Treating knee osteoarthritis: from conservative care to surgery

Conservative treatments: relieving pain and maintaining mobility

The goal of non-surgical treatments is to reduce pain, preserve joint function , and maintain quality of life. These treatments are tailored to each case by the physician, taking into account the patient's profile, symptom intensity, and comorbidities.

Medication

• Analgesics, including paracetamol, are recommended as a first-line treatment by the HAS (2019 guidelines) due to their favorable safety profile. If ineffective, NSAIDs may be prescribed for a short duration under medical supervision.
• The non-steroidal anti-inflammatory drugs (NSAIDs) may be prescribed during more intense painful phases. Their prolonged use is medically supervised.
• slow-acting anti-osteoarthritic drugs (glucosamine, chondroitin, diacerein) are subject to evaluations with results that vary between studies. Their prescription is at the discretion of the primary care physician or rheumatologist.

Intra-articular injections

• corticosteroid injections act on joint inflammation. They are particularly indicated during congestive flare-ups (sudden swelling with intense pain), with a limited frequency over time.
• hyaluronic acid injections (viscosupplementation) aim to improve joint lubrication. No longer covered by national health insurance since December 2017, their effectiveness remains variable depending on the patient and the studies.

Physical therapy and orthotics

• Physical therapy, prescribed by a doctor, plays a central role in conservative management: muscle strengthening and maintaining joint mobility help reduce pain and preserve knee function.
• orthopedic insoles are indicated when misalignment of the lower limb overloads a joint compartment. The knee brace can provide mechanical support in certain situations, particularly for patellofemoral osteoarthritis.

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When should surgery be considered?

Surgery is not an inevitable step in knee osteoarthritis. It is considered when several criteria converge:

• Failure of conservative treatments : pain persists despite well-managed and appropriate medical care ‍
• Significant functional impairment : significant impact on daily activities, sleep, or professional life ‍
• An advanced radiological stage, consistent with the symptoms experienced

Age is a central factor in the discussion. For a young, active patient (under 55-60 years old), a realignment osteotomy may be preferable to preserve the joint for as long as possible. For an older patient with severe, global knee osteoarthritis, the total knee replacement is the most frequently discussed option.

There is no single threshold for determining the "right time" for surgery; it is a personalized decision that takes into account clinical data, the radiological stage, and the level of constraint each patient is willing to accept. Faced with this decision, many patients feel a legitimate sense of hesitation and want to ensure that the procedure is truly indicated in their specific case.

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Osteotomy, unicompartmental replacement, total replacement: a personalized decision

These three procedures are not interchangeable. Each corresponds to a specific clinical situation.

Realignment osteotomy is intended for younger patients (generally under 60) with osteoarthritis localized to a single compartment and a misalignment of the lower limb (bow-legged or knock-kneed). The procedure corrects the leg axis to shift mechanical stress onto the healthy joint compartment. It does not replace the cartilage but can significantly delay the need for a replacement.

Unicompartmental knee replacement is suitable for patients with isolated damage to a single compartment (most often the medial femorotibial joint), with a generally preserved leg axis. Less invasive than a total replacement, it preserves the cruciate ligaments and unaffected joint structures. It is not indicated in cases of global knee osteoarthritis.

Total knee replacement is the most common option for advanced osteoarthritis affecting multiple compartments. It replaces all joint surfaces and is recommended when other options are no longer suitable.

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A second opinion from an orthopedic surgeon specializing in knee surgery allows for a comparison of these options within the patient's specific context: age, leg axis, affected compartments, radiological stage, and functional expectations.