New Guidelines on Total Knee Replacements

The American Academy of Orthopaedic Surgeons (AAOS) introduced a new clinical practice guideline (CPG) for adults undergoing surgery to improve motion and relieve pain caused by osteoarthritis of the knee. The guidelines focus on the surgical procedure most commonly performed for this condition, total knee replacement (TKR).

“Total knee replacement is a safe and effective technique that benefits patients immensely. Many of the guidelines in the CPG are strongly recommended because the literature and other evidence of good outcomes was very compelling,” said David Jevsevar, MD, MBA, chair of the AAOS Committee on Evidence-Based Quality and Value.

Better known as “wear-and-tear” arthritis, osteoarthritis of the knee happens when cartilage in the knee joint breaks down from repeated use, hereditary factors, or related diseases. Bone-on-bone contact creates symptoms that can include pain, swelling, and stiffness in the knee, and decreased ability to walk or rise from a sitting position.

In cases where surgery is warranted, the CPG is the first evidence-based guideline for diagnosis, treatment, rehabilitation and safety for patients. The guidelines are timely because TKR is the No. 1 procedure, in terms of costs, reimbursed by the Centers for Medicare and Medicaid Services (CMS). Effective April 2016, CMS will issue bundled payment for TKR in designated geographic markets–one fixed cost reimbursement for everything from initial consult through recovery. Health care institutions can use the new guideline to assist in planning the highest quality care to comply with the new rules, according to Dr. Jevsevar.

The CPG, Surgical Management of Osteoarthritis of the Knee, provides guidelines for physicians and patients to consider when making decisions about knee replacement. The AAOS recognizes that a patient’s lifestyle and expectations, along with physician experience, also heavily influence treatment decisions. Among the key CPG recommendations in the report that received a “strong” rating are:

• Reduction of risk factors such as weight and smoking
• Administration of multi-modal anesthesia, including local anesthetic and nerve blockade around the knee joint to decrease pain and opioid use following TKR
• Treatment with tranexamic acid to decrease postoperative blood loss and transfusions following TKR
• Starting rehabilitation the same day TKR is performed to reduce length of hospital stay.

The Society of Military Orthopaedic Surgeons, Arthroscopy Association of North America, American Geriatrics Society, American College of Radiology, The Knee Society, and American Association of Hip and Knee Surgeons endorsed the CPG.