Surgical Management of Osteoarthritis of the Knee- AAOS Guideline 2016

In 2016, American Academy of Orthopaedic Surgeons (AAOS) came out with the guidelines on Surgical Management of Osteoarthritis of the Knee. The major recommendations of the same are as follows:-

Body Mass Index (BMI) as a Risk Factor

Strong evidence supports that obese patients have less improvement in outcomes with total knee arthroplasty (TKA).(Strong Evidence)

Diabetes as a Risk Factor

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

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. (Moderate Evidence)

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 TKA. (Limited Evidence)

Cirrhosis/Hepatitis C as a Risk Factor

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

Preoperative Physical Therapy

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

Delay TKA

Moderate evidence supports that an eight month delay to TKA does not worsen outcomes. (Moderate Evidence)

Periarticular Local Anesthetic Infiltration

Strong evidence supports the use of peri-articular local anesthetic infiltration compared to placebo in TKA to decrease pain and opioid use. (Strong Evidence)

Peripheral Nerve Blockade

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

Neuraxial Anesthesia

Moderate evidence supports that neuraxial anesthesia could be used in TKA to improve select perioperative outcomes and complication rates compared to general anesthesia. (Moderate Evidence)

Tourniquet: Blood Loss Reduction

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

Tourniquet: Postoperative Pain Reduction

Strong evidence supports that tourniquet use in TKA increases short term post-operative pain. (Strong Evidence)

Tourniquet: Postoperative Function

Limited evidence supports that tourniquet use in TKA decreases short term post-operative function. (Limited Evidence)

Tranexamic Acid

Strong evidence supports that, in patients with no known contraindications, treatment with tranexamic acid decreases postoperative blood loss and reduces the necessity of postoperative transfusions following TKA. (Strong Evidence)

Antibiotic Bone Cement

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

Cruciate Retaining Arthroplasty

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

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. (Strong Evidence)

Patellar Resurfacing: Pain and Function

Strong evidence supports no difference in pain or function with or without patellar resurfacing in TKA. (Strong Evidence)

Patellar Resurfacing: Reoperations

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

Cemented Tibial Components Versus Cementless Tibial Components

Strong evidence supports the use of tibial component fixation that is cemented or cementless in TKA due to similar functional outcomes and rates of complications and reoperations. (Strong Evidence)

Cemented Femoral and Tibial Components versus Cementless Femoral and 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. (Moderate Evidence)

All Cemented Components versus Hybrid Fixation (Cementless Femoral Component)

Moderate evidence supports the use of either cementing all components or hybrid fixation (cementless femur) in TKA due to similar functional outcomes and rates of complications and reoperations. ( Moderate Evidence)

All Cementless Components versus Hybrid Fixation (Cementless Femoral Component)

Limited evidence supports the use of either all cementless components or hybrid fixation (cementless femur) in TKA due to similar rates of complications and reoperations. (Limited Evidence)

Bilateral TKA

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

Unicompartmental Knee Arthroplasty (UKA): Revisions

Moderate evidence supports that TKA could be used to decrease revision surgery risk compared to UKA for medial compartment osteoarthritis. (Moderate Evidence)

UKA: Deep Vein Thrombosis (DVT) and Manipulation Under Anesthesia

Limited evidence supports that UKA might be used to decrease the risk of DVT and manipulation under anesthesia compared to TKA for medial compartment osteoarthritis. (Limited Evidence)

UKA versus Osteotomy

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

Surgical Navigation

Strong evidence supports not using intraoperative navigation in TKA because there is no difference in outcomes or complications. (Strong Evidence)

Pain and Function

Strong evidence supports not using patient specific instrumentation compared to conventional instrumentation for TKA because there is no difference in pain or functional outcomes.

Patient Specific Instrumentation: Transfusions and Complications

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

Drains

Strong evidence supports not using a drain with TKA because there is no difference in complications or outcomes. (Strong Evidence)

Cryotherapy Devices

Moderate evidence supports that cryotherapy devices after KA do not improve outcomes.(Moderate Evidence)

Continuous Passive Motion (CPM)

Strong evidence supports that CPM after KA does not improve outcomes. (Strong Evidence)

Postoperative Mobilization: Length of Stay

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

Postoperative Mobilization: Pain and Function

Moderate evidence supports that rehabilitation started on day of TKA compared to rehabilitation started on postop day 1 reduces pain and improves function. (Moderate Evidence)

Early Stage Supervised Exercise Program: Function

Moderate evidence supports that a supervised exercise program during the first two months after TKA improves physical function. (Moderate Evidence)

Early Stage Supervised Exercise Program: Pain

Limited evidence supports that a supervised exercise program during the first two months after TKA decreases pain. (Limited Evidence)

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 TKA to improve physical function. (Limited Evidence)