Dr. N. K. Agarwal’s “Ludhiana – Protocol” for Knee Preservation: A Multimodal Approach Without Major Surgery
Dr. N. K. Agarwal’s “Ludhiana – Protocol” for Knee Preservation: A Multimodal Approach Without Major Surgery
Knee osteoarthritis does not always mean that knee replacement is the only option. In appropriately selected patients, a knee-preservation approach may combine several treatments to address pain, joint function, mechanical alignment and also systemic inflammation.
Osteoarthritis of the Knee is no longer considered only wear and tear of cartilage. It has been established to be the result of a systemic inflammatory process which also involves inflammation of all the structures in and around the joint.
This is the philosophy behind Dr. N. K. Agarwal’s “Ludhiana – Protocol for Multimodal Knee Preservation”, an integrated clinical treatment pathway developed and implemented by Dr. N. K. Aggarwal at N K Aggarwal Joints & Spine Centre, Ludhiana. The protocol combines both Local and systemic treatments. In selected treatments in a structured sequence, the exact approach is individualised and tailored to the patient’s condition.
The Ludhiana Protocol
Local Treatment: Local treatment includes arthroscopic joint lavage followed by injections of high molecular weight Hyaluronic Acid, PRP/GFC and Ozone-Oxgen mixture. Realignment procedure is also done when necessary.
1. Knee Cleaning: Arthroscopic Joint Lavage
Arthroscopic joint lavage is also described as limited joint debridement. The procedure is performed using ozonized saline, under IV antibiotic cover and local anaesthesia. The objective is to flush out inflammatory enzymes and debris from wear and tear of meniscus and articular cartilage. This reduces the inflammatory load in the joint, improves the environment and optimises the efficacy of Ozone, Hyaluronic Acid and PRP/GFC injections. Arthroscopic lavage and debridement have been studied in knee osteoarthritis, including non-end-stage disease.[1][2]
2. “Grease” Injection: High Molecular Weight Hyaluronic Acid
The next step involves High Molecular Weight Hyaluronic Acid (HA), commonly explained to patients as a “grease” or lubrication injection. Hyaluronic acid is naturally present in synovial fluid and contributes to joint lubrication and its viscoelastic properties. Depletion of natural Hyaluronic acid is usually the starting point of osteoarthritis of the knee. HA injections have been extensively studied for knee osteoarthritis, with systematic reviews reporting improvements in pain and function in selected patients.[3] Ludhiana Protocol, uses HA to support the lubrication and joint environment.
3. PRP/Growth Factor Concentrate: Supporting the Biological Response
Platelet-Rich Plasma (PRP) or autologous Growth Factor Concentrate is prepared from the patient’s own blood. These preparations contain biologically active substances that may support the biological environment of the joint and help in repair and restoration of damaged cartilage. Systematic reviews and meta-analyses have reported improvements in pain and function following PRP treatment in selected patients with knee osteoarthritis.[4][5]
The protocol combines PRP/Growth Factor Concentrate with HA. A 2024 systematic review and meta-analysis reported better outcomes for several pain and functional measures with PRP plus HA compared with HA/PRP or GFC alone.[6]
4. Oxygen-Ozone Therapy
Ozone therapy has been studied in knee osteoarthritis, with systematic reviews reporting improvements in pain and function, particularly over the short term.[7][8] Recent research has also examined the duration of these effects.[9] It has been further reported in many studies that intra articular injections of Hyaluronic Acid and Ozone Oxygen mixture, give much better result when used in combination, compared to when each one is used alone.[18]
5. Knee Alignment
The protocol also assesses knee alignment and the way forces are distributed through the joint. Varus or valgus malalignment can increase loading on specific compartments of the knee, and research has associated malalignment with progression of knee osteoarthritis.[10][11] When appropriate, mechanical overload may be managed through non-operative measures such as unloader braces, selected orthotics and targeted gait or neuromuscular rehabilitation. [12][13][14]. As part of the Ludhiana Protocol, a minimally invasive approach is used for correction of varus/valgus deformity by pie crusting of ligaments under local anaesthesia.
Systemic Treatment: Systemic treatment targets Systemic inflammation. The medications include low dose, low frequency DMARDS, and other supplementary/supportive drugs which are customized to each patient’s needs.
Why a Multimodal Approach?
The Ludhiana Protocol brings different treatment concepts together, for local and systemic treatment of Osteoarthritis of Knee. Various modalities used have been proven to be complementary and synergistic. They improve and potentiate each other’s efficacy. The purpose is to create a patient-specific knee-preservation pathway, rather than relying on a single treatment.
Is the Ludhiana Protocol Suitable for Everyone?
Treatment depends on the patient’s symptoms, age, X-rays or MRI findings, severity of arthritis, alignment, activity level and overall health.
If started during the early phase of disease it can help avoid the need for Knee Replacement Surgery. Even if started at later stages, it can help postpone the need for knee replacement surgery. The protocol is especially useful for patients who are unfit for major surgery.
