Updated Guideline Issued for Surgical Management of Osteoarthritis of the Knee

A revised edition of the Clinical Practice Guideline (CPG) for Surgical Management of Osteoarthritis of the Knee, issued by the American Academy of Orthopaedic Surgeons, provides 2 new evidence-based recommendations and updates 19 of the 38 recommendations from the 2015 version.

In addition to providing guidelines for specific surgical techniques and procedures for knee osteoarthritis (OA), the CPG also highlights important lifestyle considerations that can play a role in surgical outcomes and complications.

“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

  • Optimization of perioperative glucose control (less than 126mg/dL) after total knee arthroplasty (TKA) should be attempted in diabetic and non-diabetic patients with an HgbA1C below 6.5, as hyperglycemia can lead to less favorable postoperative outcomes and higher complication rates (strong recommendation).
  • There is no difference in postoperative functional scores between patients with a BMI below 30 and obese patients (BMI of 30 to 39.9); however, there may be an increased risk of complications of surgical site infections in morbidly obese patients (BMI over 40) (strong recommendation).
  • There is no difference between surfacing and not resurfacing the patella in TKA (strong recommendation).
  • There is no difference in composite/functional outcomes or complications between kinematic and mechanical alignment principles in TKA (new strong recommendation).

“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,” Dr. Srivastava said. “Therefore, if the current evidence demonstrates no difference in outcomes, the extra cost might not be necessary.”

Pain Management Recommendations

The updated CPG continues to recommend multimodal pain management techniques and ways to reduce opioid usage, including a new recommendation of moderate strength focused on counseling patients to avoid opioids prior to TKA. Studies have shown a decrease in postoperative functional scores and increased pain scores and complications when opioids are taken prior to surgery.

In addition, there is a strong recommendation for peripheral nerve blockades for TKA to decrease postoperative pain and opioid requirements with no difference in complications or outcomes, as well as a strong recommendation for the use of periarticular local infiltrations to reduce 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, 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.”

Robotics Recommendations

The use of robotics in TKA and unicompartmental knee arthroplasty is included in the CPG as a new option. No significant difference is seen 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,” Dr. Godin said. “In 5 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.”

The CPG can be found here.

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