 40% (413/1021) in new/never treated, new/previously
osteoarthritis treated, and return patients, respectively. Intra-articular injection with either corticosteroids or hyal-
nonoperative management uronic acid was the most common intervention (32%) followed by physical therapy (29%). As the severity
cost of care of OA increased, adherence to the AAOS guidelines decreased (61%, 60%, 54%, and 49% for Kellgren-
Lawrence grades I through IV, respectively). The estimated annual costs associated with our treatment
recommendations were $2,403,543.18, of which $1,206,757.8 (50.2%) was supported by evidence. The
most expensive treatment intervention was intra-articular hyaluronic acid injection, which carried a
strong evidence against its use.
Conclusion: Adherence to the recommendations contained within the AAOS CPGs was modest regardless
of the Kellgren-Lawrence grade or history of treatment. Given the size of the affected patient population,
there is a need for uniformly accepted guidelines to clarify the role and timing of the different treatment
interventions. CPGs should be combined with education, patient engagement, and shared decision-
making to minimize variation in treatment patterns, improve patient outcomes, and lower overall
costs of care.
© 2019 Elsevier Inc. All rights reserved.

Osteoarthritis (OA) of the knee is the most common joint dis-

order in the United States, affecting 10% of men and 13% of women
aged 60 years and older [1]. The prevalence of knee OA is projected
One or more of the authors of this paper have disclosed potential or pertinent
to increase as our population ages [1] with the lifetime risk of
conflicts of interest, which may include receipt of payment, either direct or indirect, developing symptomatic knee OA estimated at 45% [2]. Several
institutional support, or association with an entity in the biomedical field which predisposing factors have been identified including older age, fe-
may be perceived to have potential conflict of interest with this work. For full male gender, obesity, trauma, and occupational overuse [1]. In or-
disclosure statements refer to https://doi.org/10.1016/j.arth.2019.08.051.
der to assist in providing evidence-based tools for clinical decision-
* Reprint requests: Mohamad J. Halawi, MD, Department of Orthopaedic Surgery,
University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT making in patients presenting with symptomatic knee OA, the
06030. American Academy of Orthopedic Surgeons (AAOS) has published

https://doi.org/10.1016/j.arth.2019.08.051
0883-5403/© 2019 Elsevier Inc. All rights reserved.
2 K.P. Meiyappan et al. / The Journal of Arthroplasty xxx (2019) 1e6

Clinical Practice Guidelines (CPGs) [3]. The CPGs are composed of Table 1
recommendations ranging from consensus to inconclusive, weak, Patient Characteristics by Visit Type.

moderate, and strong based on available evidence. Characteristics New Visit/No New Visit/Previous Return
The economic burden of disabling knee OA is substantial. The Previous Treatment Visit
annual ambulatory resource utilization for individuals aged 65 and Treatment

