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The American Academy of Orthopaedic Surgeons

Evidence-Based Clinical Practice Guideline on
Surgical Management of Osteoarthritis of the Knee
Brian McGrory, MD David Jevsevar, MD, MBA
Kristy Weber, MD Kevin G. Shea, MD
John A. Lynott, MD Kevin J. Bozic, MD, MBA
John C. Richmond, MD William Shaffer, MD
Charles Moore Davis III, MD, PhD Deborah Cummins, PhD
Adolph Yates, Jr., MD Jayson N. Murray, MA
Atul F. Kamath, MD Patrick Donnelly, MA
Vinod Dasa, MD Nilay Patel, MA
Gregory Alexander Brown, MD, PhD Ben Brenton, MSAE
Tad L. Gerlinger, MD Peter Shores, MPH
Tomas Villanueva, DO, MBA, FACPE, SFHM Anne Woznica, MLS
Sara Piva, PT, PhD Erica Linskey
James Hebl, MD Kaitlyn Sevarino, MBA

Introduction
The AAOS Evidence-Based Guideline on Surgical Management of Osteoarthritis of the Knee includes both diagnosis and treatment.
This clinical practice guideline has been endorsed by the Arthroscopy Association of North America (AANA) and the Society of
Military Orthopaedic Surgeons (SOMOS). This brief summary of the AAOS Clinical Practice Guideline contains a list of the
recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recom-
mendation was developed and the complete evidence report are contained in the full guideline at http://www.aaos.org/Quality/
Clinical_Practice_Guidelines/Clinical_Practice_Guidelines/.

Summary of Recommendations
BMI AS A RISK FACTOR
Strong evidence supports that obese patients have less improvement in outcomes with total knee arthroplasty (TKA).

Disclosure: The disclosure information for the Work Group members and the AAOS staff on this guideline are found in Appendix IX (page 509) of the
guideline document at http://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/SMOAK%20CPG__12.4.15.pdf

Disclaimer: This Clinical Practice Guideline was developed by an AAOS multidisciplinary volunteer Work Group based on a systematic review of the current
scientic and clinical information and accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not intended to be a xed
protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as
those found in a clinical trial. Patient care and treatment should always be based on a clinicians independent medical judgment, given the individual
patients clinical circumstances.

The complete AAOS guideline is available at http://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/SMOAK%

20CPG__12.4.15.pdf

J Bone Joint Surg Am. 2016;98:688-92 d http://dx.doi.org/10.2106/JBJS.15.01311

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Strength of Recommendation: Strong wwww

DIABETES AS A RISK FACTOR

Moderate evidence supports that patients with diabetes are at higher risk for complications with total knee arthroplasty (TKA).

Strength of Recommendation: Moderate wwwq

CHRONIC PAIN AS A RISK FACTOR

Moderate evidence supports that patients with select chronic pain conditions have less improvement in patient reported outcomes with TKA.

Strength of Recommendation: Moderate wwwq

DEPRESSION/ANXIETY AS A RISK FACTOR

Limited evidence supports that patients with depression and/or anxiety symptoms have less improvement in patient reported
outcomes with total knee arthroplasty (TKA).

Strength of Recommendation: Limited wwqq

CIRRHOSIS/HEPATITIS C AS A RISK FACTOR

Limited evidence supports that patients with cirrhosis or hepatitis C are at higher risk for complications with total knee arthroplasty (TKA).

Strength of Recommendation: Limited wwqq

PREOPERATIVE PHYSICAL THERAPY

Limited evidence supports that supervised exercise before total knee arthroplasty (TKA) might improve pain and physical function
after surgery.

Strength of Recommendation: Limited wwqq

DELAY TKA
Moderate evidence supports that an 8-month delay to total knee arthroplasty (TKA) does not worsen outcomes.

Strength of Recommendation: Moderate wwwq

PERIARTICULAR LOCAL ANESTHETIC INFILTRATION

Strong evidence supports the use of periarticular local anesthetic inltration compared with placebo in total knee arthroplasty
(TKA) to decrease pain and opioid use.

