Updated guidelines regarding the use of corticosteroid or hyaluronic acid injections for knee osteoarthritis issued by the American Academy of Orthopaedic Surgeons had a “subtle but significant” impact on clinical practice, suggests a recent study.

In the study, Nicholas A. Bedard, MD, of University of Iowa Hospitals and Clinics, Iowa City, and colleagues, evaluated the impact of the updated guidelines for nonsurgical treatment of knee osteoarthritis, which the AAOS issued in 2008 and 2013.

They focused on corticosteroid injection, intended to reduce inflammation, and hyaluronic acid, intended to supplement the natural fluids within the knee joint.

As part of the study, published recently in The Journal of Bone & Joint Surgery, they analyzed an insurance database of more than 1 million patients treated between 2007 and 2015.

Overall, about 38% of patients received at least one steroid injection and 13% had at least one hyaluronic acid injection, according to a media release from Wolters Kluwer Health.

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, the rate of increase in steroid injection slowed significantly.

By 2013, there was new conflicting evidence on the 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, the release explains.

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.

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, the release continues.

“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,” Bedard says.

[Source(s): Wolters Kluwer Health, EurekAlert]