Is moderate osteoarthritis (OA) an indication for knee replacement?

From the Guidelines

Knee replacement surgery is typically indicated for severe osteoarthritis that causes significant pain and functional limitation despite conservative treatments, not specifically for moderated osteoarthritis. The decision for knee replacement is based on the severity of symptoms, functional limitations, and the impact on quality of life, rather than simply the radiographic stage of osteoarthritis. Patients should first try conservative treatments including physical therapy, weight loss if appropriate, activity modification, assistive devices (canes or braces), and medications such as acetaminophen, NSAIDs, or intra-articular corticosteroid injections. When these measures fail to provide adequate relief and the patient experiences persistent pain, significant difficulty with daily activities, and reduced quality of life, knee replacement may be considered. The decision should be individualized based on the patient's overall health status, age, activity level, and expectations, with the understanding that artificial joints have a limited lifespan of typically 15-20 years. A thorough evaluation by an orthopedic surgeon is necessary to determine if knee replacement is appropriate, as stated in the 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons clinical practice guideline for the optimal timing of elective hip or knee arthroplasty for patients with symptomatic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy is ineffective 1. Some key points to consider include:

• The guideline conditionally recommends proceeding directly to surgery without delay for additional nonoperative treatment of the joint problem in patients who have moderate-to-severe symptomatic OA or advanced symptomatic ON with secondary arthritis who are indicated for TJA and for whom nonoperative therapy has been ineffective 1.
• The guideline also conditionally recommends against delaying surgery to meet a rigid weight or body mass index threshold in patients with obesity and moderate-to-severe symptomatic OA or advanced symptomatic ON with secondary arthritis who are indicated for TJA 1.
• The evidence for each PICO question was very low quality except for physical therapy and nicotine cessation, which had low quality of evidence, primarily due to indirectness, as the studies that would address our questions directly would compare results in patients randomized to immediate arthroplasty versus those delayed for the proposed intervention 1. It is essential to prioritize the patient's quality of life, morbidity, and mortality when making decisions about knee replacement surgery, and to consider the latest evidence and guidelines when determining the best course of treatment 1.

From the Research

Indications for Knee Replacement

• Knee replacement surgery is frequently done and highly successful in relieving pain and improving knee function in people with advanced arthritis of the joint, with osteoarthritis being the most common indication for the procedure 2.
• The decision to undergo knee replacement surgery should be based on a thorough evaluation of the patient's condition, including the severity of symptoms, response to conservative treatment, and impact on quality of life 3, 4.
• Core indication criteria for total knee arthroplasty (TKA) in patients with knee osteoarthritis include:
  • Intermittent or constant knee pain for at least 3-6 months
  • Radiological confirmation of structural knee damage
  • Inadequate response to conservative treatment for at least 3-6 months
  • Adverse impact of knee disease on patient's quality of life for at least 3-6 months
  • Patient-reported suffering/impairment due to knee disease 3
• Additional indication criteria, contraindication criteria, and risk factors for adverse outcome should also be considered in the decision-making process 3.

Moderated OA and Knee Replacement

• Moderated osteoarthritis (OA) is not explicitly mentioned as an indication for knee replacement surgery in the provided studies.
• However, the studies suggest that knee replacement surgery is generally considered for patients with advanced OA who have failed conservative treatment and have significant symptoms and impairment 5, 2, 3, 4, 6.
• The decision to undergo knee replacement surgery should be individualized and based on a thorough evaluation of the patient's condition, including the severity of symptoms, response to conservative treatment, and impact on quality of life 3, 4.