2023+SIOT立场声明：膝骨关节炎的非手术治疗.pdf

Pesareetal.Journal of Orthopaedics and Traumatology (2023)24:47 https:/doi.org/10.1186/s10195-023-00729-zREVIEW ARTICLEOpen Access The Author(s)2023.Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use,sharing,adaptation,distribution and reproduction in any medium or format,as long as you give appropriate credit to the original author(s)and the source,provide a link to the Creative Commons licence,and indicate if changes were made.The images or other third party material in this article are included in the articles Creative Commons licence,unless indicated otherwise in a credit line to the material.If material is not included in the articles Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use,you will need to obtain permission directly from the copyright holder.To view a copy of this licence,visit http:/creativecommons.org/licenses/by/4.0/.Journal of Orthopaedicsand TraumatologyItalian Orthopaedic andTraumatology Society(SIOT)position statement onthenon-surgical management ofknee osteoarthritisElisa Pesare1,Giovanni Vicenti1*,Elisaveta Kon2,3,Massimo Berruto4,Roberto Caporali5,Biagio Moretti1 and Pietro S.Randelli6,7,8 Abstract Background Knee osteoarthritis(OA)is a chronic disease associated with a severe impact on quality of life.However,unfortunately,there are no evidence-based guidelines for the non-surgical management of this disease.While recog-nising the gap between scientific evidence and clinical practice,this position statement aims to present recommen-dations for the non-surgical management of knee OA,considering the available evidence and the clinical knowledge of experienced surgeons.The overall goal is to offer an evidenced-based expert opinion,aiding clinicians in the man-agement of knee OA while considering the condition,values,needs and preferences of individual patients.Methods The study design for this position statement involved a preliminary search of PubMed,Google Scholar,Medline and Cochrane databases for literature spanning the period between January 2021 and April 2023,followed by screening of relevant articles(systematic reviews and meta-analyses).A Societ Italiana Ortopedia e Traumatolo-gia(SIOT)multidisciplinary task force(composed of four orthopaedic surgeons and a rheumatologist)subsequently formulated the recommendations.Results Evidence-based recommendations for the non-surgical management of knee OA were developed,covering assessment,general approach,patient information and education,lifestyle changes and physical therapy,walking aids,balneotherapy,transcutaneous electrical nerve stimulation,pulsed electromagnetic field therapy,pharmacologi-cal interventions and injections.Conclusions For non-surgical management of knee OA,the recommended first step is to bring about lifestyle changes,particularly management of body weight combined with physical exercise and/or hydrotherapy.For acute symptoms,non-steroidal anti-inflammatory drugs(NSAIDs),topic or oral,can be used.Opioids can only be used as third-line pharmacological treatment.Glucosamine and chondroitin are also suggested as chronic pharmacological treatment.Regarding intra-articular infiltrative therapy,the use of hyaluronic acid is recommended in cases of chronic knee OA platelet-rich plasma(PRP)as second line),in the absence of active acute disease,while the use of intra-artic-ular injections of cortisone is effective and preferred for severe acute symptoms.*Correspondence:Giovanni VFull list of author information is available at the end of the articlePage 2 of 9Pesareetal.Journal of Orthopaedics and Traumatology (2023)24:47 Highlights 1.NSAIDs(topical or oral formulations)are a better choice for acute symptoms,compared with acetaminophen in knee osteoarthritis non-surgical treatment.2.SIOT recommend opioid use only while patients are waiting for surgical treatment,if NSAIDs are ineffective against pain.3.Considering intra-articular infiltrative therapy,the use of hyaluronic acid is recommended in cases of chronic knee OA in the absence of active acute disease,while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.4.The use of growth factor injections and/or PRP in symptomatic knee OA is only favoured in highly specialised centresKeywords Osteoarthritis,Knee OA,SIOT position statement,Non-surgical managementIntroductionOsteoarthritis(OA)is the most common form of arthri-tis and a major cause of disability 1.The most common site of OA is the knee joint,with an estimated overall prevalence in the general adult population of 24%2.The frequency of this condition is bound to increase further due to population ageing.Recommendations for the management of knee OA have been published by several different scientific authorities including,amongst others,the Osteoarthritis Research Society International(OARSI)3,the Ameri-can College of Rheumatology(ACR)4,the American Academy of Orthopedic Surgeons(AAOS)5,6,the European League Against