The American Academy of Orthopaedic Surgeons (AAOS) issued a new Clinical Practice Guideline (CPG) for the Management of Ankle Osteoarthritis (OA). This is the first CPG to provide 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. To view the full guideline, click here.

“The introduction of this CPG to the orthopaedic community is important because ankle OA disproportionately affects younger, active, working-age patients,” said Christopher Gross, MD, FAAOS, co-chair of the CPG workgroup. “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.”
Treatment options for ankle OA, 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. However, the CPG workgroup noted that there may be a short-term benefit 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,” said Dr. Gross.

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,” said Jeannie Huh, MD, FAAOS, co-chair of the CPG workgroup. “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 the management of ankle OA; however, using nonsteroidal 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 the progression of OA symptoms.

“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,” said Dr. Huh. “In the meantime, we encourage patients and orthopaedic 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 orthopaedic 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 orthopaedic surgeons and is available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.