The American Academy of Orthopaedic Surgeons (AAOS) has issued an update to their Clinical Practice Guideline (CPG) for Surgical Management of Osteoarthritis (OA) of the Knee. The latest version offers new and updated evidence-based recommendations.
Managing Knee OA via Surgery
OA is the most common form of arthritis impacting the knee and typically occurs in individuals >50 years. The degeneration of the joint due to OA can greatly impact patient mobility and activity levels and can cause significant joint pain and stiffness. Symptomatic OA of the knee can be managed surgically via procedures such as knee replacement, or total knee arthroplasty (TKA), which can relieve pain and restore knee function.
The new CPG from the AAOS updates previous guidelines published in 2015. In addition to evidence-based recommendations about surgical techniques and procedures for knee OA, the CPG also offers information on modifiable factors and lifestyle considerations as well as information regarding how comorbidities (e.g., diabetes, opioid use, obesity) impact surgical outcomes.
“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, in a press release.
The CPG includes a strong recommendation stating no difference between TKA with or without patellar resurfacing (kneecap replacement). Another strong recommendation is the optimization of patient perioperative glucose control (<126mg/dl) in diabetic patients and non-diabetic patients with HgbA1C <6.5.
Based on strong evidence, the CPG states there is no difference in postoperative function in patients with a body mass index (BMI) <30 or in obese patients (BMI 30–39.9). However, there may be an increased risk of complications and infection in morbidly obese patients (BMI >40).
In addition, a new strong recommendation states there is no difference in functional outcomes or complications between TKA performed using mechanical (conventional) alignment versus TKA using kinematic alignment, which utilizes a technological or robotic component, “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.”
A multimodal pain management technique and the reduction of opioid use is recommended in knee replacement patients. New for 2022, the guideline offers a moderate-strength recommendation in favor of counseling patients to avoid opioids prior to surgery, as studies have shown preoperative opioid use can reduce postoperative functional improvement and increase pain.
The full guidelines is available on the AAOS website and via OrthoGuidelines.