What is the appropriate management for a patient with left knee osteoarthritis of the medial femorotibial compartment, early patellofemoral osteoarthritis, an intra‑articular loose osseous body, a small joint effusion, and an incidental enchondroma of the proximal tibial shaft?

Management of Left Knee Osteoarthritis with Loose Body and Incidental Enchondroma

Begin with conservative non-operative management including weight loss, structured exercise with quadriceps strengthening, and analgesics, while the loose body should be considered for arthroscopic removal if symptoms persist after conservative treatment. 1

Immediate Management Priorities

Conservative Treatment Foundation

• Initiate self-management education programs and encourage active participation in self-care 1
• Prescribe weight loss if BMI is elevated (as demonstrated in the case example where BMI reduction from 33 to 28 improved outcomes before surgery) 1
• Start structured physical therapy focusing on quadriceps strengthening exercises 1
• Consider short-term patellar taping for pain relief, particularly given the early patellofemoral osteoarthritis 1

Pharmacological Management

• Use analgesics as first-line pain control 1
• Consider intra-articular corticosteroid injections for symptom relief (typically provides 2 months of relief as shown in clinical examples) 1
• Topical diclofenac sodium can be applied: 40 mg (2 pump actuations) on each painful knee, twice daily to clean, dry skin 2
• Do NOT prescribe glucosamine and/or chondroitin (no evidence of benefit) 1

Addressing the Loose Intra-Articular Body

Surgical Consideration

The loose osseous body warrants arthroscopic removal if conservative measures fail, as this is a specific indication where surgery may provide benefit 1

Key decision point: Patients may consider partial meniscectomy or loose body removal as conditions warrant, but should NOT undergo routine arthroscopy with débridement or lavage for osteoarthritis alone 1

Common Pitfall to Avoid

• Do not perform arthroscopic lavage or débridement for the osteoarthritis itself (no proven benefit) 1
• Medial joint line tenderness should not be used as the sole indication for arthroscopy 3
• The loose body removal is justified by mechanical symptoms, not the osteoarthritis

Managing Medial Compartment Osteoarthritis

Biomechanical Considerations

• The medial compartment bears 70-80% of joint load during gait, making it the most frequently affected compartment 3
• Do NOT prescribe lateral heel wedges for medial compartmental osteoarthritis (contraindicated) 1
• Evidence for valgus-directing braces is insufficient to make a recommendation 1

Advanced Imaging Considerations

MRI may be indicated if symptoms persist after conservative treatment, particularly to evaluate for bone marrow lesions and synovitis which correlate with pain in osteoarthritis patients 1

Managing Patellofemoral Osteoarthritis

Specific Interventions

• Patellofemoral osteoarthritis is a distinct clinical entity requiring targeted treatment 4, 5
• Physiotherapy has high-quality evidence for short-term relief (GRADE: high quality) 5
• Patellar taping has moderate-quality evidence for short-term relief (GRADE: moderate quality) 5
• Anterior knee pain during stairs and squatting is characteristic and should be specifically addressed 4, 6, 7

Monitoring Progression

• Patellofemoral progression occurs in approximately 15% of cases as isolated disease 8
• Multiple radiographic views (PA, lateral) are needed to fully assess progression across all compartments 8

Managing the Incidental Enchondroma

Reassurance and Surveillance

The enchondroma requires no active treatment - it is unchanged since prior imaging, shows benign features (intact cortex, no periosteal reaction), and is asymptomatic 1

Key reassuring features:

• Stable size over time
• Intact overlying cortex
• No periosteal reaction
• No suspicious features for malignancy 1

No further imaging or intervention is needed unless the lesion changes or becomes symptomatic

When to Consider Surgical Intervention

Indications for Arthroplasty

Consider total knee arthroplasty when:

• Conservative measures fail after adequate trial (typically 3-6 months)
• Progressive symptoms despite weight loss, exercise, and medical management
• Significant functional limitation affecting quality of life 1

The tricompartmental nature of this patient's disease (medial tibiofemoral, patellofemoral, plus loose body) suggests that if surgery becomes necessary, total knee arthroplasty with patellar resurfacing would be more appropriate than isolated procedures 1, 5

Preoperative Optimization

If surgery becomes necessary:

• Optimize weight and achieve good diabetic control if applicable 1
• Complete structured physical therapy for quadriceps strengthening 1
• Discontinue narcotic medications if possible 1

Small Joint Effusion Management

The small effusion is secondary to the osteoarthritis and loose body 1

• Ultrasound-guided aspiration can be performed if needed for symptom relief or diagnostic purposes 1
• Effusions are uncommon with isolated tendinopathy and suggest intra-articular pathology 3
• Consider aspiration if infection or crystal arthropathy needs exclusion 1