Appraisal of clinical practice guidelines and recommendations for the management of hip and knee osteoarthritis: a systematic review

Introduction: Multiple guidelines for management of hip and knee osteoarthritis (OA) exist. However, adherence is often poor, possibly related to their quality and/or inconsistent recommendations. This systematic review of hip and knee OA clinical practice guidelines aimed to appraise their quality and determine the level of consensus in recommendations across higher quality ones. Methods: This systematic review (PROSPERO: CRD42021216154) searched six databases, guideline repositories and association websites in August 2021. Two authors independently screened articles, with a third author resolving any conflicts. Data were independently extracted by 2 authors. Quality was appraised using the AGREE II tool (six domains) by two authors independently, with ratings finalised through consensus. Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consensus in recommendations across higher quality guidelines was reported descriptively. Results: Twenty-four guidelines were included. Seven (29%) were high quality. ‘Applicability’ (barriers and facilitators, implementation) domain scores were the lowest on average across all guidelines (average 32%). Of the seven high quality guidelines, two provided recommendations for OA generally, three provided separate recommendations for hip and knee OA, one provided recommendations for physiotherapy management of hip OA and one focused solely on knee arthroscopy. Of the six high quality guidelines not focused on arthroscopy, all strongly recommended education, exercise, and weight management, although one was conditional for weight management in hip OA. Four of the six guidelines considered pharmacological management, with recommendations consistently favouring (strong or conditional) non-steroidal anti-inflammatory drugs (NSAIDs) (considering co-morbidities) and intra-articular steroid injections. Recommendations regarding paracetamol varied, with two guidelines conditional for, one neutral and one conditional against. Three out of four guidelines recommended against opioids, and one was conditional for. Recommendations for hyaluronic acid injections were variable, particularly for knee OA (conditional against 2/3, conditional for 1/3). Two out of three recommended strongly against platelet rich plasma, and one was neutral. Guidelines concurred with a strong recommendation against stem cells (n=3) and arthroscopy (n=3, including the arthroscopy guideline) for knee OA. Discussion: Guideline quality varied greatly. Within higher quality guidelines, first-line recommendations consistently include exercise, education and weight management. Consistent with previous guideline appraisals for OA and other musculoskeletal conditions, applicability domain scores were low for most guidelines, highlighting a paucity of guidance on ‘how to’ implement current guidelines. This, combined with a lack of consensus on pharmacological management, may help explain low adherence to guidelines. Future guidelines should prioritise providing implementation guidance. Implication for practice:•Higher quality guidelines for hip and knee OA consistently recommend that clinicians implement exercise, education, and weight management, alongside consideration of NSAIDs and intra-articular steroid injections.•Limitations in applicability of current guidelines alongside poor consensus on pharmacological options including paracetamol and injectables (hyaluronic acid, PRP) create challenges for guideline adherence when treating OA. My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract