title: Assessment of clinical practice guideline methodology for the treatment of knee osteoarthritis with intra-articular hyaluronic acid.
abstract: BACKGROUND
  Clinical practice guidelines are of increasing importance in the decision making for the treatment of knee osteoarthritis. Inconsistent recommendations regarding the use of intra-articular hyaluronic acid for the treatment of knee osteoarthritis have led to confusion among treating physicians.
  
  
  METHODS
  Literature search to identify clinical practice guidelines that provide recommendations regarding the use of intra-articular hyaluronic acid treatment for knee osteoarthritis was conducted. Included guidelines were appraised using the AGREE II instrument. Guideline development methodologies, how the results were assessed, the recommendation formation, and work group composition were summarized.
  
  
  RESULTS
  Overall, 10 clinical practice guidelines were identified that met our inclusion criteria. AGREE II domain scores were variable across the included guidelines. The methodology utilized across the guidelines was heterogeneous regarding the evidence inclusion criteria, analysis of evidence results, formulation of clinical practice recommendations, and work group composition. The recommendations provided by the guidelines for intra-articular hyaluronic acid treatment for knee osteoarthritis are highly inconsistent as a result of the variability in guideline methodology. Overall, 30% of the included guidelines recommended against the use of intra-articular hyaluronic acid in the treatment of knee osteoarthritis, while 30% deemed the treatment an appropriate intervention under certain scenarios. The remaining 40% of the guidelines provided either an uncertain recommendation or no recommendation at all, based on the high variability in reviewed evidence regarding efficacy and trial quality.
  
  
  CONCLUSIONS
  There is a need for a standard "appropriate methodology" that is agreed upon for osteoarthritis clinical practice guidelines in order to prevent the development of conflicting recommendations for intra-articular hyaluronic acid treatment for knee osteoarthritis, and to assure that treating physicians who are utilizing these guidelines are making their clinical decisions on the best available evidence. At present, the inconsistent recommendations provided for intra-articular hyaluronic acid treatment make it difficult for clinical professionals to determine its appropriateness when treating patients with knee osteoarthritis.
authors.affiliation: David Geffen School of Medicine, University of California of Los Angeles, 9854 W Bald Mountain Court, Agua Dulce, Los Angeles, CA 91390. Electronic address: journals@royaltman.com.
authors.forename: Roy D
authors.initials: RD
authors.lastname: Altman
authors.affiliation: Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Emil
authors.initials: E
authors.lastname: Schemitsch
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: Asheesh
authors.initials: A
authors.lastname: Bedi
mesh_terms: D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage / Q000627:therapeutic use*; D007270:Injections, Intra-Articular; D020370:Osteoarthritis, Knee / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D055675:Viscosupplements / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D055675:Viscosupplements; D006820:Hyaluronic Acid
keywords: Guidelines; Hyaluronic acid; Knee; Osteoarthritis; Viscosupplementation