Medical and Surgical Management of Osteoarthritis of Knees

Abstract

Background: Knee osteoarthritis (OA) is a progressive whole-joint degenerative disease and a major global cause of pain, disability, and reduced quality of life. Multiple medical, biologic, and surgical treatment options exist, yet optimal sequencing, patient selection, and timing of surgery remain areas of clinical uncertainty. A comprehensive synthesis of current evidence is required to guide individualized treatment pathways. Objective: To systematically review the literature on medical, intra-articular injection-based, and surgical management of knee osteoarthritis, with particular emphasis on comparative effectiveness, surgical indications, and optimal timing of operative intervention. Methods: This systematic review followed PRISMA guidelines. Searches of PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library were conducted for studies published between January 2000 and December 2024. Eligible studies included randomized controlled trials, cohort studies, and high-quality systematic reviews evaluating conservative management, intra-articular therapies, osteotomies, unicompartmental knee arthroplasty (UKA), and total knee arthroplasty (TKA). Data were extracted on patient characteristics, interventions, clinical outcomes, functional scores, and complications. Risk of bias was assessed using the Cochrane RoB tool, Newcastle–Ottawa Scale, and AMSTAR-2. A narrative synthesis was performed due to clinical heterogeneity. Results: A total of 432 records were identified, with 17 studies meeting inclusion criteria. Non-pharmacological strategies and NSAIDs provided symptomatic relief in early disease, while corticosteroids and hyaluronic acid offered short-term benefit. Platelet-rich plasma demonstrated longer-lasting improvements in early to moderate OA compared with corticosteroids and HA. High tibial and distal femoral osteotomies were effective joint-preserving procedures for younger, active patients with unicompartmental OA and malalignment. UKA yielded faster recovery and more natural knee kinematics in appropriately selected patients with isolated disease. TKA provided the most predictable long-term pain relief and functional improvement in advanced or multicompartmental OA, with implant survivorship exceeding 90% at 10–15 years. Timing and patient selection emerged as the most important determinants of surgical outcomes. Conclusion: Effective management of knee OA requires a stage-specific, individualized approach integrating conservative, biologic, and surgical strategies. Non-operative therapies remain foundational in early OA, while biologic injections may bridge symptoms until surgical intervention is appropriate. Osteotomy and UKA offer valuable joint-preserving options in selected patients, whereas TKA remains the definitive treatment for advanced disease. Aligning treatment modality with disease stage, alignment, compartment involvement, and patient goals optimizes long-term outcomes and joint function.