older with knee OA is estimated at 26 visits (10 visits higher than N 242 (22%) 181 (17%) 673 (61%)
OA-free subjects matched by age and sex) [4] at an average cost of Age 59 ± 11 60 ± 12 61 ± 12
Body mass index 32 ± 7 33 ± 8 34 ± 8
$132 per treatment event [5]. In an era of value-based medicine,
Sex
CPGs may reduce variation in practice, emphasize the provision of Female 151 (62%) 112 (62%) 397 (59%)
high-quality care, and help facilitate appropriate utilization of re- Male 91 (38%) 69 (38%) 273 (41%)
sources and overall healthcare expenditure. To date, the extent to Kellgren-Lawrence grade
I 11 (5%) 3 (2%) 7 (1%)
which orthopedic providers adhere to CPGs remains unclear. A
II 62 (26%) 35 (21%) 122 (20%)
recent survey of members of the American Association of Hip and III 105 (44%) 66 (40%) 235 (38%)
Knee Surgeons found poor compliance with the CPGs for treatment IV 612 (26%) 63 (38%) 258 (41%)
of knee OA with excessive use of intra-articular injections [6]. Insurance
The purpose of this study is to present our institutional experience Medicaid 107 (44%) 60 (33%) 193 (29%)
Medicare 53 (22%) 53 (29%) 212 (31%)
with the AAOS CPGs for nonoperative management of knee OA. Our
Commercial 81 (33%) 64 (35%) 266 (40%)
questions were 3-fold: How often did our orthopedic practitioners Other 1 (0.4%) 4 (2%) 2 (0.3%)
follow the recommendations contained within the AAOS CPGs? Were
there any variations by visit type or OA severity? What were the
estimated costs associated with the treatment recommendations?
This information is helpful to guide discussion regarding the utility of was 33.4 (range, 19.0-59.4), and 60.2% of patients were female.
CPGs, raise awareness of the CPGs among musculoskeletal providers, Overall, the most prevalent KL stage was III. Also, 242 patients
and stimulate discussion on value-based care delivery. (22%) were new with no history of treatment, 181 (17%) were new
but received previous treatment, and 673 (61%) were return pa-
Materials and Methods tients. The demographics were evenly distributed among the
different visit types, except for higher rates of advanced KL grades
Approval of our institutional review board was obtained. We in return patients. Table 1 describes the characteristics of the
retrospectively reviewed 1184 consecutive patient visits to our or- study patients.
thopedic clinic with knee pain secondary to OA. Visits were identi- A total of 1955 treatment interventions were made. Among
fied using ICD-10 codes M17.0, M17.10, M17.11, M17.12, M17.31, those interventions, 730 (37%) were strongly recommended, 271
M17.32, M17.4, M17.5, and M17.9 corresponding to knee OA. Patients (14%) were moderately recommended, 421 (22%) had inconclusive
with unknown treatment history were excluded. In all, 88 patient evidence to recommend for or against their use, and 393 (20%) had
visits were excluded, leaving 1096 encounters available for analysis. strong recommendation against their use (Table 2). The most
Patients were seen by providers ranging from nurse practitioners to common treatment recommendations were physical therapy (29%)
nonoperative orthopedic physicians to orthopedic surgeons. followed by intra-articular injections with corticosteroids (17%) and
Data collected from our electronic medical records were age, hyaluronic acid (15%). These were also the most common in-
gender, body mass index (BMI), Kellgren-Lawrence (KL) OA grade, terventions regardless of KL grade or visit type.
type of visit (new patient without history of treatment, new patient Among new patients without history of treatment, 64% of
with previous treatment, and established patient), insurance type treatment interventions had strong or moderate strength of
(Medicaid, Medicare, commercial, or other), and treatment rec- recommendation, 17% were inconclusive, and 6% had strong evi-
ommendations. Additionally, we collected estimated and/or bill- dence against their use. Among new patients with prior treat-
able costs for each treatment recommendation. The KL OA grade ment, 49% of treatment interventions had strong or moderate
was assigned by investigators based on most recent radiographs strength of recommendation, 18% were inconclusive, and 17% had
taken before each visit. Each treatment recommendation was strong evidence against their use. Among return patients, 40.5% of
assigned one point. Patients who received multiple treatment treatment interventions had strong or moderate strength of
recommendations were assigned one point for each recommen- recommendation, 25.4% were inconclusive, and 29% had strong
dation. Treatments not included in the AAOS CPGs were classified evidence against their use. Return patients were less likely to
under “not applicable” category. These primarily consisted of receive strongly recommended interventions (P < .001 for phys-
topical over-the-counter medications, such as lidocaine, menthol, ical therapy and P ¼ .005 for nonsteroidal anti-inflammatory drugs
and capsaicin patches. [NSAIDs]) and more likely to receive hyaluronic acid injections
Descriptive statistics including mean/standard deviation for (P < .001). Table 3 and Figure 1 summarize the treatment rec-
continuous variable and frequency/proportion for categorical var- ommendations by visit type.
iables were calculated to characterize the data. Each treatment
instance was treated as an independent event. Comparisons of the
frequency of treatments prescribed between KL grade, insurance Table 2
type, and provider type were carried out with the chi-square or Adherence to AAOS Recommendations by Strength of Evidence.
Fisher exact test where appropriate. In the case of statistical sig-
AAOS Position Strength of N (%)
nificance, adjusted residuals were obtained to determine which Recommendation
proportions where statistically different.
Recommend Strong 730 (37)
Suggest Moderate 271 (14)
Results Unable to recommend for or against Inconclusive 421 (22)
Cannot recommend Strong 393 (20)
A total of 1096 consecutive patient visits were analyzed. The Not applicable Not applicable 140 (7)

average age was 60.4 years (range, 21-90 years). The average BMI AAOS, American Academy of Orthopaedic Surgeons.
 K.P. Meiyappan et al. / The Journal of Arthroplasty xxx (2019) 1e6 3

Table 3
Treatment Recommendations by Visit Type.

