Guest Post: New AUC for Surgical Management of Knee OA

knee-spotlight-image.pngOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD and Grigory Gershkovich, MD.

The AAOS recently reviewed the evidence for surgical management of osteoarthritis of the knee (SMOAK) and issued a set of appropriate use criteria (AUC) that help determine the appropriateness of clinical practice guidelines (CPGs). These AUC can be accessed on the OrthoGuidelines website: www.orthoguidelines.org/auc.

The AUC were developed after a panel of specialists reviewed the 2015 CPGs on SMOAK and made appropriateness assessments for a multitude of clinical scenarios and treatments. The panel found 21% of the voted-on items “appropriate”; 25% were designated “maybe appropriate,” and 54% were ranked as “rarely appropriate.”

Importantly, these AUC do not provide a substitute for surgical decision making. The physician should always determine treatment on an individual basis, ideally with the patient fully engaged in the decision.

This OrthoBuzz post summarizes some of the updated conclusions according to three clinical time points—pre-operative, peri-operative, and postoperative—specifying the strength of supporting evidence.  This post is not intended to review appropriateness for every clinical scenario. We encourage physicians to explore the OrthoGuidelines website for complete AUC information.

Pre-operative

Strong evidence: Obese patients exhibit minimal improvement after total knee arthroplasty
(TKA), and such patients should be counseled accordingly.

Moderate evidence: Diabetic patients have a higher risk of complications after TKA.

Moderate evidence: An 8-month delay to TKA does not worsen outcomes.

Peri-operative

Strong evidence: Both peri-articular local anesthetics and peripheral nerve blocks decrease postoperative pain and opioid requirements.

Moderate evidence: Neuraxial anesthesia may decrease complication rates and improve select peri-operative outcomes.

Moderate evidence: Judicious use of tourniquets decreases blood loss, but tourniquets may also increase short-term post-operative pain.

Strong evidence:  The use of tranexamic acid (TXA) reduces post-operative blood loss and the need for transfusions.

Strong evidence: Drains do not help reduce complications or improve outcomes.

Strong evidence: There is no difference in outcomes between cruciate-retaining and posterior stabilized implants.

Strong evidence: All-polyethylene and modular components yield similar outcomes.

Strong, moderate, and limited evidence to support either cemented or cementless techniques, as similar outcomes and complication rates were found.

Strong evidence: There is no difference in pain/function with patellar resurfacing.

Moderate evidence: Patellar resurfacing decreases 5-year re-operation rates.

Moderate evidence shows no difference between unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).

Moderate evidence favors TKA over UKA to avoid future revisions.

Strong evidence against the use of intraoperative navigation and patient-specific instrumentation, as no difference in outcomes has been observed.

Postoperative

Strong evidence:  Rehab/PT started on day of surgery reduces length of stay.

Moderate evidence: Rehab/PT started on day of surgery reduces pain and improves function.

Strong evidence: The use of continuous passive motion machines does not improve outcomes after TKA.

Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.

Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.

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