What is the best treatment approach for a patient with severe osteoarthritis of the medial joint and patella femoral joint with mild medial subluxation of the femur?

Treatment of Severe Medial and Patellofemoral Osteoarthritis with Mild Medial Subluxation

For a patient with severe tricompartmental osteoarthritis involving both the medial tibiofemoral and patellofemoral compartments with mild medial subluxation, total knee arthroplasty (TKA) is the definitive treatment when conservative measures have failed to provide adequate symptom control. 1

Initial Conservative Management

Before proceeding to surgery, a structured conservative approach should be implemented, though expectations for success should be tempered given the severity of disease described:

Non-Pharmacological Interventions (First-Line)

• Exercise therapy is strongly recommended and should include quadriceps strengthening, hip abductor/external rotator exercises, and balance training 1, 2
• Weight loss is strongly recommended if BMI ≥25 kg/m², as demonstrated in the case example where BMI reduction from 33 to 28 improved surgical candidacy 1
• Self-efficacy and self-management programs are strongly recommended to optimize patient engagement 1
• Physical therapy should be supervised initially, with progression to a home exercise program 1

Bracing Considerations

• Tibiofemoral bracing with hinges is strongly recommended for medial compartment OA to reduce medial compartment loading by 11-17% and improve pain 1, 3
• However, bracing is NOT recommended for tricompartmental disease - realignment braces work best for unicompartmental disease, not the severe tricompartmental involvement described here 3
• Given the patellofemoral involvement with subluxation, patellar taping may provide short-term pain relief (days, not weeks) 1, 2

Pharmacological Management

• Topical NSAIDs are strongly recommended as first-line pharmacologic treatment for knee OA 1, 4
• Oral NSAIDs are strongly recommended when topical agents are insufficient or when polyarticular involvement exists 1, 4
• Acetaminophen receives only conditional recommendation and is controversial in recent guidelines 1, 4
• Duloxetine receives conditional recommendation for pain management 1, 4
• Tramadol receives conditional recommendation but should be used cautiously 1, 4

Injection Therapy

• Intra-articular corticosteroid injections are strongly recommended for knee OA and can provide 2 months of relief as demonstrated in the case example 1, 4
• Hyaluronic acid injections are NOT recommended by AAOS guidelines with strong evidence against their use 2, 4

Surgical Management Algorithm

When to Proceed to Surgery

TKA should be considered when:

• Conservative management (exercise, weight optimization, NSAIDs, injections) has failed to provide adequate symptom control 1
• Pain significantly impacts activities of daily living and quality of life 1
• Radiographic evidence shows tricompartmental disease with severe joint space loss 1

Why TKA Over Other Surgical Options

• Arthroscopic debridement is not appropriate for severe tricompartmental OA 1
• Unicompartmental knee arthroplasty is contraindicated when both medial tibiofemoral AND patellofemoral compartments are severely affected 1
• Patellofemoral arthroplasty alone is inappropriate given the severe medial tibiofemoral involvement 5
• High tibial osteotomy is not suitable for tricompartmental disease with patellofemoral involvement 1

Preoperative Optimization

Before proceeding with TKA, optimize:

• Weight reduction to BMI <30 if possible (ideally <28 as in the case example) 1
• Diabetes control if present 1
• Quadriceps strengthening through structured physical therapy 1
• Discontinue opioids if being used - the case example specifically notes the patient never used narcotics, which is ideal 1

Expected TKA Outcomes

• Pain relief and functional improvement are expected in the vast majority of patients 1
• Independent ambulation without assistive devices by 3 months postoperatively 1
• No pain medication requirement by 3 months in many patients 1

Common Pitfalls to Avoid

• Do not delay TKA indefinitely in severe tricompartmental disease - the case example demonstrates that after conservative measures fail (exercise, weight loss, injections), proceeding to surgery is appropriate 1
• Do not prescribe valgus-directing braces for this patient - the evidence is inconclusive for medial unicompartmental OA, and this patient has tricompartmental disease 1, 3
• Do not use lateral heel wedges - they are specifically NOT recommended for medial compartmental OA 1
• Do not recommend glucosamine or chondroitin - there is no evidence of clinically significant benefit 2, 6
• Do not offer hyaluronic acid injections - strong evidence exists against their use 2

Clinical Decision Point

The key clinical decision is whether conservative management has been adequately attempted and failed. Given the description of "severe" osteoarthritis in both medial and patellofemoral compartments with subluxation, this patient likely requires TKA. However, a 3-6 month trial of comprehensive conservative management (weight loss, exercise, NSAIDs, corticosteroid injection) should be documented before proceeding to surgery, as demonstrated in the AAOS case example 1.