The Arizona HOPCo Specialty Care Network is the only
URAC-accredited MSK clinically integrated network in the country.

Management of Osteoarthritis of Knee Clinical Practice

Clinical Region





All adult patients with knee osteoarthritis (OA) will be assessed and provided care throughout the continuum based on the Bree Collaborative and American Academy of Orthopedic Surgeons Guidelines (AAOS,2022).


Standardizing the processes of care can improve quality and utilization outcomes, including length of stay, costs, complications and 30-day readmissions (Loftus, et. al., 2014; Barbieri, et. al., 2009).  In addition, Medicare is expected to mandate a bundled payment program, further incentivizing organizations to improve financial and clinical performance.  Although implementation of one of two interventions alone can improve quality and utilization outcomes (Loftus, et. al, 2014), a comprehensive approach is recommended (Bree, 2013).

The Bree Collaborative is a widely recognized comprehensive approach and “defines the expected components of pre-operative, intra-operative, and post-operative care needed for successful TKR/ surgery” (Bree, 2013).  The Bree Collaborative is a partnership among many different stakeholders within the State of Washington that is working to identify and promote strategies to reduce variation in care while improving care, safety, and health with evidence-based recommendations.


In December of 2022 the AAOS published its evidence based clinical practice guideline to help guide provider decision making towards evidence-based treatments of OA of the knee. The AAOS guideline is supported by the American society of Anesthesiologists, The Knee Society, The American College of Radiology, American Association of Hip and Knee Surgeons, and the Geriatrics Healthcare Professionals. The AAOS guideline contains 20 recommendations for the pre-operative, perioperative, and postoperative care of patients with OA of the knee who are considering surgical treatment. The AAOS conducted an extensive literature review and analyzed evidence. Recommendations were graded by the strength of methodology of the available evidence. A strong recommendation means the quality of supporting evidence is high (two or more high strength studies with consistent findings for recommending for or against the intervention), a moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), and a limited recommendation means there is a lack of compelling evidence and an unclear balance between benefits and potential harm (AAOS, 2022 McGrory, et. al., 2016)

Clinical Approach

The clinical approach is based on consensus guidelines and includes expected practices which will be designed and implemented for the patients with knee osteoarthritis. Recommended clinical care is also included.

Expected Clinical Care


  1. Providers are responsible for gathering all the necessary documentation to demonstrate that minimum requirements for surgery have been met.
  2. Patients should meet the following minimum requirements prior to surgery:
    1. Conservave treatment, managed by the PCP or Specialist, for a minimum of 3 months (Bree, 2013; AAOS, 2022). Treatment opons include:
      1. NSAIDS
      2. Unloader brace
      3. Assistive device for ambulation (e.g., cane, walker)
      4. Weight reduction program
      5. Therapeutic intra-articular cortisone injection (maximum 2-3 injections/year)
      6. Physical therapy: Strengthening, gait, training, ROM
      7. Therapeuc intra-arcular viscosupplementaon injecon for mild to moderate OA should be used aer failed corsone injecon and aer all other treatment opons listed above have failed. Can be repeated every 6 months if relief noted (Navarro-Sarabia, et. al., 2011; Perez-Serna, et. al., 2011).
    2. Advanced joint disease.
    3. BMI less than 40 (Surgical Management of Osteoarthritis of the Knee, 2022)
      1. An appeal process will be in place for Patients who have parcipated in an approved weight loss program for 90 days and a provider recommends proceeding with TKR surgery for a Patient who does not meet the appropriatenessstandards(Bree, 2015).
    4. Hgb A1c
      1. ≤ 7.0 within last 12 weeks prior to surgery may proceed with surgery.
      2. > 7.0 within last 12 weeks prior to surgery postpone until:
        1. Repeat HgbA1C is ≤ 7.0 OR
        2. After a three-month period, patient receives a leer from an endocrinologist or PCP stating that patient is at optimal control OR
        3. patient has exhausted oponsfor improved control of diabetes, has improved control of diabetes, but unlikely to make further gains due to underlying condition for which they need surgery, and their HgbA1C is considered clinically reasonable to proceed with proposed surgery.
    5. Staged arthroplasty must be performed a minimum 31 days from the index procedure in order to not be considered a readmission by CMS guidelines
    6. Same day bilateral arthroplasty islimited to paents with significant bilateral deformity where staging would alter their clinical outcome.
  3. Recommend all patients parcipate in a total joint education class and shared decision making. Caregivers are included in education, so they understand expectaons.
  4. Patients will obtain DME:
    1. Front wheeled walker
    2. Seat riser
    3. TED hose
    4. Shoehorn extender (THA)-optional
    5. Reacher-optional
  5. Patients will have appropriate work up consistent with their co-morbidities prior to surgery.
  6. Antibiotics in pre-op holding:
    1. Cefazolin (Ancef) 2 gm (less than 120 kg) or 3 gm (120 kg or greater) IV within 1 hour of cut me, or
    2. Options for penicillin/cephalosporin allergic/intolerant patients:
      1. Vancomycin 1 gm (less than 90 kg) or 1.5 gm (90 kg or greater) IV within 2 hours of cut time