Rheumatism(EULAR)2 and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis(ESCEO)1.We have collated recommendations from these sources and combined them with the results of an extensive literature search,using our own expert knowledge to produce a set of evidence-based recommendations for the non-surgical management of this condition.Material andmethodsA working group of five Societ Italiana Ortopedia e Traumatologia(SIOT)members was established,con-sisting of four orthopaedic surgeons and a rheumatolo-gist with extensive experience in the treatment of knee OA and the analysis and interpretation of related evi-dence.One member of the task force(EP)collected the literature,searching entries in PubMed,Google Scholar,Medline and Cochrane databases dated between January 2011 and August 2021.Keywords for the search included osteoarthritis,knee OA,guidelines,clinical practice,non-surgical management and conservative treatment,and the results were limited to humans,randomised controlled trial,meta-analysis,review and systematic review.Inclusion and exclusion decisions were based on group consensus.A second researcher(GV)indepen-dently verified the number of articles identified to avoid potential discrepancies.Study characteristics and data were extracted onto a Microsoft Excel spreadsheet.The following data were extracted for each study:first author,title,design of the study and year of publication.Initially,titles and abstracts of all records were reviewed.Only full-text articles written in English were included,and several articles were excluded after this preliminary review process.Full-text copies of the studies were then obtained and assessed by the authors.The Preferred Reporting Items for Systematic Reviews and Meta-analyses(PRISMA)guidelines 7 were followed.The material was presented to the task force in an ini-tial meeting.A total of 16,479 articles were identified in the following databases:PubMed,Cochrane,Med-line and Google Scholar.Overall,3654 duplicates were removed.After inspection of the titles and abstracts and applying the inclusion criteria,a total of 30 studies were reviewed further(Fig.1).In subsequent meetings,a schematic chart of conserva-tive treatment recommendations for knee OA was agreed by task force members.The consensus of the working group was based on both evidence from the literature and expert opinion.By electronic communication,it was possible to draft the manuscript,sharing corrections and suggestions from individual members with the rest of the team.Among the several available recommendations for the management of knee OA,those from the Osteoarthritis Research Society International(OARSI)3,the Ameri-can College of Rheumatology(ACR)4,the American Academy of Orthopedic Surgeons(AAOS)5,6,the European League Against Rheumatism(EULAR)2 and the European Society for Clinical and Economic Aspects Page 3 of 9Pesareetal.Journal of Orthopaedics and Traumatology (2023)24:47 of Osteoporosis and Osteoarthritis(ESCEO)8 were selected for examination.ResultsLifestyle andphysical therapyWeight managementThis represents one of core treatments for knee OA,in combination with exercise and self-management pro-grammes.SIOT strongly recommended core treatment in early onset OA and in mild/moderate OA,as well as in severe cases.Weight loss is considered to be effec-tive in those who are overweight body mass index(BMI)25 kg/m2)or obese(BMI 30 kg/m2).Specifi-cally,loss of 5%of body weight can be associated with changes in clinical and functional outcomes 4.Selfmanagement andeducationSIOT consider self-management and education one of the core treatments together with weigh management and exercises.Structured patient education programmes aim to inform patients about their condition and the available treatment strategies,to reduce the likelihood of disease progression and severity.Awareness regard-ing OA aetiology,risk factors(especially if modifiable),expected prognosis and therapeutic strategies can help to reduce misunderstandings and mistakes in patients(for example,the misconception that physical exercise can be harmful to the joints).Education of family members can also be useful.Self-management and education are also strongly recommended by the OARSI 9,EULAR 2,AAOS 5,6 and ESCEO 8.Balneotherapy/spa therapyBalneotherapy represents a conservative treatment that may have beneficial effects on pain and stiffness,with a tolerable economic profile 10.It consists of the use of thermal waters that are therapeutically active by virtue of mineral composition,mud and natural gas.In numerous papers,balneotherapy is described as a treatment with favourable results 11,12.SIOT moderately recommend the use in mild OA.Canes,walking sticks,crutches,walkersDepending on the severity of the disease and the needs of each patient,these devices can aid walking,significantly reducing the load on the lower limbs,improving stabil-ity and assisting movement.The