What are the treatment options for an adult patient with knee osteoarthritis who has failed corticosteroid injections, declines surgical intervention, and requests a gel injection?

Treatment Approach for Knee Osteoarthritis After Failed Corticosteroids When Patient Declines Surgery and Requests Gel Injection

You should not routinely offer hyaluronic acid (gel) injections, as the American Academy of Orthopaedic Surgeons recommends against their use due to inconsistent evidence and inability to identify responders, but if the patient has exhausted all other conservative treatments and has significant surgical risk factors with mild radiographic disease, gel injections may be considered as a last resort. 1

Why Gel Injections Are Not First-Line

• The AAOS guideline is based on 17 high-quality and 11 moderate-quality studies that do not consistently support clinical benefit of hyaluronic acid 1
• The high number needed to treat and inability to predict which patients will respond makes routine use problematic 1
• NICE guidelines explicitly state that intra-articular hyaluronan injections are not recommended for treatment of osteoarthritis 2

What You Should Offer Instead (In Order of Priority)

1. Optimize Non-Pharmacological Core Treatments First

• Strengthening and low-impact aerobic exercise are strongly recommended by the American College of Rheumatology, with effect sizes of 0.52 for pain and 0.46 for disability 1, 3
• Weight loss if BMI ≥25 kg/m² with a minimum 5% reduction significantly improves function 1, 3
• Self-management educational programs to teach coping skills and activity modifications 1, 3
• These core treatments should be considered first for every person with osteoarthritis before escalating to other options 2

2. Topical NSAIDs as First-Line Pharmacologic Treatment

• Topical diclofenac gel is highly effective with minimal systemic toxicity, particularly appropriate for elderly patients or those with cardiovascular/GI risk factors 1, 4
• Minimal systemic absorption avoids gastrointestinal, cardiovascular, renal, and hepatic toxicity 4
• Pooled safety data shows similar low rates of adverse effects in high-risk patients compared to low-risk patients 4

3. Oral NSAIDs or COX-2 Inhibitors (If Topical Insufficient)

• Use at the lowest effective dose for the shortest duration 1, 4
• Mandatory proton pump inhibitor co-prescription for gastroprotection 1, 4
• Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing 4

4. Tramadol as Alternative Analgesic

• Conditionally recommended for moderate to severe pain 1, 3

5. Repeat Intra-Articular Corticosteroid Injections

• Can be repeated for moderate to severe pain flares, with benefits typically lasting only 3 months 1
• Short-term benefit is well established, with pain reduction at one week post-injection (WMD -21.91; 95% CI -29.93 to -13.89) 5
• Evidence of pain reduction extends from two to three weeks, but lack of evidence for efficacy beyond four weeks 5

If Patient Still Insists on Gel Injection After Exhausting Above Options

Hyaluronic acid should only be considered as a last resort, after failure of all conservative treatments listed above, and specifically in patients with:

• Mild radiographic disease 1
• Significant surgical risk factors that make them poor surgical candidates 1
• Understanding that cost-effectiveness is a major concern and they must be informed about the limited efficacy 6

Evidence Supporting Limited Use of Gel Injections

• HA products may have symptomatic effects and appear more durable than corticosteroids, with benefits between 5-13 weeks post-injection 3, 5
• Hyaluronic acid injections might provide pain reduction in mild OA of knee up to 24 weeks 6
• However, there is no data that HA injections will cause osteophytes to regress or cartilage to regenerate in patients with substantial and irreversible bone and cartilage damage 6

Common Pitfalls to Avoid

• Do not use hyaluronic acid as a routine next step after failed steroid injections, as this contradicts current evidence-based guidelines 1
• Do not neglect core non-pharmacological treatments such as exercise and weight loss, which are as important as any injection 1
• Do not forget gastroprotection when prescribing oral NSAIDs 1, 4

When to Reconsider Surgical Referral

• Referral for joint replacement should be reconsidered when joint symptoms substantially affect quality of life and symptoms remain refractory to comprehensive non-surgical treatment for 3-6 months 1
• Referral should occur before prolonged and established functional limitation develops 2, 1
• Patient-specific factors including age, sex, smoking, obesity, and comorbidities should not be barriers to referral 2