Surgical Management of Knee Osteoarthritis

Publication Date: December 2, 2022

Summary of Recommendations

DRAINS

Drains should not be used with total knee arthroplasty because there is no significant difference in complications or outcomes. (M)
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CEMENTLESS FIXATION: CEMENTED FEMORAL & TIBIAL COMPONENTS VS. CEMENTLESS FEMORAL & TIBIAL COMPONENTS

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

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

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. (M)
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PERIPHERAL NERVE BLOCKADE (PNB)

Peripheral nerve blockades for total knee arthroplasty lead to decreased postoperative pain and opioid requirements with no difference in complications or outcomes. (S)
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PERIARTICULAR LOCAL INFILTRATION

Periarticular injections used in total knee arthroplasty lead to decreased postoperative pain and opioid requirements. (S)
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SURGICAL NAVIGATION

There is no difference in outcomes, function, or pain between navigation and conventional techniques. (M)
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TRANEXAMIC ACID

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). (S)
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RISK FACTORS: BODY MASS INDEX (BMI)

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. (S)
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RISK FACTORS: DIABETES/HYPERGLYCEMIA

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. (S)
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TOURNIQUETS

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

Evidence reports that there is no difference between patellar surfacing or non-patellar resurfacing in total knee arthroplasty.
(S)
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CRUCIATE RETAINING ARTHROPLASTY

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

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. (S)
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KINEMATIC VS. MECHANICAL ALIGNMENT

There is no difference in composite/functional outcomes or complications between kinematic or mechanical alignment principles in total knee arthroplasty.
(S)
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PRE-OPERATIVE OPIOID USE

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. (M)
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CEMENTLESS FIXATION: ALL CEMENTLESS COMPONENTS VS. HYBRID FIXATION (CEMENTLESS TIBIAL COMPONENT)

All cementless components or hybrid fixation (cementless femur) in total knee arthroplasty show similar functional outcomes and rates of complications and reoperations.
(L)
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UNICOMPARTMENTAL KNEE ARTHROPLASTY VS. HIGH/PROXIMAL TIBIAL OSTEOTOMY

The practitioner could use unicompartmental knee arthroplasty or tibial osteotomy for the treatment of knee osteoarthritis. (L)
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UNICOMPARTMENTAL KNEE ARTHROPLASTY VS. HIGH/PROXIMAL TIBIAL OSTEOTOMY

The practitioner could use unicompartmental knee arthroplasty or tibial osteotomy for the treatment of knee osteoarthritis. (L)
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BILATERAL SIMULTANEOUS TOTAL KNEE ARTHROPLASTY VS. STAGED

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. (C)
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RISK FACTORS: SMOKING

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. (C)
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ROBOTICS IN TOTAL KNEE ARTHROPLASTY

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

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

Disclaimer

Overview

Title

Surgical Management of Knee Osteoarthritis

Authoring Organization

Endorsing Organizations

Publication Month/Year

December 2, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Home health, Hospital, Long term care, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, occupational therapist, physical therapist, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management, Rehabilitation

Diseases/Conditions (MeSH)

D020370 - Osteoarthritis, Knee

Keywords

knee osteoarthritis, surgical management, total knee replacement (TKR), partial knee replacement

Source Citation

American Academy of Orthopaedic Surgeons on the Surgical Management of Osteoarthritis of the Knee Clinical Practice Guideline. https://www.aaos.org/smoak2cpg.org Published 12/02/2022

Supplemental Methodology Resources

Data Supplement, Data Supplement