LOL AAOS! You Guys Crack Me Up – More Steroids and Less PRP for Knees!

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It’s official, the American Academy of Orthopedic Surgeons is now officially off its collective rocker. Instead of adding PRP to their knee arthritis treatment guidelines, which would be an evidence-based thing to do in 2021, the AAOS has avoided all evidence and doubled down on the ridiculous practice of injecting steroids into knees! However, wait, it gets far worse and more humorous than that, so let’s dig into the wacky new “guidelines”.

The New 2021 AAOS Knee OA Guidelines

I was first introduced to the new American Academy of Orthopedic Surgeons (AAOS) knee osteoarthritis guidelines by a story in an orthopedics mag that looks like it was sponsored by the makers of Zilretta (1). What’s that? It’s a long-acting high-dose steroid medication used to treat the symptoms of knee OA.

The article stated:

“With changes to 19 of the 29 recommendations from the previous guideline, the new document focused only on less invasive non-arthoplasty treatments.  Notably, the guidelines mentioned a relatively new treatment, a time-release corticosteroid, Zilretta®.”

Given that we now know for sure that high-dose corticosteroids destroy knee cartilage, why would anyone invent a long-acting high-dose steroid? Your guess is as good as mine. Hence, this launched me on a journey to investigate more about these guideline changes and guess what folks, I was not disappointed by the AAOS’s nutty new document.

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You Can’t Make This Stuff Up

AAOS knee arthritis guidelines 2021

The latest knee arthritis guidelines from the American Academy of Orthopedic Surgeons came out at the end of August 2021 (62). As you can see above, the AAOS guidelines committee used a star system to grade the evidence in favor of using various treatments for knee arthritis. That makes sense because many people are used to seeing a similar system to rate everything from hotels to doctors online. What makes no sense is the shenanigans that the surgeons used to prop up the treatments that create chunks of orthopedic surgical income and suppress the ones that don’t.

Let’s dig into this buffet of self-dealing and ignoring the actual published evidence. First, you can’t look away from the train wreck that is the three-star recommendation for using a partial meniscectomy to treat knee OA. We have three large randomized controlled trials that show that the procedure is no better than a sham surgery or physical therapy (2-4). Hence, that’s not moderate evidence of efficacy as is claimed, that’s evidence of lack of efficacy. Add to that the fact that most meniscus tears in middle-aged and elderly people represent normal aging and you have a guidelines committee that must have squinted pretty hard and said three hail Marys while doing the sign of the cross to call this “moderate evidence” (5).

Another ridiculous assertion is that “lavage/debridement” is a 3-star treatment for knee arthritis. We know this isn’t even close to true as that procedure was determined to be no better than the placebo way back in 2002! (10) A 2013 article published in the American Journal of Sports Medicine noted that there was already a 39% drop in that surgery based on that then decade-old paper (11). So here we are, almost two decades after Moseley’s groundbreaking research showing that this surgery was no more effective than a faked procedure and AAOS is claiming that there is moderate evidence to support its use? In what universe is that true?

Next up is corticosteroids. These are the steroid injections given by surgeons to people with knee arthritis. As discussed above, we know that the steroid that Zilretta is based on, triamcinolone, is a high-dose anti-inflammatory. This is the most commonly injected knee steroid medication that we know destroys cartilage based on a randomized controlled trial published in the New England Journal of Medicine (6). Again, that’s not moderate evidence of efficacy, that’s four-star evidence of harm.

You also can’t look away from the pharma-sponsored aspects of this guideline, which are frankly a slap in the face of the opioid crisis that has killed almost a million Americans since the first high-dose opioids were introduced (7). Meaning the AAOS lists “Oral Narcotics” as a 4-star treatment for knee arthritis? That’s bizarre as a 2016 meta-analysis clearly showed that NSAIDs worked about as well for knee OA pain as narcotics (8). While NSAIDs have their own issues with increasing cardiac sudden death risk, at least they don’t leave you physically addicted (9)!

PRP Is a 2-Star Therapy?

As I have written many times before, we have much more evidence that PRP is effective to treat knee arthritis than any orthopedic surgery including knee replacement, partial meniscectomy, or lavage/debridement. In fact, there are dozens of RCTs showing that PRP is effective for knee osteoarthritis and many more showing it’s effective in other orthopedic conditions (12-61). This evidence is against a backdrop showing that few orthopedic surgeries have basic evidence that they’re more effective than doing nothing or conservative care (62). In fact, I created a table from that seminal British Medical Journal systematic review:

To learn more about how awful the evidence base is for common orthopedic surgical procedures, read this blog entry. 

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Why Am I So Hard on My Orthopedic Surgery Colleagues?

I get flack all the time from various orthopedic surgeons I know concerning the fact that I am much too hard on surgeons. However, looking at this AAOS guideline, is there any wonder why? This thing is so bad and so divorced from what’s published in the medical literature that its theater of the absurd. So listen up surgical boys and girls, you want respect? Earn it by actually letting the evidence drive your surgical decision-making.

The upshot? This guideline is insane. It basically says we need more discredited surgeries with no evidence of efficacy, more steroids to kill cartilage, and we’ll throw in some high-dose narcotics that cause addiction just for fun! Is it any wonder I’m critical of this specialty? It’s stuff like this, ignoring surgical outcomes, that has forced patients in droves to look for surgical alternatives.

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References:

(1) Orthopedics this Week. AAOS UPDATES KNEE OA GUIDELINE, HIGHLIGHTS ZILRETTA® Accessed 10/17/21 https://ryortho.com/breaking/aaos-updates-knee-oa-guideline-highlights-zilretta/

(2) Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. N Engl J Med 2013; 369:2515-2524

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(5) Risberg MA, Degenerative meniscus tears should be looked upon as wrinkles with age—and should be treated accordingly. 
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(63) American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline (3rd Edition). https://www.aaos.org/oak3cpg Published August 31, 2021. Accessed October 17, 2021
Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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