AAOS Updates Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee

ROSEMONT, Ill. (January 10, 2023)—The American Academy of Orthopaedic Surgeons (AAOS) issued an update to the Clinical Practice Guideline (CPG) for Surgical Management of Osteoarthritis of the Knee, which replaces the previous edition released in 2015. This CPG provides two new evidence-based recommendations and updates to 19 of the 38 recommendations. In addition to providing guidelines for specific surgical techniques and procedures for knee osteoarthritis (OA), the CPG also highlights important lifestyle considerations including diabetes, BMI and opioid use, all of which can play a role in surgical outcomes and complications.

OA is the most common form of arthritis in the knee and can have a severe impact on activity levels. This degenerative “wear and tear” typically occurs in people 50 years of age and older and is often associated with joint pain, stiffness and difficulty with purposeful movement. Surgical interventions, such as arthroplasty for symptomatic OA of the knee, is performed to relieve pain and restore function.

“We want to do everything possible to help our patients undergoing knee OA surgery experience favorable functional outcomes while reducing the risk of operative and postoperative complications, including pain or reoperation,” said Ajay Srivastava, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value. “Updates to this CPG include a rigorous systematic process, resulting in a guide that provides physicians with the information needed for shared decision-making with their patients.”

Highlights of the CPG include:

• A strong recommendation that the optimization of perioperative glucose control (<126mg/dl) after total knee arthroplasty should be attempted in diabetic and non-diabetic patients with HgbA1C <6.5, as hyperglycemia can lead to less favorable postoperative outcomes and higher complication rates.
• A strong recommendation showing that there is no difference in postoperative functional scores between patients with a BMI less than 30 and obese patients (BMI 30-39.9); however, there may be an increased risk of complications of surgical site infections in morbidly obese patients (BMI greater than 40).
• A strong recommendation that there is no difference between patellar surfacing (kneecap replacement) or non-patellar resurfacing in TKA.
• A new strong recommendation stating that there is no difference in composite/functional outcomes or complications between kinematic or mechanical alignment principles in TKA.

“A total knee replacement with kinematic alignment often incorporates a technological aspect such as a robot or a custom jig, which can potentially add cost to the surgery,” said Dr. Srivastava. “Therefore, if the current evidence demonstrates no difference in outcomes, the extra cost might not be necessary.”

The updated CPG continues to recommend multimodal pain management techniques and ways to reduce opioid intake including a new recommendation of moderate strength focused on counseling patients to avoid opioids prior to their TKA. Studies have shown a decrease in postoperative functional scores and increased pain scores and complications when opioids are taken prior to surgery. Additionally, a strong recommendation for peripheral nerve blockades for TKA can lead to decreased postoperative pain and opioid requirements with no difference in complications or outcomes, and a strong recommendation for periarticular local infiltrations used in TKA also lead to decreased postoperative pain.

“New evidence demonstrates the effectiveness of both pain management techniques, especially when used together, to decrease postoperative pain without increasing complications,” said Jonathan Godin, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value. “However, if a surgical facility isn’t able to perform a peripheral nerve blockade, I’d still encourage the use of an injection with local anesthetic around the knee capsule to decrease postoperative pain.”

The use of robotics in TKA and unicompartmental knee arthroplasty are included in the CPG as new options and demonstrate no significant difference in function, outcomes, or complications in the short term between robotic-assisted and conventional surgery.

“What remains to be seen is the granular, midterm or long-term data pertaining to the use of robotics for these arthroplasty procedures,” said Dr. Godin. “In five years, the next work group will have access to midterm outcomes, and it will be very interesting to see if this continues to hold true or not.”

This CPG was prepared by the AAOS Surgical Management of Osteoarthritis of the Knee Guideline physician work group (clinical experts) with the assistance of the AAOS Clinical Quality and Value (CQV) Department (methodologists).

CPGs are not meant to be stand-alone documents, but rather serve as a point of reference and educational tool for both healthcare professionals managing patients knee OA and orthopaedic surgeons. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances.
 
The full Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee is intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.

About the AAOS
With more than 38,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

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