Last updated January 11, 2023

Surgical Management of Knee Osteoarthritis

Summary of Recommendations

DRAINS

Drains should not be used with total knee arthroplasty because there is no significant difference in complications or outcomes. (M)
312070

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)
312070

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)
312070

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)
312070

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)
312070

PERIARTICULAR LOCAL INFILTRATION

Periarticular injections used in total knee arthroplasty lead to decreased postoperative pain and opioid requirements. (S)
312070

SURGICAL NAVIGATION

There is no difference in outcomes, function, or pain between navigation and conventional techniques. (M)
312070

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)
312070

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)
312070

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)
312070

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)
312070

PATELLAR RESURFACING

Evidence reports that there is no difference between patellar surfacing or non-patellar resurfacing in total knee arthroplasty.
(S)
312070

CRUCIATE RETAINING ARTHROPLASTY

Cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasty (TKA) designs have similarly efficacious/favorable postoperative outcomes. (S)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

Recommendation Grading

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