Guideline sources The following summarized guidelines for the management of knee osteoarthritis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR/AAHKS 2023), the American Academy of Orthopaedic Surgeons (AAOS 2022), and the American College of Rheumatology (ACR 2020). 1 2 3 4 Guidelines 1. Medical management Non-opioid analgesics: As per AAOS 2022 guidelines: Offer topical NSAIDs, if not contraindicated, to improve function and quality of life in patients with knee OA. A https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 1/8 6/29/23, 5:44 AM Knee osteoarthritis Pathway Offer oral NSAIDs and acetaminophen, if not contraindicated, to improve pain and function in patients with knee OA. A As per ACR 2020 guidelines: Offer NSAIDs (topical and oral) in patients with knee OA. A Consider offering acetaminophen in patients with knee OA. C Opioids: As per AAOS 2022 guidelines, do not use oral opioids, including tramadol, in patients with knee OA because of the significant increase of adverse events and the lack of effectiveness in improving pain or function. D As per ACR 2020 guidelines: Consider offering tramadol in patients with knee OA. C Avoid using non-tramadol opioids in patients with knee OA. Consider offering non-tramadol opioid in certain circumstances, particularly when alternatives have been exhausted. D Duloxetine: consider offering duloxetine in patients with knee OA. C Agents with no evidence for benefit: As per ACR 2020 guidelines: Avoid using colchicine in patients with knee OA. D Do not use the following agents in patients with knee OA: bisphosphonates hydroxychloroquine methotrexate. D 2. Nonpharmacologic interventions Weight loss: As per AAOS 2022 guidelines, recognize that there is no difference in postoperative functional scores between patients with a BMI < 30 and 30-39.9; however, there may be an increased risk of complications, especially surgical site infections, in patients with morbid obesity (BMI 40). A As per AAOS 2022 guidelines, advise sustained weight loss to improve pain and function in overweight and obese patients with knee OA. B As per ACR 2020 guidelines, advise losing weight in overweight and obese patients with knee OA. A Physical therapy: As per AAOS 2022 guidelines: Offer supervised exercise, unsupervised exercise, and/or aquatic exercise to improve pain and function in patients with knee OA. A https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 2/8 6/29/23, 5:44 AM Knee osteoarthritis Pathway Consider offering neuromuscular training (balance, agility, coordination) programs in combination with traditional exercise to improve performance-based function and walking speed in patients with knee OA. C As per ACR 2020 guidelines: Advise exercising in patients with knee OA. A Consider advising balance exercises in patients with knee OA. C Smoking cessation: advise smoking cessation before total knee arthroplasty, as a history of smoking may result in higher complications, lower functional scores, higher pain scores, and surgical site infections. B Dietary supplements: as per AAOS 2022 guidelines, insufficient evidence to support the use of the following supplements in patients with knee OA, although they may be helpful in reducing pain and improving function in patients with mild-to-moderate knee OA: turmeric ginger extract glucosamine chondroitin vitamin D. I Cognitive behavioral therapy: consider offering CBT in patients with knee OA. C Self-management programs: As per AAOS 2022 guidelines, advise participating in self-management programs to improve pain and function in patients with knee OA. A As per ACR 2020 guidelines, advise participating in self-efficacy and self-management programs in patients with knee OA. A Assistive devices: As per AAOS 2022 guidelines: Consider offering use of canes to improve pain and function in patients with knee OA. C Consider offering brace treatment to improve function, pain, and quality of life in patients with knee OA. C As per ACR 2020 guidelines, advise using walking canes in patients with knee OA if the disease in one or both knees causes a sufficiently large impact on ambulation, joint stability, or pain. A Show 2 more Footwear: As per AAOS 2022 guidelines, do not use lateral wedge insoles in patients with knee OA. D As per ACR 2020 guidelines, avoid using modified shoes, lateral and medial wedged insoles in patients with knee OA. D Alternative and complementary therapies: As per AAOS 2022 guidelines, consider offering manual therapy in addition to an exercise program to improve pain and function in patients with knee OA. C https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 3/8 6/29/23, 5:44 AM Knee osteoarthritis Pathway Show 4 more As per ACR 2020 guidelines, advise practicing Tai chi in patients with knee OA. A Show 2 more As per ACR 2020 guidelines, do not perform transcutaneous electrical stimulation in patients with knee OA. D 3. Therapeutic procedures Intra-articular corticosteroids: As per AAOS 2022 guidelines, consider administering intra-articular corticosteroids for short- term relief in patients with symptomatic knee OA. C As per ACR 2020 guidelines: Administer intra-articular corticosteroid injections in patients with knee OA. A Consider preferring intra-articular corticosteroids over other injections in patients with knee OA. C Other intra-articular injections: As per AAOS 2022 guidelines: Do not administer intra-articular hyaluronic acid routinely in patients with symptomatic knee OA. D Consider administering intra-articular platelet-rich plasma to reduce pain and improve function in patients with symptomatic knee OA. C As per ACR 2020 guidelines: Avoid administering the following agents intra-articularly in patients with knee OA: hyaluronic acid botulinum toxin prolotherapy. D Do not administer the following agents intra-articularly in patients with knee OA: stem cells TNF inhibitors IL-1 receptor antagonists platelet rich plasma. D Therapeutic arthroscopy: do not perform arthroscopy with lavage and/or debridement in patients with a primary diagnosis of knee OA. D Dry needling: insufficient evidence to recommend dry needling in patients with knee OA. I Denervation: consider offering denervation therapy to reduce pain