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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The non-operative treatment of OA is often highly effective for all stages of the disease; 2) A non-operative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered.

There are many potential causes of pain in an arthritic knee. These include intra-articular (e.g. degenerative meniscal tears, loose bodies, synovitis) and extra-articular (tendonitis, e.g. ilio-tibial band syndrome, bursitis, muscle overload syndromes and referred pain) sites. The potential sources of pain in an arthritic knee produce a wide range of symptoms that are not necessarily correlated with objective measurements (e.g. x-rays, MRI). Moreover, the natural history of an arthritic knee is unpredictable and variable.

The treatment of the young, arthritic knee patient of all stages requires a systematic and consistent non-surgical approach. This approach includes the use of: 1) analgesics/anti-inflammatory agents; 2) activity modification; 3) alternative therapies; 4) exercise; 5) injections/lavage. The response to each form of non-surgical treatment is unpredictable at each stage (Kellgren 1–4) of OA. The placebo effect of each form of treatment, including the physician-patient interaction, is 50–60% in patients with mild-moderate OA.

The components of a non-operative treatment program include: 1) Education-emphasizing the importance of the patient taking charge of his/her care; 2) Appropriate activity/life style modifications-emphasizing the importance of remaining active while avoiding activities that aggravate symptoms (e.g. running to biking); 3) Medications-oral, topical, intra-articular; 4) Physical therapy. There are extensive data to support each of these interventions. The AAOS has issued guidelines based upon a review of the literature-based effectiveness of conservative interventions.