What is the best treatment approach for a patient with chondrocalcinosis of the knee?

Treatment of Chondrocalcinosis of the Knee

For chondrocalcinosis of the knee, treatment depends entirely on clinical presentation: asymptomatic chondrocalcinosis requires no treatment, acute CPP crystal arthritis demands joint aspiration with intra-articular corticosteroid injection as first-line therapy, and chronic symptomatic disease should be managed identically to osteoarthritis with NSAIDs, exercise, and weight loss. 1

Asymptomatic Chondrocalcinosis (Radiographic Finding Only)

• No treatment is required or recommended for asymptomatic chondrocalcinosis detected incidentally on imaging 1
• This is simply an age-related radiographic finding in most elderly patients and does not predict future symptomatic disease 1

Acute CPP Crystal Arthritis (Pseudogout Attack)

First-Line Treatment

• Joint aspiration combined with intra-articular corticosteroid injection is the optimal and safest treatment for acute monoarticular or oligoarticular attacks 1
• Apply ice or cool packs to the affected joint 1
• Temporary rest of the joint 1
• For many patients, these local measures alone are sufficient without systemic therapy 1

Second-Line Systemic Options (when intra-articular injection not feasible)

• Oral NSAIDs with gastroprotective treatment if indicated (particularly in elderly patients with comorbidities) 1
• Low-dose oral colchicine: 0.5 mg up to 3-4 times daily, with or without an initial 1 mg loading dose 1
  • Both NSAIDs and colchicine are effective but their use is severely limited by toxicity in older patients who often have renal impairment and other comorbidities 1

Third-Line Options (for polyarticular attacks or contraindications to above)

• Short tapering course of oral corticosteroids 1
• Parenteral corticosteroids 1
• Parenteral ACTH (adrenocorticotropic hormone) 1

Critical Pitfall: Avoid oral narcotics including tramadol—they increase adverse events without improving pain or function 1

Prophylaxis Against Recurrent Acute Attacks

• Low-dose oral colchicine (0.5-1 mg daily) for patients with frequent recurrent attacks 1
• Low-dose oral NSAIDs with gastroprotective treatment if indicated 1

Chronic CPP Crystal Inflammatory Arthritis

Pharmacological Options (in order of preference)

1. Oral NSAIDs (with gastroprotective treatment if indicated) and/or colchicine (0.5-1.0 mg daily) 1
2. Low-dose corticosteroids 1
3. Methotrexate 1
4. Hydroxychloroquine 1

Osteoarthritis with CPPD

The management objectives and treatment options are identical to osteoarthritis without CPPD 1

Non-Pharmacological Treatment (Strongly Recommended)

• Patient education programs to improve pain (strong recommendation) 1
• Quadriceps strengthening exercises and range of motion exercises to reduce pain and improve function 1
• Sustained weight loss for overweight/obese patients (moderate recommendation) 1
• Canes may be used to improve pain and function (moderate recommendation) 1

Pharmacological Treatment

• Oral acetaminophen as first-line analgesic (strong recommendation) 1
• Oral NSAIDs when acetaminophen insufficient or for moderate-to-severe pain (strong recommendation) 1
  • Must not be contraindicated
  • Use gastroprotective treatment in at-risk patients 1

Interventional Options

• Intra-articular corticosteroid injections for symptomatic effusions or acute exacerbations 1

Critical Pitfall: Do NOT routinely use hyaluronic acid injections—the 2022 AAOS guidelines recommend against routine use due to inconsistent evidence 1

Screen for Associated Metabolic Conditions

If detected, treat underlying conditions including: 1

• Hyperparathyroidism
• Hemochromatosis
• Hypomagnesemia

Key Clinical Distinctions

The EULAR guidelines emphasize that optimal treatment requires tailoring to the specific clinical phenotype: 1

• Isolated chondrocalcinosis = no treatment
• Acute CPP crystal arthritis = local measures ± systemic anti-inflammatory therapy
• Chronic CPP crystal inflammatory arthritis = prophylactic anti-inflammatory therapy
• OA with CPPD = standard OA management

Common Pitfall: Unlike gout, there is currently no treatment that modifies CPP crystal formation or promotes crystal dissolution 1