AAOS Releases Clinical Practice Guideline for Ankle Osteoarthritis Management

The American Academy of Orthopaedic Surgeons (AAOS) has issued a new Clinical Practice Guideline (CPG) for ankle osteoarthritis (OA) management that provides recommendations on non-operative and operative treatments for ankle OA.

Due to gaps in the current research, the guideline includes only two recommendations and identifies where further research is needed to help provide clear treatment options for patients.

“The introduction of this CPG to the orthopedic community is important because ankle OA disproportionately affects younger, active, working-age patients,” said Christopher Gross, M.D., the CPG workgroup co-chair. “Unlike the hip and knee OA population, which traditionally affects an older population, ankle OA is a distinct clinical entity, and I’m glad that it has been recognized with its own guideline.”

Ankle OA treatment options—which include joint-preserving procedures, ankle arthrodesis (a procedure that permanently joins the shinbone to the ankle bone), and total ankle arthroplasty—have expanded, underscoring the need for an ankle-specific, evidence-based guideline.

The CPG features two recommendations: a moderate recommendation against using intra-articular platelet-rich plasma (PRP) to treat symptomatic ankle OA, and a strong recommendation against using intra-articular hyaluronic acid (HA) alone to treat ankle OA. The CPG workgroup, however, said a short-term benefit may exist in pain and function when HA is combined with corticosteroids.

“I administered PRP injections for ankle OA for about 10 years, and I remain supportive of biologic treatment options, but unfortunately, there is no high-quality evidence demonstrating that PRP provides better pain control than injecting saline into the ankle,” Dr. Gross stated.

Additionally, access to HA remains limited because many insurance payers do not cover its use for ankle OA. At present, there is no clear, complete protocol for combining HA with a corticosteroid, making it harder to offer these treatment options to patients. 

“When you combine HA with a corticosteroid, it seems to have a better effect than either the steroid or the HA alone,” commented Jeannie Huh, M.D., the CPG workgroup co-chair. “We hope these findings will help improve patient access to effective treatment options.”

The guideline also contains 11 consensus recommendations and one limited-strength option, which are formed when there is little to no evidence on the topic. Highlights of the consensus recommendations include:

• Intra-articular corticosteroid injections may provide short-term symptom relief
• There is no reliable evidence that intra-articular stem cell therapy is beneficial for symptomatic ankle OA
• Patients with mild to moderate symptomatic ankle OA who wish to avoid surgery may benefit from skilled physical therapy, which could improve patient-reported outcomes and potentially affect OA progression
• Physical therapy may improve range of motion, return to work or activity, strength and gait restoration for patients who have surgery
• Prescription opioids should not be used in managing ankle OA; however, using non-steroidal anti-inflammatory drugs and/or acetaminophen may be used for initial symptomatic relief, when no other medical contraindications exist
• Weight reduction may improve patient-reported outcomes and affect OA symptom progression.

“While this CPG provided a broad overview of various interventions to help manage symptomatic OA, we are hopeful that future CPGs will review definitive surgical treatments,” Dr. Huh concluded. “In the meantime, we encourage patients and orthopedic surgeons to engage in shared decision-making, analyzing the pros and cons of available procedures to find the option that is best for the patient.”

CPGs are not intended to be stand-alone documents, but rather serve as a point of reference and educational tool for orthopedic surgeons and healthcare professionals managing patients with symptomatic ankle OA. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment and the individual patient’s specific clinical circumstances. The guideline is not intended for use as a benefits determination document.

The full Clinical Practice Guideline for the Management of Ankle Osteoarthritis is intended for reference by orthopedic surgeons and is available through AAOS’ OrthoGuidelines website and free mobile app.

With more than 39,000 members, the AAOS is the world’s largest medical association of musculoskeletal specialists. AAOS provides comprehensive education to help orthopedic surgeons and allied health professionals best treat patients in their daily practices. AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.