Patients will receive:
  1. Tranexamic acid, 1000mg IV at inducon to decrease postoperave blood loss and reduce the necessity of postoperave transfusions following TKA in paents with no known contraindicaons (AAOS, 2022)
  2. 0.35% dilute povidone-iodine (Betadine) soak (using product for single paent use) (Brown, et. al., 2012). Use in hemiarthroplasty or uniarthroplasty is at the providers discreon.
  3. Post-operave x-ray to assess for retained foreign object
  4. Silver-impregnated water-proof dressing (Mepilex) (Grosso, et. al., 2016; Cai, et. al., 2014)
  5. Peri-arcular Ortho cocktail injecon for TKA to decrease postoperave pain and opioid requirements (AAOS, 2021).


  1. Foley catheters for primary TJA
  2. CPMs for primary TJA (Alkire& Swank, 2010; Maniar, et.al, 2012)
  3. PCAs for primary TJA
  4. Cold machines for primary TJA
  5. Femoral blocks for primary TJA
  6. Trapeze bed for primary TJA
  7. Abduction pillow for primary THA
  8. Transfusion if Hgb is above 7 (unless clinically indicated)
  1. The patients will be mobilized on the day of surgery (Bree, 2013; AAOS, 2015; Pua & Ong, 2014)
  2. Rounds and discharges are conducted in the morning and preferably completed as early as possible.
  3. Transition to PO antibiotics after initial IV dose for 7 days postop.
  4. Routine discharge medications:
    1. ASA 81 mg BID for 6 weeks
    2. Colace 100 mg PO BID
  5. Consider multi-modal approach to pain management to minimize need for prolonged opiates
    1. Opioid pain medications:
      1. Short-course Oxycodone Immediate-Release 5-10 mg PO Q6H PRN Moderate-Severe Pain
    2. Non-opioid pain medications (i.e. multi-modal)
      1. Benefits include superior pain control, improved patient satisfaction, minimize opioid related morbidity
    3. Medications such as acetaminophen, NSAIDS (e.g. ibuprofen, celecoxib) should be considered if not contraindicated
    4. Consider GI prophylaxis-as needed for aspirin or NSAID usage and patient risk factors.
  6. DVT prophylaxis:
    1. PO ASA 81mg BID for 6 weeks for standard risk paents with first dose at 20 hours post-op during hospital stay (Bozic, et. al., 2010)
    2. Rivaroxaban (Xarelto) 10mg for 6 weeks for high-risk paents with first dose at 20 hours post-op during hospital stay (or equivalent medicaon)
    3. TED hose bilaterally on during the day, off at night for 4 weeks optional
    4. SCDs bilaterally to be on while in bed during hospital stay

      *High Risk: History of DVT/PE, active malignancy, females on hormone therapy or oral contraceptive that will not come off their medications, or any patient with multiple co-morbidities the physician feels puts the patient at increased risk.


  1. Inpatient rehab admission is rarely indicated after primary TKA
  2. Skilled Nursing Facility admission is infrequently indicated after TKA
    1. When admitted to a skilled nursing facility, length of stay should be as efficient as clinically possible
  3. When formal therapy is clinically indicated, outpatient physical therapy is preferred over home health therapy.
    1. The length of time the patient participates in formal therapy and the frequency of visits should be commensurate with clinical need.


