Navigating Conservative Treatment and Injection Therapy in Knee Osteoarthritis, With Brian T. Palumbo, MD

For patients with knee osteoarthritis (OA), the conservative treatment landscape has remained largely stable over the past decade — but within that relative stasis, extended-release intra-articular corticosteroid therapy represents one of the more meaningful advances, according to Brian T. Palumbo, MD, a fellowship-trained, board-certified orthopedic surgeon at Florida Orthopaedic Institute in Tampa, Florida, and assistant professor in the Department of Orthopaedic Surgery and Sports Medicine at the University of South Florida.

In a conversation with HCPLive, Palumbo described the foundation of conservative OA management as largely unchanged: weight loss, activity modification, strength and functional training, and general optimization of health and well-being remain the cornerstone interventions. On the pharmacologic side, conventional intra-articular corticosteroid injections continue to serve a practical role — effective and inexpensive, but limited in duration, with pain relief that in his experience may extend 3 to 9 months in patients with advanced disease before requiring repeat intervention. Other specialty injection options, including hyaluronic acid and platelet-rich plasma, have accumulated a more mixed evidence base, and Palumbo characterized the literature on many of these agents as inconclusive.

Against that backdrop, he highlighted triamcinolone acetonide extended-release injectable suspension (Zilretta) as one of the few genuine advances in conservative knee OA therapy in recent years. Zilretta, FDA-approved in October 2017, is the first and only extended-release intra-articular corticosteroid for OA knee pain, formulated using poly(lactic-co-glycolic acid) microsphere technology that enables sustained local drug release in the synovium while reducing systemic corticosteroid exposure. In the pivotal phase 3 trial, a single intra-articular injection of triamcinolone acetonide extended-release 32 mg demonstrated statistically significant improvement in mean average daily pain intensity at week 12 versus placebo, with improvements in WOMAC pain, stiffness, and physical function versus both placebo and conventional triamcinolone acetonide crystalline suspension maintained through week 24.

Palumbo's approach to injection therapy is age-stratified. In patients under 60 — often highly active and presenting with earlier-stage disease — he favors the most conservative possible interventions, using injections sparingly and prioritizing strength and functional rehabilitation to defer surgical intervention. In older patients, who more commonly present with advanced radiographic and symptomatic disease, he takes a more consistently interventional posture, using injection therapy more regularly as part of an ongoing symptom management strategy. He noted that this older cohort represents those most commonly being counseled toward total hip or knee arthroplasty when conservative measures no longer provide adequate relief. The distinction reflects not just disease severity but patient goals: younger patients typically want functional preservation and delay of surgery, while older patients often prioritize pain control and quality of life.

“My experience with regular corticosteroids is [they are] very effective and cheap, although not incredibly long lasting. If we get 3, 6, 9, months of relief for patients with severe arthritis, that's pretty good. But as far as long lasting, conservative treatments, there's just not a ton out there,” Palumbo said.

Palumbo’s relevant disclosures include DJO Orthopedic and Conformis.

Reference

Conaghan PG, Hunter DJ, Cohen SB, et al. Effects of a single intra-articular injection of a microsphere formulation of triamcinolone acetonide on knee osteoarthritis pain: a double-blinded, randomized, placebo-controlled, multinational study. J Bone Joint Surg Am. 2018;100(8):666-677. doi:10.2106/JBJS.17.00154