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Published by American Academy of Orthopaedic Surgeons · GRADE Evidence-to-Decision Framework
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.
Key Takeaways
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.
Drains should not be used with total knee arthroplasty because there is no significant difference in complications or outcomes.
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.
Cemented femoral and tibial components or hybrid fixation (cementless femur) in total knee arthroplasty show similar functional outcomes and rates of complications and reoperations.
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.
Peripheral nerve blockades for total knee arthroplasty lead to decreased postoperative pain and opioid requirements with no difference in complications or outcomes.
Periarticular injections used in total knee arthroplasty lead to decreased postoperative pain and opioid requirements.
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).
There is no difference in outcomes, function, or pain between navigation and conventional techniques.
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.
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.
Evidence reports that there is no difference in outcomes, function, pain, or blood transfusions between the use of tourniquets and nonuse of tourniquets.
Evidence reports that there is no difference between patellar surfacing or non-patellar resurfacing in total knee arthroplasty.
Cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasty (TKA) designs have similarly efficacious/favorable postoperative outcomes.
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.
There is no difference in composite/functional outcomes or complications between kinematic or mechanical alignment principles in total knee arthroplasty.
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.
All cementless components or hybrid fixation (cementless femur) in total knee arthroplasty show similar functional outcomes and rates of complications and reoperations.
The practitioner could use unicompartmental knee arthroplasty or tibial osteotomy for the treatment of knee osteoarthritis.
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.
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.
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.
Evidence suggests no significant difference in function, outcomes, or complications in the short term between robotic assisted and conventional total knee arthroplasty (TKA).
Evidence suggests no significant difference in function, outcomes, or complications in the short term between robotic assisted and conventional unicompartmental knee arthroplasty.
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
Therapeutic Area
MusculoskeletalGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: GRADE Evidence-to-Decision Framework
Evidence Distribution
Evidence Levels
Recommendation Strength
Contraindications
Difficulty
advanced
Learning Paths