Treatment Recommendation AAOS Position Strength of New Visit/No New Visit/Previous Return Visit P Value
Recommendation Previous Treatment
Treatment

Physical therapy Recommend Strong 73 (13%)a 49 (12%) 108 (10%)a <.001

Self-management 180 (31%)a 111 (27%) 186 (17%)a
Referral
NSAIDs Recommend Strong 85 (15%) 69 (17%) 120 (11%)a .005
Oral 14 (2%) 4 (1%) 18 (2%)a
Topical
Weight loss Suggest Moderate 41 (7%) 31 (8%) 85 (8%) .906
Acetaminophen Unable to recommend for or against Inconclusive 13 (2%) 11 (3%) 24 (2%) .821
Opioids Unable to recommend for or against Inconclusive 0 (0%) 1 (0%) 5 (0%) .285
Knee brace Unable to recommend for or against Inconclusive 22 (4%) 32 (8%)a 36 (3%) <.001
Corticosteroid injection Unable to recommend for or against Inconclusive 69 (12%) 51 (12%) 214 (19%) .541
Hyaluronic acid injection Cannot recommend Strong 10 (2%)a 35 (8%)a 258 (23%)a <.001
Glucosamine Cannot recommend Strong 8 (3%)a 0 (0%0 5 (1%) .003
Other recommendations not Not applicable Not applicable 67 (28%)a 17 (9%) 56 (8%)a <.001
captured by the clinical
practice guidelines

AAOS, American Academy of Orthopaedic Surgeons; NSAIDs, nonsteroidal anti-inflammatory drugs.

a
Indicates statistical difference.

Compared to new patients, return patients were more likely to Discussion

have more severe KL grade. Figure 2 depicts the KL stage distri-
bution by visit type. As the KL grade increased, there was a decline In this study, we found that adherence to the AAOS CPGs for
in the use of AAOS-supported recommendations. Specifically, nonoperative treatment of knee OA was modest regardless of the
patients with KL grade IV were more likely to receive injection KL grade, prior treatment, payer type, or provider type. Adherence
with corticosteroids (P ¼ .007) or hyaluronic acid (P < .001). was especially low in established patients with KL grade IV. Among
Table 4 and Figure 3 summarize the treatment recommendations new patients with no history of treatment or those with mild OA
by KL grade. (KL grades I and II), 36%-38% of treatment interventions had either
The treatment interventions were evenly distributed among inconclusive or strong evidence against their use. From an eco-
all payer types except for higher likelihood of recommending nomic standpoint, the estimated annual costs associated with our
weight loss for Medicaid beneficiaries (P < .001) who had higher treatment recommendations were $2,403,543.18, of which only
BMI (P < .001). Table 5 summarizes the treatment recommen- 50.2% was supported.
dations by payer type. There were no differences in the There is currently limited information on this topic. We are only
treatment recommendation by provider type (physician vs aware of a survey of American Association of Hip and Knee Sur-
advanced practice provider [APP]) except for the injection used. geons members. In that survey, Carlson el al [6] found that
Physicians were more likely to inject corticosteroids (P ¼ .001) nonoperative management of knee OA was not in line with the
while APPs were more likely to inject hyaluronic acid (P ¼ .013). AAOS CPGs, particularly for KL grades II (21%) and III (50%). In our
Table 6 summarizes the treatment recommendations by pro- study, the frequency of compliance with the AAOS CPGs was 60%
vider type. and 54% for the same KL grades, respectively. This is likely attrib-
The estimated annual costs associated with our treatment in- uted to different research methodologies (chart review vs survey).
terventions were $2,403,543.18, of which $1,206,757.8 (50.2%) was Consistent with Carlson el al [6], however, we found excessive use
associated with strong recommendation for their use and the of intra-articular injections. When combining corticosteroid and
remaining $1,196,785.38 (49.8%) carrying either inclusive or strong hyaluronic acid injections, they made up the most common inter-
recommendation against their use. Figure 4 summarizes the esti- vention regardless of OA severity or history of treatment (32%). The
mated annual costs of care by recommendation. high frequency of intra-articular injection is further highlighted in a