risk of falls also appears to be reduced 4,11.Walking assist devices are strongly recommended in patients with symptomatic knee OA.Exercise(land andwater based)For individuals with knee OA,the types of exercises per-formed on land include muscle strengthening,aerobic stretching and neuromuscular balance exercises,and more.13 However,most importantly,any proposed programme should be based on patient needs 8,9.Water offers natural resistance,which helps strengthen muscles 14,15;evidence shows that exercise in water provides improvements in pain and quality of life in peo-ple who are unable to perform land-based exercise due to pain.SIOT consider land and/or aquatic exercise one of core treatments together with weight loss and self-man-agement and education.Pulsed electromagnetic field therapy(PEMT).Evidence that PEMT significantly improves pain and function in people with knee OA is low in quality due to the short-term nature of the follow-ups described in the literature 16.Thus,further studies with long-term follow-ups should be performed.Cardiovascular defi-ciencies,blood sugar levels disorders,blood coagulation diseases and anti-coagulant therapies are relative con-traindications in PEMF treatment 5,17.There is a lack Fig.1 Flowchart of study selectionPage 4 of 9Pesareetal.Journal of Orthopaedics and Traumatology (2023)24:47 of consensus in literature about duration,frequency,and intensity of PEMF therapy sessions 18.Nevertheless,PEMT has proved therapeutically effec-tive for bone-and cartilage-related pathologies and can be used to reduce pain and stiffness 19.PEMT may be used to improve pain and/or function in patients with mild knee OA 20;therefore,the SIOT rec-ommendation is moderate.BisphosphonateBisphosphonates are anti-resorptive agents(currently used in the treatment of osteoporosis).They represent a potential candidate for osteoarthritis therapy 21,22.Results from evidences using bisphosphonates in OA have been encouraging but controversial:some studies suggest neridronate is effective in OA treatment 23,while others contend that clodronate could play a role as a disease-modifying drug.OARSI is weakly favour-able to risedronato due to the few studies in literature supporting its application as a reducer of the marker of cartilage degradation(CTX-II)which may contribute to slow the radiological progression of OA,particularly in patients who are not overweight 24,25.On the other side,AAOS and ACR do not recommend their use 5,26.Limitations of the studies included differences in the bisphosphonate analysed,the dose and the route of administration 27.Future studies are needed:SIOT rec-ommendation on their use is inconclusive.Oxygenozone therapy (O3 therapy)Ozone is known for its anti-inflammation effect and its work on cellular metabolism 28.In knee OA,O3 therapy is described as a safe approach with encourag-ing effects 29 with respect to pain control and func-tional recovery in the short-to-middle term 30,with an almost null adverse event rate 31 especially in combi-nation with other treatments 28.It is contraindicated in patients with a significant deficit of G-6PD,in pregnancy,in case of hyperthyroidism,thrombocytopenia and seri-ous cardio-vascular instability 32.SIOT recommenda-tion to its use in knee OA is limited.Transcutaneous electrical nerve stimulation(TENS)TENS uses a low-voltage electrical current delivered through electrodes attached to the patients skin to stimulate peripheral nerve activity(neuromodula-tion)3335.TENS can be generally delivered at two different dosing,high frequency(50e100Hz)and low frequency(2e10Hz):the use of TENS is not recom-mended in people with pacemakers and women who are pregnant should not apply TENS in the abdominal or pelvic regions 5.The literature on this is highly heterogeneous,and the available clinical trials are characterised by short follow-up periods.Thus,SIOT consider the available evidence insufficient to recom-mend this procedure 16.Firstline pharmacological treatment(management ofacute symptoms)Acetaminophen(or paracetamol)This is generally used to treat mild-to-moderate pain 36.It is weakly recommended as an initial pharmaco-logical approach in the presumption of its overall safety 8,37.However,while the OARSI recommends against its use in both the short and long term,the ESCEO and ACR make a weak recommendation for its use in the short term,and the AAOS strongly recommends its use 5,5,38.SIOT moderately recommend acetaminophen at doses no greater than 3g/day in mild/moderate OA if not contraindicated(in cases of hypersensitivity to aceta-minophen,severe hepatic impairment or severe active liver disease)5.Topical non-steroidal anti-inflammatory drugs(NSAIDs).Topical use of NSAIDs is recommended as first-line treatment,particularly in patients with comorbidities,owing to their proven efficacy and low risk of gastrointes-tinal(GI),cardiovascular or renal adverse events(OARSI,ACR,ESCEO,AAOS).To