Adherence to the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for Nonoperative Management of Knee Osteoarthritis

Background: The American Academy of Orthopaedic Surgeons (AAOS) has published evidence-based Clinical Practice Guidelines (CPGs) for the nonarthroplasty management of knee osteoarthritis (OA). The purpose of this study is to determine how closely our orthopedic providers adhered to the recommendations included in those CPGs.

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 AAOS CPGs. A secondary outcome was the associated costs of care.

Results: The total number of interventions generated during the visits was 1955. Adherence to the AAOS guidelines was 65% (362/557), 60% (226/377), and 40% (413/1021) in new/never treated, new/previously treated, and return patients, respectively. Intra-articular injection with either corticosteroids or hyaluronic acid was the most common intervention (32%) followed by physical therapy (29%). As the severity 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.