Is surgery medically indicated for a patient with bilateral primary osteoarthritis, who has severe knee pain unresponsive to conservative treatments including Monovisc (hyaluronic acid) injections and over-the-counter anti-inflammatory medications?

Is Surgery Medically Indicated for This Patient?

Surgery (total knee arthroplasty) is medically indicated for this patient with bilateral severe knee osteoarthritis who has failed conservative management including hyaluronic acid injections, over-the-counter anti-inflammatory medications, and has severe pain limiting ambulation and daily activities. 1

Clinical Reasoning

This patient presents with the classic indications for surgical referral:

• Severe bilateral knee pain limiting ambulation and daily activities represents end-stage disease with significant functional impairment 1
• Failed conservative treatments including Monovisc (hyaluronic acid) injection and over-the-counter NSAIDs 1
• The patient has exhausted appropriate non-operative options, meeting criteria for joint replacement consideration 1

Evidence Supporting Surgical Referral

When Surgery Is Indicated

Joint replacement should be considered for refractory pain associated with disability and radiological deterioration when conservative management has failed. 1 The 2022 AAOS guidelines and EULAR recommendations both support surgical referral when patients have:

• Severe pain unresponsive to conservative treatment 1
• Significant functional limitations affecting daily activities 1
• Failed appropriate non-operative interventions 1

Why Hyaluronic Acid Failure Matters

The patient received Monovisc (hyaluronic acid) injection, which is not routinely recommended by the most recent 2022 AAOS guidelines. 1 The guidelines note:

• 17 high-quality and 11 moderate-quality studies did not consistently support hyaluronic acid for knee OA 1
• The 2020 ACR/Arthritis Foundation guidelines conditionally recommend against hyaluronic acid injections, noting that when limited to low-risk-of-bias trials, the effect size approaches zero 1
• The number needed to treat is 17 patients, indicating limited efficacy 1

The failure of hyaluronic acid injection in this patient is therefore not surprising and should not delay appropriate surgical referral. 1

What Should NOT Be Done

Arthroscopic Surgery Is Not Indicated

Arthroscopic debridement or partial meniscectomy is strongly recommended against for patients with primary osteoarthritis. 1

• The 2017 BMJ clinical practice guideline makes a strong recommendation against arthroscopy for degenerative knee disease 1
• The 2009 AAOS guidelines recommend against arthroscopy with debridement or lavage in patients with primary OA 1
• These procedures provide no benefit over conservative management and delay definitive treatment 1

Additional Injections Are Not Appropriate

Before surgical referral, the only injection that might be considered is:

• Intra-articular corticosteroid injection for short-term pain relief (weeks to months), supported by 19 high-quality studies 1
• However, given the severity of symptoms and functional limitation, this would only serve as a temporizing measure while arranging surgical consultation 1

Platelet-rich plasma is strongly recommended against (inconsistent results, worse outcomes in severe OA) 1

Clinical Algorithm for This Patient

1. Confirm end-stage disease: Severe pain limiting ambulation and daily activities despite conservative treatment ✓ 1

2. Verify failed conservative management:

   • Over-the-counter NSAIDs ✓ 1
   • Hyaluronic acid injection ✓ 1
   • (Note: Physical therapy and weight loss should have been attempted if applicable) 1

3. Refer for total knee arthroplasty evaluation - This patient meets criteria 1

4. Consider corticosteroid injection only as bridge therapy while awaiting surgical consultation if pain is intolerable 1

Important Caveats

• Do not perform arthroscopic surgery - this will not help and delays appropriate treatment 1
• Do not repeat hyaluronic acid injections - evidence does not support this approach 1
• Ensure bilateral disease is addressed - both knees may require surgical planning 1
• Medical optimization should occur concurrently with surgical planning (cardiovascular risk assessment, diabetes control if present) 1

The patient has exhausted appropriate conservative options and meets established criteria for surgical intervention to improve quality of life, reduce pain, and restore function. 1