What are the treatment options for osteoarthritis (OA) of the knees, and will arthroscopy be beneficial?

Treatment Options for Knee Osteoarthritis: Arthroscopy Not Recommended

Arthroscopy with débridement or lavage is not recommended for patients with knee osteoarthritis as it does not provide meaningful clinical benefit and should not be considered as a treatment option. 1

First-Line Non-Pharmacological Treatments

Exercise Therapy

• Strongly recommended with high-quality evidence 2
  • Low-impact aerobic exercises (walking, cycling): 30 minutes, 3-5 times weekly 2
  • Resistance training: 2-3 times weekly, 8-12 repetitions 2
  • Quadriceps strengthening exercises 1, 2
  • Aquatic exercises: particularly beneficial for deconditioned patients 2

Weight Management

• Strongly recommended for overweight patients (BMI >28 kg/m²) 1, 2
• Weight loss results in clinically important functional improvement measured by WOMAC function scale 1
• Set explicit weight-loss goals with structured meal plans 2

Self-Management Education

• Patients should be encouraged to participate in self-management educational programs 1
• These programs empower patients to better manage their condition 3

Pharmacological Treatments

First-Line Medications

• Acetaminophen/Paracetamol: Preferred for long-term oral analgesia 2
• Oral NSAIDs (like naproxen): Recommended for patients with inflammation and stiffness 2, 4
  • Naproxen has been shown to reduce joint pain/tenderness and increase range of motion 4
  • Caution: Higher risk of gastrointestinal adverse events with long-term use 2, 4

Second-Line Medications

• Duloxetine: Consider as adjunct therapy for severe/refractory pain (30-60 mg/day) 2
• Tramadol: Appropriate when other options fail 2
• Opioid analgesics: Reserved for severe OA pain refractory to other treatments 2

Intra-articular Injections

• Corticosteroid injections: Recommended for short-term relief (1-3 months), especially for acute exacerbations with effusion 2
• Hyaluronic acid injections: Conditionally recommended for patients with contraindications to NSAIDs 2

Mechanical Interventions

• Assistive devices: Walking stick on the contralateral side to reduce pain 2
• Patellar taping: Suggested for short-term relief of pain and improved function 1
• Appropriate footwear: Shoes with shock-absorbing properties 2
• NOT recommended: Lateral heel wedges for medial compartmental OA 1

Surgical Options

NOT Recommended

• Arthroscopy with débridement or lavage: Not beneficial for OA 1, 3
• Free-floating interpositional devices: Not recommended for unicompartmental OA 1

Recommended Surgical Options

• Total joint replacement: Strongly recommended for end-stage disease not responding to conservative measures 2
• Partial meniscectomy or loose body removal: May be considered in specific cases 1
• Realignment osteotomy: May be considered in appropriate cases 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Exercise therapy (focus on quadriceps strengthening)
   • Weight loss if overweight
   • Self-management education

2. Add first-line medications if needed:

   • Acetaminophen for mild pain
   • NSAIDs for pain with inflammatory component

3. Consider intra-articular injections:

   • Corticosteroids for acute flares
   • Hyaluronic acid for those who cannot take NSAIDs

4. For refractory cases:

   • Add duloxetine or tramadol
   • Consider referral for surgical evaluation if severe symptoms persist

Important Caveats

• Arthroscopy for degenerative meniscal tears in OA is not indicated even with mechanical symptoms like locking or catching 3
• NSAIDs should be used cautiously due to potential gastrointestinal side effects 2, 4
• Exercise therapy should be tailored to patient's fitness level and comorbidities 2
• Total knee replacement should only be considered after exhausting appropriate conservative options 2, 3

Remember that knee OA management requires consistent application of these treatments, with regular assessment of pain control and functional status to monitor efficacy and adjust treatment as needed.