EXTENDED REPORT

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

K M Jordan¹⁰, N K Arden¹, M Doherty⁵, B Bannwarth², J W J Bijlsma³, P Dieppe⁴, K Gunther⁷, H Hauselmann⁸, G Herrero-Beaumont⁹, P Kaklamanis¹¹, S Lohmander¹⁴, B Leeb¹², M Lequesne¹³, B Mazieres¹⁵, E Martin-Mola¹⁶, K Pavelka¹⁷, A Pendleton¹⁸, L Punzi¹⁹, U Serni, B Swoboda²¹, G Verbruggen²², I Zimmerman-Gorska²³, M Dougados⁶

¹ Nigel Arden, Southampton General Hospital, Southampton S016 6YD, UK
² Bernard Bannwarth, Laboratoire de Thérapeutique, Université Bordeaux II, 33076 Bordeaux Cedex, France
³ Johannes Bijlsma, Department of Rheumatology and Immunology, University Hospital Utrecht, 3508 Utrecht GA, The Netherlands
⁴ Paul Dieppe, MRC Health Services Research Collaboration, University of Bristol, Canynghe Hall, Whiteladies Road, Bristol BS8 2PR, UK
⁵ Michael Doherty, Rheumatology Unit R.U.G., City Hospital, Nottingham NG5 1PB, UK
⁶ Maxime Dougados, Service de Rheumatologie B, Hôpital Cochin, 75014 Paris, France
⁷ Klaus-Peter Gunther, Department of Orthopaedic Surgery, University of Dresden, D-Dresden, Germany
⁸ Hans Hauselmann, Centre for Rheumatology and Bone Disease, Clinic Im Park, Hirslanden Group, Bellariast. 38, CH 8038 Zurich, Switzerland
⁹ Gabriel Herrero-Beaumont, Rheumatology Department, Clinique de la Conception, 28040 Madrid, Spain
¹⁰ Kelsey Jordan, Florence Cottage, 17 Dover Street, Southampton SO146GG, UK
¹¹ Phaedon Kaklamanis, 16 Anaperon Polemon, 11521 Athens, Greece
¹² Burkhard Leeb, NÖ Zentrum für Rheumatology, Stockerau Hospital, A-2000 Stockerau, Austria
¹³ Michel Lequesne, 31-33 rue Guillemot, 75014 Paris, France
¹⁴ Stefan Lohmander, Deparment of Orthopaedics, University Hospital, S-22185 Lund, Sweden
¹⁵ Bernard Mazieres, Service de Rhumatologie, 1 avenue Jean Poulhès, CHU Rangueil, 31054 O, Cedex France
¹⁶ Emilio Martin-Mola, Divisione di Reumatologia, Hosptial La Paz, 28046 Madrid, Spain
¹⁷ Karel Pavelka, Institute of Rheumatology, 12850 Praha 2, Czech Republic
¹⁸ Adrian Pendleton, 9 Prince Edward Drive, Stranmillis, Belfast BT9 5GB, Northern Ireland
¹⁹ Leonardo Punzi, Universita degli studi di Padova, Policlinico Universitario - VIII Piano, Via Giustiniani, 2, 35128 Padova, Italy
²⁰ Umberto Serni, Divisione di Reumatologia, Istituto Ortopedico Toscano, Florence, Italy
²¹ Berndt Swoboda, Ortopedik Poliklinik der Universität Erlangen-Nuremberg, D-91054 Erlangen, Germany
²² Gust Verbruggen, Rheumatology Unit, U.Z R.U.G., B-7000 Gent, Belgium
²³ Irena Zimmermann-Gorska, Department of Rheumatology and Rehabilitation, Karol Marcinkowski University of Medical Sciences, 28 Czerwca 1956r, 135/147, 61-545 Poznan, Poland

Correspondence to:
Correspondence to:
Professor M Dougados
Institut de Rhumatologie, Hardy B, Hopital Cochin 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; m.doug{at}cch.ap-hop-paris.fr

Objectives: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

Methods: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

Results: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

Conclusion: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered.

Keywords: knee; osteoarthritis; recommendations; treatment; evidence based medicine; guidelines

Abbreviations: ES, effect size; HA, hyaluronic acid; NSAIDs, non-steroidal anti-inflammatory drugs; OA, osteoarthritis; QS, quality score; RCT, randomised controlled trial; TKR, total knee replacement

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