100.0%
90.0% 100
Treatment Distribution

80.0% 90
Kellgren-Lawrence Stage

26
70.0% 80 38 41
60.0% 70
Distribution

50.0% 60
44
40.0% 50
40
40 38
30.0%
30
20.0%
20 26
10.0% 21 20
10
0.0% 5 2 1
0
New Visit/ No New Visit/ Previous Return Visit Total
New Visit/No Previous New Visit/History of Return Visit
previous treatment Treatment
Treatment Previous Treatment
Type of Visit
I II III IV
Supported Inconclusive Not supported

Fig. 1. Treatment distribution by visit type. Fig. 2. Kellgren-Lawrence stage distribution by visit type.
4 K.P. Meiyappan et al. / The Journal of Arthroplasty xxx (2019) 1e6

Table 4
Treatment Recommendations by Kellgren-Lawrence Grade.

Treatment Recommendation AAOS Position Strength of Kellgren-Lawrence Grade P Value

Recommendation
I II III IV

Physical therapy Recommend Strong 5 (12%) 59 (14%) 81 (11%) 71 (11%)a .001

Self-management 12 (28%) 86 (20%) 140 (19%) 85 (13%)a
Referral
NSAIDs Recommend Strong 5 (12%) 70 (17%) 108 (14%) 81 (13%) .194
Oral 1 (2%) 10 (2%) 15 (2%) 10 (2%)
Topical
Weight loss Suggest Moderate 3 (7%) 30 (7%) 56 (8%) 65 (10%) .270
Acetaminophen Unable to recommend for or against Inconclusive 0 (0%) 12 (3%) 16 (2%) 17 (3%) .761
Opioids Unable to recommend for or against Inconclusive 0 (0%) 3 (1%) 2 (0.3%) 0 (0%) .186
Knee brace Unable to recommend for or against Inconclusive 4 (9%) 17 (4%) 36 (5%) 29 (4%) .425
Corticosteroid injection Unable to recommend for or against Inconclusive 5 (12%) 51 (12%) 129 (17%) 142 (22%)a <.001
Hyaluronic acid injection Cannot recommend Strong 2 (5%) 45 (11%) 100 (13%) 110 (17%)a .007
Glucosamine Cannot recommend Strong 2 (5%)a 8 (2%)a 2 (0.3%) 0 (0%) <.001
Other recommendations not Not applicable Not applicable 4 (9%) 31 (7%) 60 (8%) 36 (6%) .252
captured by the clinical
practice guidelines

AAOS, American Academy of Orthopaedic Surgeons; NSAIDs, nonsteroidal anti-inflammatory drugs.

a
Indicates statistical difference.

review of more than 1 million patients with knee OA captured in best highlighted by the conflicting results of 2 Cochrane meta-
the Humana database from 2007 to 2015. In that study, Bedard et al analyses published 1 year apart by the same research group [10,11].
[7] found that 38% of patients had at least 1 corticosteroid injection At our institution, one of the most commonly cited reason for
and 12.9% had at least 1 hyaluronic acid injection. There was little to limited adherence to the AAOS CPGs was lack of awareness, espe-
no effect of the AAOS CPGs on intra-articular injection use, which cially among APPs. Interestingly, our stratification by provider type
continued to increase over the study period. did not show major practice differences between physicians and
The reasons for the modest adherence to the AAOS CPGs are APPs. This is likely because most APPs were trained by those phy-
likely multifactorial. Some providers and patients believe certain sicians. The second most common reason was the perception of “I
therapies (such as viscosupplementation or corticosteroid in- have to do something” in patients presenting with significant pain.
jections) are beneficial, despite evidence to the contrary. Other There also appears to be an opinion difference among our physician
providers may not be fully aware of the evidence supporting the providers, with long-established surgeons and sports medicine
CPG recommendations. Additionally, lack of consensus combined providers being in favor of using injections. In addition, there were
with inadequate pain relief can lead providersdwho are often a number of misconceptions among patients. For example, some
faced with the pressure to appease patient requests for an inter- patients believed that certain supported treatment modalities (eg,
ventiondto attempt alternative treatments. Conflicting guidelines NSAIDs) were ineffective and refused to try them. Another
in the management of knee OA may be another important misconception was that certain unsupported modalities (eg, hyal-
contributing factor. For example, the Osteoarthritis Research Soci- uronic acid injection) cushioned the joint and some patients spe-
ety International (OARSI) also published CPGs for nonoperative cifically requested them. Clearly, there is need for standardization
management of knee OA [8]. Within the OARSI CPGs, intra-articular of nonoperative care for knee OA and education of providers and
corticosteroid injection is designated as an appropriate interven- patients, especially that 22% of treatment recommendations in new
tion. In addition, the OARSI CPGs do not condemn the use of hy- patients without previous treatment were unsupported. There is
aluronic acid injection, which carries an uncertain designation [8]. also a need for development of more effective treatment modalities
Other specialty societies, such as the American Academy of Family as our currently available interventions are limited. Equally
Physicians and the American College of Rheumatology, state that important is the recognition of patients with severe, persistent OA
corticosteroid injections may be considered when other treatments pain who are not candidates for knee arthroplasty. No amount of
have failed [9]. The challenge of defining an accepted recommen- AAOS CPGs, supported or unsupported, may alleviate pain in those
dation regarding the use of intra-articular corticosteroid injection is patients who may ultimately need to be referred to pain manage-
ment specialists.
Aside from intra-articular injections, there was a surprisingly
100% very low frequency of using recommended interventions such as
90%
NSAIDs and weight loss despite our patient population being obese
Treatment Distribution

