Evidence-based and Patient-centered Indication for Knee Arthroplasty – Update of the Guideline

Abstract

Background

Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated.

Methods

For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications.

Results

Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI ≥ 40 kg/m²). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee.

Conclusions

The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.

Keywords

knee arthroplasty - unicondylar knee arthroplasty - knee osteoarthritis - clinical practice guideline - indication

• References

• 1 Statistisches Bundesamt (DESTATIS). Die 20 häufigsten Operationen insgesamt (OPS5) 2021. Accessed September 13, 2023 at: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Tabellen/drg-operationen-insgesamt.html
• 2 Endoprothesenregister Deutschland (EPRD). EPRD Jahresbericht 2022. Mit Sicherheit mehr Qualität. Accessed September 13, 2023 at: https://www.eprd.de/fileadmin/user_upload/Dateien/Publikationen/Berichte/Jahresbericht2022-Status5_2022–10–25_F.pdf
• 3 Stöve J, Flechtenmacher J, Lützner J. et al. Gonarthose – Therapiemarathon mit viel Geduld. Physikalische und medikamentöse Therapie. Orthopädie und Unfallchirurgie Mitteilungen und Nachrichten 2021; 11: 12-16
• 4 Weng Q, Goh SL, Wu J. et al. Comparative efficacy of exercise therapy and oral non-steroidal anti-inflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomised controlled trials. Br J Sports Med 2023; 57: 990-996
• 5 Nakano N, Shoman H, Olavarria F. et al. Why are patients dissatisfied following a total knee replacement? A systematic review. Int Orthop 2020; 44: 1971-2007
• 6 Bannuru RR, Osani MC, Vaysbrot EE. et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage 2019; 27: 1578-1589
• 7 Deutsche Gesellschaft für Orthopädie und Unfallchirurgie e. V. (DGOU). S2k-Leitlinie Indikation Knieendoprothese (AWMF-Registernummer 187–004). Accessed September 13, 2023 at: https://register.awmf.org/de/leitlinien/detail/187–004
• 8 National Health Service (NHS) Digital. Finalised Patient Reported Outcome Measures (PROMs) in England for Hip and Knee Replacement Procedures (April 2021 to March 2022). Accessed September 13, 2023 at: https://digital.nhs.uk/data-and-information/publications/statistical/patient-reported-outcome-measures-proms/finalised-hip-and-knee-replacement-procedures-april-2021-to-march-2022
• 9 Evans JT, Walker RW, Evans JP. et al. How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019; 393: 655-663
• 10 Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG). Qualitätsreport 2020. Accessed July 26, 2021 at: https://iqtig.org/downloads/berichte/2019/IQTIG_Qualitaetsreport-2020_2021–02–11.pdf
• 11 Schäfer T, Pritzkuleit R, Jeszenszky C. et al. Trends and geographical variation of primary hip and knee joint replacement in Germany. Osteoarthritis Cartilage 2013; 21: 279-288
• 12 Schmitt J, Lange T, Günther KP. et al. Indication Criteria for Total Knee Arthroplasty in Patients with Osteoarthritis – A Multi-perspective Consensus Study. Z Orthop Unfall 2017; 155: 539-548
• 13 Deutsche Gesellschaft für Orthopädie und Unfallchirurgie e. V. (DGOU). S3-Leitlinie Evidenz- und konsensbasierte Indikationskriterien zur Hüfttotalendoprothese bei Coxarthrose (EKIT-Hüfte). AWMF-Registernummer 187–001. Accessed March 02, 2022 at: https://www.awmf.org/leitlinien/detail/ll/187–001.html
• 14 Youlden DJ, Dannaway J, Enke O. Radiographic severity of knee osteoarthritis and its relationship to outcome post total knee arthroplasty: a systematic review. ANZ J Surg 2020; 90: 237-242
• 15 Shohat N, Heller S, Sudya D. et al. Mild radiographic osteoarthritis is associated with increased pain and dissatisfaction following total knee arthroplasty when compared with severe osteoarthritis: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30: 965-981
