Surgical Versus Non-Surgical Treatments for the Knee: Which Is More Effective?

Abstract

Osteoarthritis is a degenerative joint disease that is extremely prevalent in society. It affects more than 25% of Americans above the age of 18 years. According to July 2020 publication by the Centers for Disease Control (CDC), osteoarthritis affects approximately 325 million Americans. One of the organs that is most affected by osteoarthritis is the knee. Over the years, we have developed non-surgical treatments, such as physical therapy (PT) and injections, and surgical treatments, such as total knee arthroplasty (TKA) and arthroscopic lavage, for knee osteoarthritis (KOA). If a patient fails with non-surgical options, which are tried first to avoid the risks of surgery, the patient may be considered for knee surgery. This article will investigate the different non-surgical options and TKA as treatment options for KOA based on current literature. The goal of this paper is to be a comprehensive resource for physicians and patients with KOA to make an informed decision. A systematic literature search was conducted using PubMed. The search terms were based on the type of treatments for KOA. To find articles that compared TKA to non-surgical treatments, the terms included "osteoarthritis", "total knee", and "non-surgical treatments," in combination. For other non-surgical treatments such as PT, weight reduction, and injections, a combination of the treatment, "osteoarthritis", and "knee" were included in the search. For the tier 1 process, any randomized controlled trials were included. Any case reports, observational studies, and cross-sectional studies were eliminated from the search. For the tier 2 review process, any articles that did not have relevance to the topic were eliminated after reading the abstracts of the articles. After review of the literature, the data seem to suggest that TKA with 12 weeks of non-surgical treatment improved pain and functionality of the knee more than just 12 weeks of non-surgical treatment when followed up at 12 and 24 months. However, non-surgical treatment before TKA delays the need for surgery. Supervised PT, either in a group or individual format, has been shown to delay TKA in 95% patients in the group that received PT at the end of one year. In addition, weight reduction has been shown as an effective strategy to improve pain and functionality in KOA patients, which decreases the urgency for surgery. Furthermore, platelet-rich plasma (PRP) injections have been shown to have long-term symptomatic relief for KOA compared to hyaluronic acid (HA) and corticosteroid injections. However, HA and corticosteroid injections are beneficial in treating KOA more than receiving no treatment. Physicians often have difficulty deciding whether to pursue conservative or surgical treatment for patients with KOA. The non-surgical treatments explored in this review - PT, injections, and weight reduction - can provide symptomatic relief and, in some cases, delay the need for surgical intervention. However, based on some randomized clinical trials mentioned in the article, patients receiving TKA have more relief, better quality of life, and improved functionality compared to non-surgical therapy. However, a critical review of this important field of debate shows that there are limited randomized controlled studies comparing the effectiveness of TKA and non-surgical treatments for KOA. We believe that this controversial topic needs further clinical investigation.

Keywords: knee injections; knee osteoarthritis (koa); physical therapy; surgical treatment; weight loss.

Figure 1. PRISMA flow chart depicting detailed methodology

PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses

Figure 2. Comparison of WOMAC scores at baseline and after eight weeks for PT arm (individual PT + group PT) and control arm

WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; PT, physical therapy [14]

Figure 3. Comparison of WOMAC scores between individual PT versus group PT in patients with knee osteoarthritis

WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; PT, physical therapy [16]

Figure 4. Comparison of KOOS scores for tele-health and OBPT groups with knee osteoarthritis

KOOS, Knee Injury and Osteoarthritis Outcome Score; OBPT, office-based PT [19]

Figure 5. Comparison of WOMAC pain and function scores for individuals with different weight loss % at 18 months

WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index [26]

Figure 6. Comparison of WOMAC scores between diet only versus exercise only versus diet + exercise groups at baseline and 18 months

WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index [29]

Figure 7. Comparison of WOMAC scores after injection of triamcinolone hexacetonide and methylprednisolone

WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index [34]

Figure 8. Comparison of KSS scores after PRP and CS injections in patients with knee osteoarthritis

KSS, Knee Society Score; PRP, platelet-rich plasma; CS, cortisone [53]

Figure 9. Comparison between TKA group and non-surgical treatment group in terms of KOOS subscale scores at the 12-month follow-up

TKA, total knee arthroplasty; KOOS, Knee Injury and Osteoarthritis Outcome Score [57]

Figure 10. Comparison between TKA group and non-surgical treatment group in terms of KOOS subscale scores at the 24-month follow-up

TKA, total knee arthroplasty; KOOS, Knee Injury and Osteoarthritis Outcome Score [59]

Figure 11. Comparison between supervised non-surgical treatment group and non-supervised non-surgical treatment group in terms of KOOS subscale scores at the 24-month follow-up

KOOS, Knee Injury and Osteoarthritis Outcome Score [59]