Towards a consensus definition of "refractory osteoarthritis". A systematic review
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Published on: March 24, 2023
Alberto Migliore1, Orazio De Lucia2, Christiaan Heusdens3,4
1Rheumatology Unit, San Pietro Fatebenefratelli Hospital, Rome, Italy.
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.