The Osteoarthritis Research Society International (OARSI) published two editions of guidelines (Part I/II) for the treatment of osteoarthritis of the hip/knee (OA) in 2007 and 2008, respectively. This update of the OARSI guidelines (Part I/II) was conducted to update the evidence on the efficacy of existing treatments and to assess whether the original guidelines needed to be revised. The authors performed a statistical analysis of 64 systematic reviews, 266 randomized controlled trials, and 21 economic assessments published between January 31, 2006, and January 31, 2009, that met the candidate criteria.
1. Non-pharmacological treatment
1.1 Self-management, education and information
The vast majority of treatment guidelines recommend: self-management of OA patients, education of OA patients, and provision of information about OA and its treatment as core recommendations for the treatment of hip/knee OA.
1.2 Exercise therapy
Both strength training and aerobic exercise can relieve knee OA pain, and strength training can also relieve hip OA pain. In addition water exercise can relieve hip/knee OA pain and improve function. Participating in group exercise is more effective than exercising alone at home.
1.3 Weight loss
Weight loss can partially improve knee OA pain and joint function. The recommendation that hip OA patients should maintain a low body weight is still based on expert opinion and no research evidence.
1.4 Acupuncture
A total of 9 relevant systematic review studies over 3 years have confirmed the effectiveness of this therapy for pain relief.
1.5 Electromagnetic therapy
A systematic review study conducted in 2006 concluded that this method was ineffective, so electromagnetic therapy is not recommended for patients with hip/knee OA.
2. Drug therapy
1.1 Acetaminophen
Acetaminophen is ineffective in improving joint stiffness and function in patients with symptomatic knee OA. In terms of improving pain, the OARSI, NICE, and AAOS guidelines all include it in their core recommendations at a maximum dose of 4 g/day, and EULAR further recommends this dose of acetaminophen as the preferred oral analgesic for the treatment of moderate pain in OA. However, there is growing evidence that this drug has significant side effects, with dosing above 3g/day significantly increasing the risk of gastrointestinal perforation, ulceration and bleeding, and can cause moderate renal impairment, while the drug is also prone to liver damage.
2.2 Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs (NSAIDs) are more effective than acetaminophen in controlling pain and have better patient compliance. Non-selective NSAIDs have 2-fold higher gastrointestinal side effects than selective NSAIDs (COX-2 inhibitors, celecoxib). For high-risk patients with a history of gastrointestinal bleeding, selective NSAIDs should be applied along with oral proton pump inhibitors (PPIs).
2.3 Topical NSAIDs
The vast majority of guidelines include topical NSAIDs as the recommended regimen for the treatment of symptomatic OA. When using ibuprofen for chronic knee pain in the elderly, topical application is initially more effective than oral pain relief, and oral ibuprofen is more effective in the second year.
2.4 Opioids
Opioids have a moderate pain-reducing effect and a mild to moderate improvement in joint function. However, side effects are more frequent and include nausea (30%), constipation (23%), vertigo (20%), drowsiness (18%), and vomiting (13%).
2.5 Intra-articular corticosteroid injection
A systematic review study found relatively high rates of pain relief with the first intra-articular corticosteroid injection, but the effect diminished with subsequent injections, which meant that the frequency of injections needed to be increased later to maintain efficacy. This method was not effective in improving joint function and stiffness.
2.6 Intra-articular injection of sodium hyaluronate (IAHA)
A meta-analysis comparing the effects of IAHA and intra-articular corticosteroid injections confirmed that intra-articular corticosteroid injections were more effective in relieving pain at 2 weeks after injection, with no difference between the two at 4 weeks, IAHA was more effective at 8 weeks, and IAHA showed a statistically significant advantage at 12 weeks.
2.7 Glucosamine
Current evidence from even the most conservative trials suggests that glucosamine sulfate is effective, while glucosamine hydrochloride is considered ineffective. The incidence of patients taking glucosamine sulfate 1500 mg/day for more than 1 year undergoing total knee replacement after 5 years is less than -half that of blank controls. However this conclusion is influenced by many factors such as the patient’s degree of joint pain and limitation, age, gender, surgeon and the patient’s willingness to undergo surgery.
2.8 Chondroitin sulfate
Chondroitin sulfate has a moderate effect in relieving pain. Patients treated with chondroitin sulfate had a significantly slower rate of development of knee joint space narrowing compared to controls.
2.9 Avocado soybean unsaponifiables (ASU)
Systematic review studies have shown a mild to moderate pain-reducing effect of ASU, with patients taking ASU having twice the response rate of placebo.
2.10 Vitamin E
Several low-quality studies have concluded that vitamin E may provide mild relief of joint pain, but this conclusion needs to be confirmed by high-quality trials.
2.ll Other nutritional supplement drugs
Due to shortcomings in experimental design, the role of mussels extract, dimethyl sulfoxide (DMSO, MSM) in the treatment of OA has not been confirmed. s_adenosylmethionine is widely used in the United States
used as a dietary supplement for OA patients, but it was not found to have a significant effect in relieving knee OA pain.
2.12 Herbs
Herbs are widely used by patients with hip/knee OA, and herbs that have been clinically tested include rosehip powder, crocus sativus glycosides, and ginger/willow bark extract. A systematic review study concluded that rosehip powder taken from Canis lupus had a mild effect on the relief of OA pain. Application of hookwort glucoside >50 mg/day also had some effect on pain relief. However, it is not clear whether ginger and willow bark extracts can relieve pain conclusion.
2.13 Dicyclomine
In vitro experiments have shown that diosgenin has an inhibitory effect on IL-lβ, which was thought to be slow-acting but long-lasting and able to improve symptoms. Recently, it has been found that although it has mild pain relief, the results vary widely from trial to trial and has diarrhea as a side effect.
2.14 Bone resorption inhibitors
Experimental evidence shows that estrogen and alendronate significantly reduce subchondral bone resorption and bone marrow edema associated with knee OA, but do not slow down bone structural changes in patients with knee OA.
3. Surgical treatment
3.1 Joint cavity lavage/cleaning
Experimental evidence shows that there is no difference between joint cavity lavage, joint cavity cleaning, and blank control surgery with only skin incision and arthroscopic placement in terms of initial pain relief and later improvement in function and pain. Some studies have concluded that there is no benefit of joint cavity lavage in unselected patients with knee OA. If the efficacy was observed at 3 months postoperatively, neither joint cavity lavage nor cleanup was effective in improving pain, function, and stiffness.
3.2 Other surgical options
There are many studies on high tibial osteotomy orthopedics (HTO) and the consistency of results is poor, but all authors agree that valgus HTO is effective in relieving pain and improving function. A systematic review study found a 25% failure rate at lO years after HTO, while the mean time to arthroplasty after HTO was 6 years. The proportion of patients with improved joint function after unicondylar arthroplasty, total knee replacement, and HTO was essentially the same, although a minority of patients developed deep vein thrombosis after undergoing unicondylar arthroplasty. As for the odds of late revision, unicondylar replacement was lower than HTO.