80%
on average. Overall, NSAIDs and weight loss made up only 8% and
70%
14% of recommended interventions despite having strong and
60%
moderate evidence to support their use respectively. In a meta-
50%

40%
analysis of high-quality clinical trials, Jevsevar et al [12] found
30%
that naproxen was the most effective single treatment for
20% decreasing pain and increasing function in patients with symp-
10% tomatic knee OA. The authors commented that naproxen was a
0% low-cost treatment with favorable cardiac risk profile. In this study,
I II III IV
NSAID use was the lowest cost item in the strongly recommended
Kellgren-Lawrence Grade category. In contrast, physical therapy was the highest cost item
Supported Inconclusive Not supported accounting for 98% of costs among AAOS-recommended in-
terventions. We are not aware of previous studies that compared
Fig. 3. Treatment distribution by Kellgren-Lawrence grade. formal physical therapy with self-directed physical activity. The
 K.P. Meiyappan et al. / The Journal of Arthroplasty xxx (2019) 1e6 5

Table 5
Treatment Recommendations by Insurance Type.

Treatment Recommendation AAOS Position Strength of Insurance Type

Recommendation
Medicare Medicaid Private P Value

Physical therapy Recommend Strong 80 (12%) 56 (9%) 99 (13%) .686

Self-management 116 (17%) 113 (18%) 108 (14%)
Referral
NSAIDs Recommend Strong 102 (15%) 82 (13%) 96 (13%) .447
Oral 9 (1%) 16 (3%) 12 (2%)
Topical
Weight loss Suggest Moderate 46 (7%) 72 (12%)a 44 (6%) <.001
Acetaminophen Unable to recommend for or against Inconclusive 13 (2%) 11 (2%) 23 (3%) .236
Opioids Unable to recommend for or against Inconclusive 2 (0%) 3 (0%) 1 (0%) .477
Knee brace Unable to recommend for or against Inconclusive 27 (4%) 27 (4%) 37 (5%) .738
Corticosteroid injection Unable to recommend for or against Inconclusive 103 (15%) 94 (15%) 139 (18%) .218
Hyaluronic acid injection Cannot recommend Strong 114 (17%) 102 (17%) 149 (20%) .276
Glucosamine Cannot recommend Strong 7 (1%) 3 (0%) 3 (0%) .297
Other recommendations not Not applicable Not applicable 56 (8%) 38 (6%) 53 (7%) .229
captured by the clinical
practice guidelines

AAOS, American Academy of Orthopaedic Surgeons; NSAIDs, nonsteroidal anti-inflammatory drugs.

a
Indicates statistical difference.