  1. All educaonal and community promoonal materials will align with these guidelines.
  2. Avoid transfusions unl the patients Hgb is <7, the paent is clinically symptomatic or considered high risk. Transfusions are ordered by the surgeon or if ordered by another provider, will be cleared by the surgeon.


  1. Alkire, M. R., & Swank, M. L. (2010). Use of Inpaent Connuous Passive Moon Versus No CPM in Computer Assisted Total Knee Arthroplasty. Orthopaedic Nursing, 29(1), 36-40.
  2. American Academy of Orthopaedic Surgeons Surgical Management of Osteoarthris of the Knee EvidenceBased Clinical Pracce Guideline. www.aaos.org/smoak2cpg Published December 02, 2022
  3. American Academy of Orthopaedic Surgeons. (2015). Surgical Management of Osteoarthris of the Knee: Evidence-Based Clinical Pracce Guideline. Rosemont, IL: AAOS.
  4. American Academy of Orthopedic Surgeons. (2013). Treatment of Osteoarthris of the Knee. Evidence Based Guideline, 2nd Edion. Rosemont, IL: AAOS.
  5. Barbieri, A., Vanhaecht, K., Van Herck, P., Sermeus, W., Faggiano, F., Marchisio, S., & Panella, M. (2009). Effects of clinical pathways in the joint replacement: a meta-analysis. BMC medicine, 7(1), 1.
  6. Bozic, K. J., Vail, T. P., Pekow, P. S., Maselli, J. H., Lindenauer, P. K., & Auerbach, A. D. (2010). Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty paents? The Journal of arthroplasty, 25(7), 1053-1060.
  7. Bree Collaborve. (2013). Bundle: Clinical Components of Total Knee or Total Hip Replacement Surgery.
  8. Brown, N. M., Cipriano, C. A., Moric, M., Sporer, S. M., & Della Valle, C. J. (2012). Dilute betadine lavage before closure for the prevenon of acute postoperave deep periprosthec joint infecon. The Journal of arthroplasty, 27(1), 27-30.
  9. Cai, J., Karam, J. A., Parvizi, J., Smith, E. B., & Sharkey, P. F. (2014). Aquacel surgical dressing reduces the rate of acute PJI following total joint arthroplasty: a case–control study. The Journal of arthroplasty, 29(6), 1098-1100.
  10. Grosso, M. J., Berg, A., LaRussa, S., Murtaugh, T., Trofa, D. P., & Geller, J. A. (2016). Silver-Impregnated Occlusive Dressing Reduces Rates of Acute Periprosthec Joint Infecon Aer Total Joint Arthroplasty. The Journal of Arthroplasty.
  11. Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Hamilton WG, Della Valle CJ; AAHKS Anesthesia & Analgesia Clinical Pracce Guideline Workgroup. Periarcular Injecon in Total Joint Arthroplasty: The Clinical Pracce Guidelines of the American Associaon of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2022 Sep;37(9):1701-1707. doi: 10.1016/j.arth.2022.03.048. PMID: 35970572.
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  13. Jacofsky, D. J., Kocisky, S., Dixon, D., & Jacofsky, M. C. (2010). Secure tracks device improves funconal recovery and pain aer total knee arthroplasty: a prospecve, randomized, pilot study. Surgical technology internaonal, 20, 357-361.
  14. Lous, T., Agee, C., Jaffe, R., Tao, J., & Jacofsky, D. J. (2014). A simplified pathway for total knee arthroplasty improves outcomes. Journal of Knee Surgery, 27(03), 221-228.
  15. Maniar, R. N., Baviskar, J. V., Singhi, T., & Rathi, S. S. (2012). To Use or Not to Use Connuous Passive Moon Post–Total Knee Arthroplasty: Presenng Funconal Assessment Results in Early Recovery. The Journal of arthroplasty, 27(2), 193-200.
  16. McGrory, B. J., Weber, K. L., Jevsevar, D. S., & Sevarino, K. (2016). Surgical Management of Osteoarthris of the Knee: Evidence-based Guideline. Journal of the American Academy of Orthopaedic Surgeons, 24(8), e87-e93.
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