This treatment is not suitable for advanced arthritis with severe deformity and structural damage.
The individual treatments within the protocol have been studied in published medical literature. Dr. N. K. Agarwal has integrated these treatment concepts into a synergistic clinical pathway, which we call “Ludhiana Protocol.”
A Patient-Specific Approach to Knee Preservation is planned. The central idea of the Ludhiana Protocol is simple: Treat the knee as a whole, not just the pain.
Medical References
[1] Ike RW, Arnold WJ, Rothschild EW, Shaw HL. Tidal irrigation versus conservative medical management in patients with osteoarthritis of the knee: a prospective randomized study. The Journal of Rheumatology. 1992;19(5):772-779.
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[2] Frías G, Font P, Muñoz-Gomariz E, et al. Assessing the efficacy of non-arthroscopic joint lavage in patients with osteoarthritis of the knee. Reumatología Clínica. 2009;5(5):189-193.
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[3] Migliorini F, Maffulli N, Schäfer L, et al. Less Pain with Intra-Articular Hyaluronic Acid Injections for Knee Osteoarthritis Compared to Placebo: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Pharmaceuticals. 2024;17(11):1557.
PubMed:
[4] Oeding JF, Varady NH, Fearington FH, et al. Platelet-Rich Plasma Versus Alternative Injections for Osteoarthritis of the Knee: A Systematic Review and Statistical Fragility Index-Based Meta-analysis of Randomized Controlled Trials. American Journal of Sports Medicine. 2024;52(12):3147-3160.
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[5] Pelluri R, Sridevi B, Guntupalli C, et al. Effect of platelet-rich plasma versus placebo or corticosteroid for knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Journal of Clinical Orthopaedics and Trauma. 2025;62:102870.
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[6] Gao J, Ma Y, Tang J, et al. Efficacy and safety of platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: a systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery. 2024;144:3947-3967.
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[7] Lino VTS, Marinho DS, Rodrigues NCP, Andrade CAF. Efficacy and safety of ozone therapy for knee osteoarthritis: an umbrella review of systematic reviews. Frontiers in Physiology. 2024;15:1348028.
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[8] Migliorini F, Giorgino R, Mazzoleni MG, et al. Intra-articular injections of ozone versus hyaluronic acid for knee osteoarthritis: a level I meta-analysis. European Journal of Orthopaedic Surgery & Traumatology. 2024;35:20.
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[9] Chen T, Tao D, Deng Z, et al. The time-effect relationship of intra-articular ozone injection for knee osteoarthritis: a systematic review and meta-analysis. 2026.
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[10] Sharma L, Song J, Felson DT, et al. The Role of Knee Alignment in Disease Progression and Functional Decline in Knee Osteoarthritis. JAMA. 2001;286(2):188-195.
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[11] Tanamas SK, Hanna FS, Cicuttini FM, et al. Does Knee Malalignment Increase the Risk of Development and Progression of Knee Osteoarthritis? A Systematic Review. Arthritis & Rheumatism. 2009;61(4):459-467.
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[12] Petersen W, Ellermann A, Zantop T, et al. Biomechanical effect of unloader braces for medial osteoarthritis of the knee: a systematic review. Archives of Orthopaedic and Trauma Surgery. 2016;136:649-656.
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[13] Rynne R, Le Tong G, Cheung RTH, Constantinou M. Effectiveness of gait retraining interventions in individuals with hip or knee osteoarthritis: A systematic review and meta-analysis. Gait & Posture. 2022;95:164-175.
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[14] Castro RQ, Oliveira JVV, Veras PM, et al. Effect of gait retraining strategies on clinical and biomechanical outcomes in subjects with knee osteoarthritis: a systematic review with meta-analysis and GRADE recommendations. Disability and Rehabilitation. 2025;47(24):6271-6279.
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[15] Sconza C, Parente A, Marotta N, Farì G, Scaturro D, Vecchio M, Mauro GL, Ammendolia A, Baricich A, de Sire A. Intra-articular injections of oxygen-ozone versus hyaluronic acid for the treatment of knee osteoarthritis: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation. 2026;39(1):216-227. doi:10.1177/10538127251358732.
[16] [ScienceDirect article corresponding to PII S096522992500113X].
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[17] Raeissadat SA, Rayegani SM, Forogh B, Hassan Abadi P, Moridnia M, Rahimi Dehgolan S. Intra-articular ozone or hyaluronic acid injection: Which one is superior in patients with knee osteoarthritis? A 6-month randomized clinical trial. Journal of Pain Research. 2018;11:111-117. doi:10.2147/JPR.S142755.
[18] Giombini A, Menotti F, Di Cesare A, Giovannangeli F, Sorrenti D, Bellomini M, et al. Comparison between intra-articular injection of hyaluronic acid, oxygen ozone, and the combination of both in the treatment of knee osteoarthrosis. Journal of Biological Regulators and Homeostatic Agents. 2016;30(2):621-625.