What is the recommended treatment for a patient with moderate osteoarthritis (OA) of the right hip, mild osteoarthritis of the left hip, and mild left patellofemoral compartment osteoarthritis, with a history of right patellar fracture fixation?

Management of Osteoarthritis in Multiple Joints

Exercise therapy should be the first-line treatment for this patient with moderate right hip OA, mild left hip OA, and mild left patellofemoral compartment OA, combined with appropriate pharmacological management. 1

Non-Pharmacological Management

Exercise Therapy (First-Line)

• Land-based exercises:

  • Strengthening exercises focusing on hip and quadriceps muscles
  • Low-impact aerobic activities (walking, stationary cycling)
  • Range of motion exercises
  • Neuromuscular training to address muscle weakness and instability 1

• Aquatic exercises:

  • Particularly beneficial for bilateral hip OA
  • Provides buoyancy that reduces joint loading
  • Offers pain-free motion and resistance for strengthening 1

Assistive Devices

• Cane use: Strongly recommended for the moderate right hip OA to improve ambulation, stability, and reduce pain 1
• Patellofemoral brace: Conditionally recommended for the left knee patellofemoral OA 1

Weight Management

• Weight loss strongly recommended if the patient is overweight or obese 1
• Target minimum weight loss of 5-10% of body weight 2

Other Physical Interventions

• Physical therapy: Should include manual therapy combined with supervised exercise 1
• Thermal modalities: Heat or cold therapy as needed for symptomatic relief 1
• Tai Chi: Strongly recommended for hip and knee OA 1, 2

Pharmacological Management

First-Line Options

• Topical NSAIDs: For the mild left patellofemoral OA 1
• Oral NSAIDs: For the moderate right hip OA and overall joint pain when not contraindicated 1
  • Use lowest effective dose for shortest duration
  • Consider GI protection in high-risk patients

Alternative/Additional Options

• Acetaminophen: May be considered for mild-to-moderate pain, though evidence suggests NSAIDs are more effective for moderate pain 1, 3

  • Maximum 4g per day
  • Less effective than NSAIDs but better safety profile for some patients 3

• Intra-articular corticosteroid injections: Could be considered for the moderate right hip OA if oral medications provide inadequate relief 1

Special Considerations for Patellofemoral OA

• Specific exercises: Focus on quadriceps strengthening and hip abductor exercises 4
• Patellofemoral taping: May help reduce pain and improve function 1, 4
• Avoid high-impact activities that increase patellofemoral joint stress 1

Monitoring and Follow-up

• Regular assessment of pain control and functional status
• Periodic evaluation of medication efficacy and side effects
• Adjustment of exercise program as function improves or symptoms change

Common Pitfalls to Avoid

1. Overreliance on medications: Exercise therapy should remain the cornerstone of treatment 1

2. Inadequate pain control: Insufficient pain management may limit participation in beneficial exercise programs 1

3. Inappropriate exercise selection: High-impact exercises should be avoided as they may accelerate joint damage 1

4. Prolonged NSAID use: Long-term use increases risk of GI, renal, and cardiovascular complications 1

5. Ignoring the patellofemoral component: Specific interventions for patellofemoral OA are needed beyond general knee OA management 4

By implementing this comprehensive approach focusing on appropriate exercise therapy, assistive devices, and judicious use of medications, this patient with multiple joint OA can achieve improved function and pain relief while minimizing medication-related risks.