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American Academy of Orthopaedic SurgeonsOrthopaedic Surgery2022advanced

Surgical Management of Knee Osteoarthritis

Published by American Academy of Orthopaedic Surgeons · GRADE Evidence-to-Decision Framework

23Recommendations
510References
2Tables
1Figures
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Summary

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Osteoarthritis is a progressive disease causing joint pain, stiffness, and difficulty with movement. This guideline systematically reviews evidence to provide recommendations for its surgical management, prioritizing pain relief and improved function while balancing potential operative benefits and harms.

OsteoarthritisKneeTotal Knee ArthroplastyTKAUnicompartmental Knee ArthroplastyUKAOrthopaedics

Key Takeaways

  • 1
    Drains should not be used routinely in total knee arthroplasty (TKA).
  • 2
    Tranexamic acid (TXA) is strongly recommended to decrease postoperative blood loss and transfusions.
  • 3
    Peripheral nerve blockades and periarticular local infiltration reduce postoperative pain and opioid requirements.
  • 4
    Similar outcomes are reported between cemented/cementless components, cruciate retaining/posterior stabilized designs, and kinematic/mechanical alignment.
  • 5
    Unicompartmental knee arthroplasty (UKA) provides improved short-term outcomes for medial compartment OA but may carry a higher long-term revision rate compared to TKA.
  • 6
    Preoperative opioid use and smoking should be mitigated to avoid higher complication rates.

What's New in This Version

This updated clinical practice guideline replaces the second edition completed in 2015 ('Surgical Management of Osteoarthritis of the Knee'). This update incorporated evidence published since 2015 and adopted the use of the GRADE Evidence-to-Decision Framework, moving away from previous rigid language stems to incorporate additional clinical context and factors into recommendation strengths.

Key Recommendations

DRAINS

  • 1

    Drains should not be used with total knee arthroplasty because there is no significant difference in complications or outcomes.

    ModerateEvidence: HighIntervention

CEMENTLESS FIXATION: CEMENTED FEMORAL & TIBIAL COMPONENTS VS. CEMENTLESS FEMORAL & TIBIAL COMPONENTS

  • 2

    Cemented femoral and tibial components or cementless femoral and tibial components in knee arthroplasty show similar rates of functional outcomes, complications, and reoperations, and conflicting evidence in comparative studies.

    ModerateEvidence: HighIntervention

CEMENTLESS FIXATION: ALL CEMENTED COMPONENTS VS. HYBRID FIXATION (CEMENTLESS FEMORAL COMPONENT)

  • 3

    Cemented femoral and tibial components or hybrid fixation (cementless femur) in total knee arthroplasty show similar functional outcomes and rates of complications and reoperations.

    ModerateEvidence: HighIntervention

UNICOMPARTMENTAL VS. TOTAL KNEE ARHTROPLASTY

  • 4

    The practitioner can use unicompartmental arthroplasty vs total knee arthroplasty for patients with predominantly medial compartment osteoarthritis, as evidence reports improved patient reported and functional outcomes in the short term; however, long-term rates of revision in unicompartmental knee arthroplasty may be higher than total knee arthroplasty.

    ModerateEvidence: HighIntervention

PERIPHERAL NERVE BLOCKADE (PNB)

  • 5

    Peripheral nerve blockades for total knee arthroplasty lead to decreased postoperative pain and opioid requirements with no difference in complications or outcomes.

    StrongEvidence: HighIntervention

PERIARTICULAR LOCAL INFILTRATION

  • 6

    Periarticular injections used in total knee arthroplasty lead to decreased postoperative pain and opioid requirements.

    StrongEvidence: HighIntervention

TRANEXAMIC ACID

  • 7

    In patients with no known contraindications, tranexamic acid (TXA) should be used because its use decreases postoperative blood loss, postoperative drain collection, and reduces the necessity of postoperative transfusions following total knee arthroplasty (TKA).

    StrongEvidence: HighIntervention

SURGICAL NAVIGATION

  • 8

    There is no difference in outcomes, function, or pain between navigation and conventional techniques.

    ModerateEvidence: HighIntervention

RISK FACTORS: BODY MASS INDEX (BMI)

  • 9

    There is no difference in postoperative functional scores between patients with a BMI < 30 and obese patients (BMI 30-39.9); however, there may be increased risk of complications in morbidly obese patients (≥40), in particular, surgical site infections.

    StrongEvidence: HighRisk Factor

RISK FACTORS: DIABETES/HYPERGLYCEMIA

  • 10

    Optimization of perioperative glucose control (<126mg/dl) after total knee arthroplasty should be attempted in diabetic patients and non-diabetic patients with hyperglycemia, as it can lead to less favorable postoperative outcomes and higher complication rates.

    StrongEvidence: HighIntervention

TOURNIQUETS

  • 11

    Evidence reports that there is no difference in outcomes, function, pain, or blood transfusions between the use of tourniquets and nonuse of tourniquets.

    StrongEvidence: HighIntervention

PATELLAR RESURFACING

  • 12

    Evidence reports that there is no difference between patellar surfacing or non-patellar resurfacing in total knee arthroplasty.

    StrongEvidence: HighIntervention

CRUCIATE RETAINING ARTHROPLASTY

  • 13

    Cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasty (TKA) designs have similarly efficacious/favorable postoperative outcomes.

    StrongEvidence: HighIntervention

PATIENT SPECIFIC TECHNOLOGY

  • 14

    The practitioner should not use patient specific technology (e.g., guides, cutting blocks) because there is no significant difference in patient outcomes, function, or pain as compared to conventional total knee arthroplasty (TKA). Additionally, it does not reduce operating time, blood loss, length of stay, and/or complications.

