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Peer-reviewedCC BY-NC 4.0Therapeutic Advances in Musculoskeletal Disease

Towards a consensus definition of “refractory osteoarthritis”. A systematic review

  • Alberto Migliore1
  • Orazio De Lucia2
  • Christiaan Heusdens3,4
  • Abdulla Alrahoomi5
  • Francesco Benazzo6
  • Xavier Chevalier7
  • Demirhan Diracoglu8
  • Marek Krochmalski9
  • Bernard Maillet10
  • Thomas Neri11,12,13
  • Jose Luis Rodrigo14,15
  • Oliver Tobolski16
1 more authors
  • Yves Henrotin17
17 affiliations
  1. 1Rheumatology Unit, San Pietro Fatebenefratelli Hospital, Rome, Italy
  2. 2Department of Rheumatology and Medical Sciences, Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Milan, Italy
  3. 3Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
  4. 4Department of Orthopedics, Antwerp University Hospital, Edegem, Belgium
  5. 5Rehabilitation Hospital, Sheikh Tahnoun Bin Mohammed Medical City, Al Ain, UAE
  6. 6Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
  7. 7Department of Rheumatology, University UPEC Paris XII, Creteil, France
  8. 8Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
  9. 9Medical Magnus Clinic, Lodz, Poland
  10. 10Polyclinique saint Odilon, Moulins, France
  11. 11Hospices Civils de Lyon, Hôpital Lyon Sud, Chirurgie Orthopédique et Traumatologique, Lyon, France
  12. 12Claude Bernard University, Lyon, France
  13. 13Gustave Eiffel University, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France
  14. 14Jefe de Servicio de Cirugia Ortopédica y Traumatología Hospital Universitario Dr. Peset, Valencia, Spain
  15. 15Departamento Cirugia, Universidad de Valencia, Valencia, Spain
  16. 16Ortho4Sport, Sportorthopädische Privatpraxis, Köln-Rodenkirchen, Germany
  17. 17musculoSKeletal Innovative research lab (mSKIL), University of Liège, Liège, Belgium
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Abstract

Background: Osteoarthritis is a highly prevalent and debilitating joint disease. Some patients continue to experience substantial symptoms despite recommended, well-conducted treatment, but the absence of a widely accepted definition of “refractory OA” complicates their identification and management.

Objective: To establish an international, multidisciplinary consensus-based clinical definition of refractory knee osteoarthritis (OA).

Design: Systematic literature review followed by a two-round Delphi consensus study. Data Sources and Methods: PubMed, MEDLINE, PreMEDLINE, and Embase were searched without language or publication date restrictions to identify definitions and operational criteria for refractory, difficult-to-treat, or treatment-failure OA. The findings informed 15 statements developed by a 13-member international, multidisciplinary Technical Expert Panel, supported by a methodologist and a scientific librarian. Two anonymous voting rounds were conducted between June and August 2025, with consensus predefined as at least 85% of ratings within the same three-point region of a nine-point Likert scale. In round 1 participants could propose additional statements for voting. Final statements were discussed at the 8th International Symposium on Intra-Articular Treatment Congress in October 2025.

Results: Of 3047 records identified, 98 were screened and 43 publications (27 original articles and 16 reviews) were included. Consensus was achieved for 13 of 15 statements: nine in round 1 with unanimous agreement and four after revision in round 2. Osteoarthritis (OA) was assessed considering its causes, features, and impact on daily life. Experts took into account symptoms, progression, and treatment response, highlighting the need for optimal management. Refractory OA was defined as: persistent symptoms (at least 3-6 months) and altered quality of life despite optimized, guideline-based multimodal conservative OA therapy.

Conclusions: A consistent definition of refractory knee OA (ROA) can identify patients with high unmet needs, support medical and surgical decision-making, and standardize eligibility for future research.

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Cite

BibTeXRIS
BibTeX
@article{migliore2026towards,
  title = {{Towards a consensus definition of “refractory osteoarthritis”. A systematic review}},
  author = {Alberto Migliore and Orazio De Lucia and Christiaan Heusdens and Abdulla Alrahoomi and Francesco Benazzo and Xavier Chevalier and Demirhan Diracoglu and Marek Krochmalski and Bernard Maillet and Thomas Neri and Jose Luis Rodrigo and Oliver Tobolski and Yves Henrotin},
  journal = {Therapeutic Advances in Musculoskeletal Disease},
  year = {2026},
  month = sep,
  doi = {10.1177/1759720x261485403},
  url = {https://doi.org/10.1177/1759720x261485403},
  note = {CC BY-NC 4.0},
}
RIS
TY  - JOUR
TI  - Towards a consensus definition of “refractory osteoarthritis”. A systematic review
AU  - Alberto Migliore
AU  - Orazio De Lucia
AU  - Christiaan Heusdens
AU  - Abdulla Alrahoomi
AU  - Francesco Benazzo
AU  - Xavier Chevalier
AU  - Demirhan Diracoglu
AU  - Marek Krochmalski
AU  - Bernard Maillet
AU  - Thomas Neri
AU  - Jose Luis Rodrigo
AU  - Oliver Tobolski
AU  - Yves Henrotin
PY  - 2026
DA  - 2026/09/15
JO  - Therapeutic Advances in Musculoskeletal Disease
DO  - 10.1177/1759720x261485403
UR  - https://doi.org/10.1177/1759720x261485403
AB  - Background: Osteoarthritis is a highly prevalent and debilitating joint disease. Some patients continue to experience substantial symptoms despite recommended, well-conducted treatment, but the absence of a widely accepted definition of “refractory OA” complicates their identification and management.  Objective: To establish an international, multidisciplinary consensus-based clinical definition of refractory knee osteoarthritis (OA).  Design: Systematic literature review followed by a two-round Delphi consensus study. Data Sources and Methods: PubMed, MEDLINE, PreMEDLINE, and Embase were searched without language or publication date restrictions to identify definitions and operational criteria for refractory, difficult-to-treat, or treatment-failure OA. The findings informed 15 statements developed by a 13-member international, multidisciplinary Technical Expert Panel, supported by a methodologist and a scientific librarian. Two anonymous voting rounds were conducted between June and August 2025, with consensus predefined as at least 85% of ratings within the same three-point region of a nine-point Likert scale. In round 1 participants could propose additional statements for voting. Final statements were discussed at the 8th International Symposium on Intra-Articular Treatment Congress in October 2025.  Results: Of 3047 records identified, 98 were screened and 43 publications (27 original articles and 16 reviews) were included. Consensus was achieved for 13 of 15 statements: nine in round 1 with unanimous agreement and four after revision in round 2. Osteoarthritis (OA) was assessed considering its causes, features, and impact on daily life. Experts took into account symptoms, progression, and treatment response, highlighting the need for optimal management. Refractory OA was defined as: persistent symptoms (at least 3-6 months) and altered quality of life despite optimized, guideline-based multimodal conservative OA therapy.  Conclusions: A consistent definition of refractory knee OA (ROA) can identify patients with high unmet needs, support medical and surgical decision-making, and standardize eligibility for future research.
SN  - 1759-720X
SN  - 1759-7218
ER  -