Strength of Recommendation: Strong wwww

PERIPHERAL NERVE BLOCKADE

Strong evidence supports that peripheral nerve blockade for total knee arthroplasty (TKA) decreases postoperative pain and opioid
requirements.

Strength of Recommendation: Strong wwww

NEURAXIAL ANESTHESIA
Moderate evidence supports that neuraxial anesthesia could be used in total knee arthroplasty (TKA) to improve select periop-
erative outcomes and complication rates compared to general anesthesia.

Strength of Recommendation: Moderate wwwq

TOURNIQUET: BLOOD LOSS REDUCTION

Moderate evidence supports that the use of a tourniquet in total knee arthroplasty (TKA) decreases intraoperative blood loss.

Strength of Recommendation: Moderate wwwq

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TOURNIQUET: POSTOPERATIVE PAIN REDUCTION

Strong evidence supports that tourniquet use in total knee arthroplasty (TKA) increases short-term postoperative pain.

Strength of Recommendation: Strong wwww

TOURNIQUET: POSTOPERATIVE FUNCTION

Limited evidence supports that tourniquet use in total knee arthroplasty (TKA) decreases short-term postoperative function.

Strength of Recommendation: Limited wwqq

TRANEXAMIC ACID
Strong evidence supports that, in patients with no known contraindications, treatment with tranexamic acid decreases postop-
erative blood loss and reduces the necessity of postoperative transfusions following total knee arthroplasty (TKA).

Strength of Recommendation: Strong wwww

ANTIBIOTIC BONE CEMENT

Limited evidence does not support the routine use of antibiotics in the cement for primary total knee arthroplasty (TKA).

Strength of Recommendation: Limited wwqq

CRUCIATE RETAINING ARTHROPLASTY

Strong evidence supports no difference in outcomes or complications between posterior stabilized and posterior cruciate retaining
arthroplasty designs.

Strength of Recommendation: Strong wwww

POLYETHYLENE TIBIAL COMPONENT

Strong evidence supports use of either all-polyethylene or modular tibial components in knee arthroplasty (KA) because of no
difference in outcomes.

Strength of Recommendation: Strong wwww

PATELLAR RESURFACING: PAIN AND FUNCTION

Strong evidence supports no difference in pain or function with or without patellar resurfacing in total knee arthroplasty.

Strength of Recommendation: Strong wwww

PATELLAR RESURFACING: REOPERATION

Moderate evidence supports that patellar resurfacing in total knee arthroplasty (TKA) could decrease cumulative reoperations after
5 years when compared to no patellar resurfacing in total knee arthroplasty (TKA).

Strength of Recommendation: Moderate wwwq

CEMENTED TIBIAL COMPONENTS VERSUS CEMENTLESS TIBIAL COMPONENTS

Strong evidence supports the use of tibial component xation that is cemented or cementless in total knee arthroplasty due to
similar functional outcomes and rates of complications and reoperations.

Strength of Recommendation: Strong wwww

CEMENTED FEMORAL & TIBIAL COMPONENTS VERSUS CEMENTLESS FEMORAL & TIBIAL COMPONENTS
Moderate evidence supports the use of either cemented femoral and tibial components or cementless femoral and tibial
components in knee arthroplasty due to similar rates of complications and reoperations.

Strength of Recommendation: Moderate wwwq

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ALL CEMENTED COMPONENTS VERSUS HYBRID FIXATION (CEMENTLESS FEMORAL COMPONENT)

Moderate evidence supports the use of either cementing all components or hybrid xation (cementless femur) in total knee
arthroplasty due to similar functional outcomes and rates of complications and reoperations.

Strength of Recommendation: Moderate wwwq

ALL CEMENTLESS COMPONENTS VERSUS HYBRID FIXATION (CEMENTLESS FEMORAL COMPONENT)

Limited evidence supports the use of either all cementless components or hybrid xation (cementless femur) in total knee
arthroplasty due to similar rates of complications and reoperations.

Strength of Recommendation: Limited wwqq

BILATERAL TKA
Limited evidence supports simultaneous bilateral total knee arthroplasty (TKA) for patients aged 70 or younger or ASA status 1-2,
because there are no increased complications.