and improve function in patients with symptomatic knee OA. C https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 4/8 6/29/23, 5:44 AM Knee osteoarthritis Pathway 4. Perioperative care Perioperative glucose control: optimize perioperative glucose control (< 126mg/dL) after total knee arthroplasty in diabetic and non-diabetic patients with HbA1c < 6.5, as hyperglycemia can lead to less favorable postoperative outcomes and higher complication rates. A Intraoperative tranexamic acid: administer tranexamic acid, if not contraindicated, to decrease postoperative blood loss, drain collection, and the necessity of transfusions following total knee arthroplasty. A 5. Surgical interventions Total knee arthroplasty (timing): consider performing elective knee arthroplasty without delay, rather than delaying for 3 months, or for a trial of physical therapy, (Low) NSAIDs, intra-articular corticosteroid injections, viscosupplementation injections, or braces and/or ambulatory aids, in patients with radiographically moderate-to-severe OA with moderate-to-severe pain or loss of function eligible for elective total joint arthroplasty decided through a shared decision-making process and completed 1 trial of appropriate nonoperative therapy. (Very low). C Show 4 more Total knee arthroplasty (surgical approach): use either a robotic-assisted or conventional approach for total knee arthroplasty due to similar results in function, outcomes, or complications in the short term. B Total knee arthroplasty (bilateral replacement): consider performing simultaneous (versus staged in > 90 days) bilateral total knee arthroplasty in appropriately selected patients, but avoided in patients at high risk of cardiopulmonary complications. C Total knee arthroplasty (anesthesia): perform periarticular local anesthetic infiltration in total knee arthroplasty to decrease pain. A Show 2 more Total knee arthroplasty (prosthesis): use either cruciate-retaining or posterior-stabilized designs for total knee arthroplasty due to similar efficacious/favorable postoperative outcomes. A Total knee arthroplasty (fixation): use either cemented or cementless femoral and tibial components for total knee arthroplasty due to similar functional outcomes, complications, and re- operations. B Show 2 more Total knee arthroplasty (patellar resurfacing): perform total knee arthroplasty either with or without patellar resurfacing due to similar outcomes. A Total knee arthroplasty (intraoperative tourniquet use): perform total knee arthroplasty either using or not using a tourniquet due to similar results in outcomes, function, pain, and blood transfusions. A Total knee arthroplasty (intraoperative techniques with no evidence for benefit): do not use drains in total knee arthroplasty because there is no significant difference in complications or https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 5/8 6/29/23, 5:44 AM Knee osteoarthritis Pathway outcomes. D Show 3 more Surgeries for medial compartment osteoarthritis: Consider performing unicompartmental arthroplasty over total knee arthroplasty for improved patient-reported and functional outcomes in the short term in patients with predominantly medial compartment OA, recognizing that long-term rates of revision in unicompartmental knee arthroplasty may be higher than total knee arthroplasty. B Show 2 more Consider performing high tibial osteotomy to improve pain and function in properly indicated patients with unicompartmental knee OA. C Consider avoiding the use of free-floating (unfixed) interpositional devices in patients with symptomatic medial compartment knee OA. D Partial meniscectomy: consider performing arthroscopic partial meniscectomy for the treatment of meniscal tears in patients with concomitant mild-to-moderate OA failed physical therapy or other nonsurgical treatments. C 6. Patient education Patient education: provide patient education programs to improve pain in patients with knee OA. A 7. Follow-up and surveillance Discharge from hospital: discharge patients to home, with or without home services, rather than acute rehabilitation facility or skilled nursing facility for fewer adverse events. B Clinical findings Patient demographics Symptoms Elderly age Grating sensation in the joint Female sex Joint pain aggravated with activity Past medical history Joint pain alleviated with rest Knee pain History of knee trauma Knee stiffness Obesity Musculoskeletal exam knee ROM https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 6/8 6/29/23, 5:44 AM Knee osteoarthritis Pathway Studies 2022 CRISTAL In adult patients undergoing hip or knee arthroplasty for OA, aspirin was not noninferior to enoxaparin with respect to symptomatic VTE at day 90. CRISTAL Study Group et al. JAMA. 2022 Aug 23. 2021 ANT-005 TKA (mid-dose) In patients, aged 18-80 years, who were undergoing elective primary unilateral total knee arthroplasty, abelacimab was superior to enoxaparin with respect to VTE. Peter Verhamme et al. N Engl J Med. 2021 Aug 12. Show 4 more References 1. Robert H Brophy, Yale A Fillingham. AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee Nonarthroplasty), Third Edition. J Am Acad Orthop Surg. 2022 May 1;30 9):e721-e729. Open 2. Sharon L Kolasinski, Tuhina Neogi, Marc C Hochberg et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res Hoboken). 2020 Feb;72 2 149 162. Open 3. American Academy of Orthopaedic Surgeons. Surgical Management of Osteoarthritis of the Knee: Evidence-Based Clinical Practice Guideline. AAOS. 2022 Dec 2. Open 4. American College of Rheumatology, American Association of Hip and Knee Surgeons. 2023 American College of Rheumatology ACR and American Association of Hip and Knee Surgeons AAHKS Clinical Practice Guideline for the Optimal Timing of Elective Total Hip or Knee Arthroplasty for Patients with Symptomatic Moderate to Severe Osteoarthritis or Osteonecrosis Who Have Failed Nonoperative Therapy. ACR. 2023 Mar 8. 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Open 11. Brian J McGrory, Kristy L Weber, David S Jevsevar et al. Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline. J Am Acad Orthop Surg. 2016 Aug;24 8):e87 93. Open https://web.pathway.md/diseases/recMqwxKp7djJJt6Y 8/8