What are the treatment or additional evaluation options for a 73-year-old female with chronic left knee pain, radiographs (x-rays) showing severe degeneration of the medial tibiofemoral joint compartment, and symptoms including pain with ambulation (walking) and intermittent knee instability (buckling)?

From the Guidelines

For a 73-year-old female with chronic left knee pain, severe medial compartment degeneration, pain with walking, and intermittent knee buckling, I recommend a multi-faceted approach prioritizing conservative management and considering the latest evidence from the American Academy of Orthopaedic Surgeons (AAOS) 1. The patient's symptoms and radiographic findings suggest severe osteoarthritis of the knee, which requires a comprehensive treatment plan to alleviate pain, improve function, and enhance quality of life.

Key Components of the Treatment Plan

• Conservative management with acetaminophen (up to 3000mg daily in divided doses) and/or NSAIDs like naproxen (250-500mg twice daily) if not contraindicated by other medical conditions
• Physical therapy focusing on quadriceps strengthening, range of motion exercises, and gait training for 6-8 weeks
• A knee unloader brace to redistribute weight away from the damaged medial compartment
• Weight loss if appropriate and activity modification to reduce stress on the knee joint
• Consideration of intra-articular corticosteroid injections (such as methylprednisolone 40mg) or hyaluronic acid injections for additional pain relief, although benefits may be temporary

Surgical Options

If conservative measures fail to provide adequate relief after 3-6 months, surgical consultation for unicompartmental knee arthroplasty or total knee replacement would be appropriate given her age and symptom severity, as recommended by the AAOS 1 and supported by earlier guidelines from EULAR 1.

Additional Considerations

• The knee buckling suggests possible instability or quadriceps weakness, which makes physical therapy particularly important to improve muscle support around the joint
• Assistive devices like a cane used in the opposite hand can also help reduce load on the affected knee and improve stability during walking By prioritizing conservative management and considering surgical options based on the latest evidence, we can optimize the patient's outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

14 CLINICAL STUDIES

1. 1 Study in Osteoarthritis of the Knee Diclofenac sodium topical solution The use of diclofenac sodium topical solution for the treatment of pain of osteoarthritis of the knee was evaluated in a single double-blind controlled trial conducted in the US, involving patients treated with diclofenac sodium topical solution at a dose of 2 pumps twice a day for 4 weeks Diclofenac sodium topical solution was compared to topical vehicle, applied directly to the study knee. In this trial, patients treated with diclofenac sodium topical solution experienced a greater reduction in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale compared to patients treated with vehicle

For a 73-year-old female with chronic left knee pain and severe degeneration of the medial tibiofemoral joint compartment, treatment options may include:

• Topical diclofenac sodium solution as studied in the clinical trial, which showed a reduction in WOMAC pain subscale compared to vehicle control 2 Additional evaluation options may include:
• Further radiographic evaluation to assess the severity of degeneration
• Physical therapy to improve knee stability and reduce pain with ambulation
• Other non-pharmacological interventions to manage osteoarthritis symptoms Note that the provided information does not explicitly address intermittent knee instability (buckling), and therefore, no conclusion can be drawn regarding the treatment of this specific symptom.

From the Research

Treatment Options

• Conservative therapy, including life-style changes, topical and oral pain medication, and intraarticular application of hyaluronic acid or platelet-rich plasma, can be considered as the first-line treatment for knee osteoarthritis 3, 4
• Intraarticular injections, such as corticosteroids, hyaluronic acid, and platelet-rich plasma, can provide short-term reduction in pain and improvement in knee function, especially in mild cases of osteoarthritis 5, 4, 6
• Surgical joint-preserving therapies, including knee arthroscopy and osteotomy, may be considered for patients with unicompartmental arthrosis and leg malalignment 3

Additional Evaluation Options

• Weight reduction, if the patient has a BMI > 28kg/m2, can help alleviate symptoms and improve outcomes 4
• Physical therapy, including aerobic, proprioception, and strengthening training, can help improve knee function and reduce pain 4
• Self-management education programs and pharmacological treatment, such as NSAIDs, can also be considered as part of a combined conservative therapy approach 4

Considerations

• The treatment of knee osteoarthritis requires a multimodal approach and depends on the symptoms and stage of the disease 3
• There is no evidence that any of the intraarticular injections can cause osteophytes to regress or cartilage and meniscus to regenerate in patients with substantial and irreversible bone and cartilage damage 5
• The use of glucocorticoids can relieve pain in the short term, but their prolonged use increases the risk of cartilage loss and progression of osteoarthritis 6