Strength of Recommendation: Limited wwqq

UKA: REVISIONS
Moderate evidence supports that total knee arthroplasty (TKA) could be used to decrease revision surgery risk compared to
unicompartmental knee arthroplasty (UKA) for medial compartment osteoarthritis.

Strength of Recommendation: Moderate wwwq

UKA: DVT & MANIPULATION UNDER ANESTHESIA

Limited evidence supports that unicompartmental knee arthroplasty might be used to decrease the risk of deep vein thrombosis
(DVT) and manipulation under anesthesia compared to total knee arthroplasty (TKA) for medial compartment osteoarthritis.

Strength of Recommendation: Limited wwqq

UKA VERSUS OSTEOTOMY

Moderate evidence supports no difference between unicompartmental knee arthroplasty (UKA) or valgus-producing proximal
tibial osteotomy in outcomes and complications in patients with medial compartment knee osteoarthritis.

Strength of Recommendation: Moderate wwwq

SURGICAL NAVIGATION
Strong evidence supports not using intraoperative navigation in total knee arthroplasty (TKA) because there is no difference in
outcomes or complications.

Strength of Recommendation: Strong wwww

PATIENT SPECIFIC INSTRUMENTATION: PAIN AND FUNCTION

Strong evidence supports not using patient specic instrumentation compared with conventional instrumentation for total knee
arthroplasty (TKA) because there is no difference in pain or functional outcomes.

Strength of Recommendation: Strong wwww

PATIENT SPECIFIC INSTRUMENTATION: TRANSFUSIONS AND COMPLICATIONS

Moderate evidence supports not using patient specic instrumentation compared to conventional instrumentation for total knee
arthroplasty (TKA) because there is no difference in transfusions or complications.

Strength of Recommendation: Moderate wwwq

DRAINS
Strong evidence supports not using a drain with total knee arthroplasty (TKA) because there is no difference in complications or
outcomes.
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Strength of Recommendation: Strong wwww

CRYOTHERAPY DEVICES
Moderate evidence supports that cryotherapy devices after knee arthroplasty (KA) do not improve outcomes.

Strength of Recommendation: Moderate wwwq

CONTINUOUS PASSIVE MOTION

Strong evidence supports that continuous passive motion (CPM) after knee arthroplasty (KA) does not improve outcomes.

Strength of Recommendation: Strong wwww

POSTOPERATIVE MOBILIZATION: LENGTH OF STAY

Strong evidence supports that rehabilitation started on the day of the total knee arthroplasty (TKA) reduces length of hospital stay.

Strength of Recommendation: Strong wwww

POSTOPERATIVE MOBILIZATION: PAIN AND FUNCTION

Moderate evidence supports that rehabilitation started on the day of total knee arthroplasty compared with rehabilitation started on
postop. day 1 reduces pain and improves function.

Strength of Recommendation: Moderate wwwq

EARLY STAGE SUPERVISED EXERCISE PROGRAM: FUNCTION

Moderate evidence supports that a supervised exercise program during the rst 2 months after total knee arthroplasty (TKA)
improves physical function.

Strength of Recommendation: Moderate wwwq

EARLY STAGE SUPERVISED EXERCISE PROGRAM: PAIN

Limited evidence supports that a supervised exercise program during the rst 2 months after total knee arthroplasty (TKA)
decreases pain.

Strength of Recommendation: Limited wwqq

LATE STAGE POSTOPERATIVE SUPERVISED EXERCISE PROGRAM: FUNCTION

Limited evidence supports that selected patients might be referred to an intensive supervised exercise program during late stage post
total knee arthroplasty (TKA) to improve physical function.

Strength of Recommendation: Limited wwqq

Update
This article was updated on May 4, 2016, because of a previous error. On page 689, under the DELAY TKA heading, the text had
previously read Moderate evidence supports that a 5-month delay to total knee arthroplasty (TKA) does not worsen outcomes. The
text now reads Moderate evidence supports that an 8-month delay to total knee arthroplasty (TKA) does not worsen outcomes.

An erratum has been published: J Bone Joint Surg Am. 2016 June 15;98(12):e53.