latter has the potential of significantly cutting down the costs of This study has some limitations. First, it is a retrospective review
care. It should be noted, however, that the exercise interventions from a single academic institution. This inherently limits the scope
that were reviewed by the AAOS when making this recommenda- of generalizability of our results. Second, it assumes that AAOS CPGs
tion were most often conducted under supervision of physical are the standard of care. Although the AAOS is meant to represent
therapists. all orthopedic surgeons, there are numerous other organizations
Adopting universally accepted CPGs for nonoperative manage- which make recommendations on how to appropriately treat knee
ment of knee OA may help not only providers but also patients who OA. Third, the cost estimates reflect standard charges in our insti-
may become more involved in their care. The CPGs can help tution any may be subject to variations by geography and payer
convince patients that certain treatments, although they may seem type. Fourth, we did not stratify the treatment interventions by
promising, do not hold evidence to support their use. Even more provider type (surgeon vs advanced practitioner vs nonoperative
promising, the CPGs may help patients see the importance of physician).
adhering to some seemingly difficult interventions, such as lifestyle In conclusion, adherence to the recommendations contained
changes. This would in turn increase the value of care as reduction within the AAOS CPG for nonarthroplasty treatment of knee OA was
in medical visits and overall costs have been demonstrated after modest regardless of the KL grade or history of treatment. Intra-
effective self-management programs for lower extremity OA [13]. articular injection with either corticosteroids or hyaluronic acid
Finally, more physician knowledge of the CPGs could allow them to was the most common intervention (32%) despite inconclusive to
better counsel patients. Although the CPGs are driven by evidence, strong recommendation against their use. Given the size of the
adherence is often a problem and can be best combatted with affected patient population, there is a need for uniformly accepted
awareness and education [14]. Clearly, there is a need to establish guidelines to clarify the role and timing of the different treatment
consensus on the appropriate treatment for each stage in the pro- interventions. However, guidelines alone are not sufficient and
cess of OA, especially in the areas of corticosteroid and hyaluronic should be combined with education, patient engagement, and
acid injections. shared decision-making to minimize variation in treatment

Table 6
Treatment Recommendations by Provider Type.

Treatment Recommendation AAOS Position Strength of Provider Type

Recommendation
Physician Midlevel P Value

Physical therapy Recommend Strong 93 (10%) 144 (11%) .898

Self-management 226 (23%) 268 (21%)
Referral
NSAIDs Recommend Strong 143 (15%) 143 (11%) .157
Oral 9 (1%) 28 (2%)
Topical
Weight loss Suggest Moderate 73 (8%) 90 (7%) .720
Acetaminophen Unable to recommend for or against Inconclusive 15 (2%) 35 (3%) .052
Opioids Unable to recommend for or against Inconclusive 3 (0%) 4 (0%) .641
Knee brace Unable to recommend for or against Inconclusive 46 (5%) 45 (4%) .163
Corticosteroid injection Unable to recommend for or against Inconclusive 175 (18%) 163 (13%) .001
Hyaluronic acid injection Cannot recommend Strong 137 (14%) 228 (18%) .013
Glucosamine Cannot recommend Strong 11 (1%) 2 (0%) .003
Other recommendations not Not applicable Not applicable 37 (4%) 110 (9%) <.001
captured by the clinical
practice guidelines

AAOS, American Academy of Orthopaedic Surgeons; NSAIDs, nonsteroidal anti-inflammatory drugs.

6 K.P. Meiyappan et al. / The Journal of Arthroplasty xxx (2019) 1e6

Fig. 4. Estimated annual costs of care by level of recommendation. Costs were determined as follows: physical therapy ($1200 per 12 sessions based on institutional billing), NSAIDs
($36.78 based on 90-day supply of naproxen 500-mg tablets), acetaminophen ($8.97 based on 90-day supply of 500-mg tablets), opioids ($65.99 based on 90-day supply of
tramadol 50-mg tablets), knee brace ($140 based on institutional billing), corticosteroid injection ($217 based on institutional billing/includes administration cost), and hyaluronic
acid injection ($1064 based on institutional experience/includes administration cost). Costs associated with weight loss and glucosamine supplements were not calculated given the
difficulty in determining such costs. The costs of prescription medications were based on average prices listed in www.goodrx.com. NSAIDs, nonsteroidal anti-inflammatory drugs.

patterns, improve patient outcomes, and lower overall costs of care. [7] Bedard NA, DeMik DE, Glass NA, Burnett RA, Bozic KJ, Callaghan JJ. Impact of
clinical practice guidelines on use of intra-articular hyaluronic acid and
Future research is needed to guide high-quality, cost-effective
corticosteroid injections for knee osteoarthritis. J Bone Joint Surg Am
nonoperative management for symptomatic knee OA. 2018;100:827e34.
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Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee
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