    StrongEvidence: HighIntervention

KINEMATIC VS. MECHANICAL ALIGNMENT

  • 15

    There is no difference in composite/functional outcomes or complications between kinematic or mechanical alignment principles in total knee arthroplasty.

    StrongEvidence: HighIntervention

PRE-OPERATIVE OPIOID USE

  • 16

    Cessation of preoperative opioids should be attempted for total knee arthroplasty (TKA), as preoperative opioid use demonstrates decreased postoperative functional scores and increased pain scores and complications.

    ModerateEvidence: LowIntervention

OPTIONS: CEMENTLESS FIXATION: ALL CEMENTLESS COMPONENTS VS. HYBRID FIXATION

  • 17

    All cementless components or hybrid fixation (cementless femur) in total knee arthroplasty show similar functional outcomes and rates of complications and reoperations.

    LimitedEvidence: ModerateIntervention

OPTIONS: UNICOMPARTMENTAL KNEE ARTHROPLASTY VS. HIGH/PROXIMAL TIBIAL OSTEOTOMY

  • 18

    The practitioner could use unicompartmental knee arthroplasty or tibial osteotomy for the treatment of knee osteoarthritis.

    LimitedEvidence: ModerateIntervention

OPTIONS: BILATERAL SIMULTANEOUS TOTAL KNEE ARTHROPLASTY VS. STAGED

  • 19

    In the absence of reliable evidence, it is the opinion of the workgroup that simultaneous bilateral total knee arthroplasty (TKA) could be performed vs. staged (>90 days) bilateral TKA in appropriately selected patients but should be performed with caution and should be avoided with patients who are at high risk of cardiopulmonary complications.

    ConsensusEvidence: LowIntervention

OPTIONS: RISK FACTORS: SMOKING

  • 20

    Smoking cessation should be attempted before total knee arthroplasty, as a history of smoking may result in higher complications, lower functional scores, higher pain scores, and SSIs.

    ConsensusEvidence: LowIntervention

OPTIONS: DISCHARGE FACILITIES / DISPOSITION

  • 21

    Discharge to home, with or without home services, is associated with fewer adverse events compared to discharge to acute rehabilitation facility or skilled nursing facility.

    LimitedEvidence: LowIntervention

OPTIONS: ROBOTICS IN TOTAL KNEE ARTHROPLASTY

  • 22

    Evidence suggests no significant difference in function, outcomes, or complications in the short term between robotic assisted and conventional total knee arthroplasty (TKA).

    LimitedEvidence: HighIntervention

OPTIONS: ROBOTICS IN UNICOMPARTMENTAL KNEE ARTHROPLASTY

  • 23

    Evidence suggests no significant difference in function, outcomes, or complications in the short term between robotic assisted and conventional unicompartmental knee arthroplasty.

    LimitedEvidence: HighIntervention

Scope & Objectives

Clinical Topic

Surgical Management of Knee Osteoarthritis

Objectives

To evaluate the current best evidence associated with surgical management of osteoarthritis of the knee and provide recommendations that will help practitioners integrate current evidence into clinical practice.

Target Patient Population

Skeletally mature patients who have been diagnosed by a trained healthcare provider with knee osteoarthritis.

Target Providers

Orthopaedic surgeonsHealthcare providers managing knee OA

Patient Criteria & Setting

Therapeutic Area

Musculoskeletal

Guideline Scope

Surgical ManagementArthroplasty

Inclusion Criteria

  • Skeletally mature patients
  • Diagnosed with knee osteoarthritis
  • Symptomatic osteoarthritis of the knee

Exclusion Criteria

  • Rheumatoid arthritis
  • Osteoarthritis of other joints
  • Other inflammatory arthropathies

Care Settings

SurgicalInpatientAmbulatory care

Special Populations

Obese patientsMorbidly obese patientsDiabetic patientsSmokers

Evidence Grading

System: GRADE Evidence-to-Decision Framework

Evidence Distribution

5695abstracts_reviewed
1595articles_recalled_for_full_text
1098articles_excluded_after_full_text
497articles_included_after_quality_analysis

Evidence Levels

LowEvidence from two or more 'Low' quality studies or evidence from a single 'Moderate' quality study.
HighEvidence from two or more 'High' quality studies.
ModerateEvidence from two or more 'Moderate' quality studies, or evidence from a single 'High' quality study.
Very LowEvidence from one 'Low' quality study or no supporting evidence.

Recommendation Strength

StrongEvidence from two or more 'High' quality studies with consistent findings recommending for or against the intervention. Or Rec is upgraded using the EtD framework.
LimitedEvidence from two or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study recommending for or against the intervention. Or Rec is downgraded using the EtD framework.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings or evidence from a single 'High' quality study recommending for or against the intervention. Or Rec is upgraded or downgraded using the EtD framework.
ConsensusEvidence from one 'Low' quality study, no supporting evidence, or Rec is downgraded using the EtD framework. In the absence of sufficient evidence, the guideline work group is making a statement based on their clinical opinion.

Safety & Contraindications

Contraindications

  • Acquired defective color vision (TXA)
  • Subarachnoid hemorrhage (TXA)
  • Active intravascular clotting (TXA)
  • Hypersensitivity to tranexamic acid (TXA)

Authors & Contributors

Jonathan GodinAjay SrivastavaMichael BlanksteinKathryn SchabelJustin T. DeenJaime BellamyNicolas PiuzziDavid ChristensenSharon Walton

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Learning Paths

Knee OsteoarthritisTotal Knee Arthroplasty (TKA)Unicompartmental Knee Arthroplasty (UKA)Orthopaedic SurgeryPerioperative CarePain Management