Treatment options for patients with advanced osteoarthritis who decline knee surgery

Abstract

Total knee arthroplasty is the treatment of choice for end-stage knee osteoarthritis (OA). However, only one-third of patients with knee OA are initially willing to undergo surgery. This narrative review aims to provide clinicians with a concise overview of the current non-surgical treatment options for knee OA based on clinical guidelines and research on novel medications and procedures. The international guidelines reviewed included those of the American Academy of Orthopedic Surgeons, American College of Rheumatology, European Alliance of Associations for Rheumatology, European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, United Kingdom National Institute for Health and Care Excellence, and Osteoarthritis Research Society International. Recommended nonsurgical treatment methods broadly encompass weight reduction strategies, oral and topical pharmaceutical treatments, intra-articular injections, bracing, and supplementation. This review also deals with research on novel nonsurgical knee OA treatment options that have not yet been universally addressed by guidelines, including minimally invasive therapies such as radiofrequency nerve ablation and genicular artery embolization, as well as pharmacological treatments such as glucagon-like peptide-1 receptor agonists, cannabinoids, and gabapentinoids, all of which clinicians can currently begin to apply in practice.

Keywords: Knee osteoarthritis; Osteoarthritis; Conservative treatment; Practice guidelines; Non-surgical treatment

Core Tip: Among the reviewed guidelines, there is agreement on first-line therapies, specifically weight loss, exercise, and topical non-steroidal anti-inflammatory drugs (NSAIDs). Secondary treatment options, such as oral NSAIDs, intra-articular corticosteroids, and acetaminophen, are recommended but with varying support. Beyond these therapies, the guidelines provide substantially varied recommendations. Emerging therapies that are not covered by current guidelines, such as minimally invasive interventions and novel pharmacological agents, offer promising alternative strategies.