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



Expected practice


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. Conservative treatment, managed by the PCP or Specialist, for a minimum of 3 months (Bree, 2013; AAOS, 2013). Treatment options 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. No intra-articular cortisone injection 3 months prior to surgery
      7. Physical therapy: Strengthening, gait, training, ROM
      8. Therapeutic intra-articular viscosupplementationinjection for mild to moderate OA should be used after failed cortisone injection and after all other treatment options 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 participated 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 appropriateness standards (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 letter from an endocrinologist or PCP stating that patient is at optimal control OR
        3. Patient has exhausted options for 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 is limited to patients with significant bilateral deformity where staging would alter their clinical outcome.
  3. Recommend all patients participate in a total joint education class and shared decision making. Caregivers are included in education, so they understand expectations.
  4. Patients will obtain DME:
    1. Front wheeled walker
    2. Seat riser
    3. TED hose
    4. 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 time, 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 induction or topically intra-operatively, to decrease postoperative blood loss and reduce the necessity of postoperative transfusions following TKA in patients with no known contraindications (AAOS, 2022)
  2. 0.35% dilute povidone-iodine (Betadine) soak (using product for single patient use) (Brown, et. al., 2012). Use in uniarthroplasty is at the providers discretion.
  3. Post-operative 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-articular Ortho cocktail injection for TKA to decrease postoperative 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 patient 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. ASA 81mg BID for 6 weeks for standard risk patients
    2. For high risk patients chemoprophylaxis at providers discretion
    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.


All educational and community promotional materials will align with these guidelines.


  1. Alkire, M. R., & Swank, M. L. (2010). Use of Inpatient Continuous Passive Motion Versus No CPM in Computer‐Assisted Total Knee Arthroplasty. Orthopaedic Nursing, 29(1), 36-40.
  2. American Academy of Orthopaedic Surgeons Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. http://www.aaos.org/smoak2cpg Published December 02, 2022
  3. American Academy of Orthopaedic Surgeons. (2015). Surgical Management of Osteoarthritis of the Knee: Evidence-Based Clinical Practice Guideline. Rosemont, IL: AAOS.
  4. American Academy of Orthopedic Surgeons. (2013). Treatment of Osteoarthritis of the Knee. Evidence Based Guideline, 2nd Edition. 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 patients? The Journal of arthroplasty, 25(7), 1053-1060.
  7. Bree Collabortive. (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 prevention of acute postoperative deep periprosthetic joint infection. 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 Periprosthetic Joint Infection After 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 Practice Guideline Workgroup. Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association 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.
  12. Harari, D., Hopper, A., Dhesi, J., Babic-Illman, G., Lockwood, L., & Martin, F. (2007). Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age and ageing, 36(2), 190-196.
  13. Jacofsky, D. J., Kocisky, S., Dixon, D., & Jacofsky, M. C. (2010). Secure tracks device improves functional recovery and pain after total knee arthroplasty: a prospective, randomized, pilot study. Surgical technology international, 20, 357-361.
  14. Loftus, 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 Continuous Passive Motion Post–Total Knee Arthroplasty: Presenting Functional 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 Osteoarthritis of the Knee: Evidence-based Guideline. Journal of the American Academy of Orthopaedic Surgeons, 24(8), e87-e93.
  17. Miranda R Norvell and others, Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy, Open Forum Infectious Diseases, Volume 10, Issue 6, June 2023, ofad224, https://doi.org/10.1093/ofid/ofad224
  18. Navarro-Sarabia, F., Coronel, P., Collantes, E., Navarro, F. J., de la Serna, A. R., Naranjo, A., … & Herrero-Beaumont, G. (2011). A 40-month multicentre, randomised placebo-controlled study to assess the efficacy and carry-over effect of repeated intra-articular injections of hyaluronic acid in knee osteoarthritis: the AMELIA project. Annals of the rheumatic diseases, 70(11), 1957-1962.
  19. Pérez-Serna, A. G., Negrete-Corona, J., Chávez-Hinojosa, E., & López-Mariscal, C. (2011). Effectiveness of sodium hyaluronate in patients with gonarthrosis: randomized comparative study. Acta Ortopédica Mexicana, 25(4), 208-215.
  20. Pua, Y. H., & Ong, P. H. (2014). Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. American Journal of Physical Medicine & Rehabilitation, 93(11), 962-970.
  21. Wasserstein, D., Farlinger, C., Brull, R., Mahomed, N., & Gandhi, R. (2013). Advanced age, obesity and continuous femoral nerve blockade are independent risk factors for inpatient falls after primary total knee arthroplasty. The Journal of arthroplasty, 28(7), 1121-1124.
  22. Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2020 Feb;91(1):3-19. doi: 10.1080/17453674.2019.1683790. Epub 2019 Oct 30. Update in: Acta Orthop. 2020 Feb 14;:1. PMID: 31663402; PMCID: PMC7006728.