• 16 Deutsche Gesellschaft für Orthopädie und Unfallchirurgie e. V. (DGOU). S2k-Leitlinie Gonarthrose (AWMF-Registernummer 187–050). Accessed September 14, 2023 at: https://register.awmf.org/de/leitlinien/detail/187–050
• 17 Wunderlich F, Eckhard L, Buttner M. et al. The INDICATE Knee expectations survey detects general patient treatment goals for total knee arthroplasty and the influence of demographic factors on patients expectations. Knee Surg Sports Traumatol Arthrosc 2023; 31: 892-904
• 18 Lützner C, Beyer F, David L. et al. Fulfilment of patients’ mandatory expectations are crucial for satisfaction: a study amongst 352 patients after total knee arthroplasty (TKA). Knee Surg Sports Traumatol Arthrosc 2023; 31: 3755-3764
• 19 Fernandes L, Hagen KB, Bijlsma JW. et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis 2013; 72: 1125-1135
• 20 National Institute for Health and Care Excellence (NICE). Osteoarthritis in over 16 s: diagnosis and management. Accessed September 13, 2023 at: https://www.nice.org.uk/guidance/ng226/resources/osteoarthritis-in-over-16s-diagnosis-and-management-pdf-66143839026373
• 21 Royal Australian College of General Practitioners (RACGP). Guideline for the management of knee and hip osteoarthritis. 2. Accessed September 20, 2022 at: http://www.acsep.org.au/content/Document/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf
• 22 Goh SL, Persson MSM, Stocks J. et al. Efficacy and potential determinants of exercise therapy in knee and hip osteoarthritis: A systematic review and meta-analysis. Ann Phys Rehabil Med 2019; 62: 356-365
• 23 International Consortium for Health Outcomes Measurements (ICHOM). Hip & Knee Osteoarthritis Data Collection Reference Guide. Version 2.2.1. Revised: April 10th, 2017. Accessed February 28, 2023 at: https://ichom.org/files/medical-conditions/hip-knee-osteoarthritis/hip-knee-osteoarthritis-reference-guide.pdf
• 24 Lützner J, Niemeier A, Calliess T. et al. Ergebnismessung in der Hüft- und Knieendoprothetik – Empfehlung der Deutschen Gesellschaft für Endoprothetik (AE). Z Orthop Unfall 2020; 158: 26-31
• 25 Kunutsor SK, Whitehouse MR, Blom AW. et al. Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One 2016; 11: e0150866
• 26 Second International Consensus Meeting on Musculoskeletal Infection. Proceedings of the Second International Consensus Meeting on Musculoskeletal Infection. Part II: Hip and Knee. Accessed January 07, 2022 at: https://icmphilly.com/wp-content/uploads/2018/11/Hip-and-Knee.pdf
• 27 Tucker K, Günther KP, Kjaersgaard-Andersen P. et al. EFORT recommendations for off-label use, mix & match and mismatch in hip and knee arthroplasty. EFORT Open Rev 2021; 6: 982-1005
• 28 Boyce L, Prasad A, Barrett M. et al. The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature. Arch Orthop Trauma Surg 2019; 139: 553-560
• 29 Chaudhry H, Ponnusamy K, Somerville L. et al. Revision rates and functional outcomes among severely, morbidly, and super-obese patients following primary total knee arthroplasty: a systematic review and meta-analysis. JBJS Rev 2019; 7: e9
• 30 Blankstein M, Browne JA, Sonn KA. et al. Go Big or Go Home: Obesity and Total Joint Arthroplasty. J Arthroplasty 2023; 38: 1928-1937
• 31 Günther KP, Haase E, Lange T. et al. Persönlichkeitsprofil und Komorbidität: Gibt es den „schwierigen Patienten “in der primären Hüftendoprothetik?. Orthopade 2015; 44: 555-565
• 32 Sepucha KR, Vo H, Chang Y. et al. Shared decision-making is associated with better outcomes in patients with knee but not hip osteoarthritis: the DECIDE-OA randomized study. J Bone Joint Surg Am 2022; 104: 62-69
• 33 Valentine KD, Cha T, Giardina JC. et al. Assessing the quality of shared decision making for elective orthopedic surgery across a large healthcare system: cross-sectional survey study. BMC Musculoskelet Disord 2021; 22: 967
• 34 Lützner C, Postler A, Beyer F. et al. Fulfillment of expectations influence patient satisfaction 5 years after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27: 2061-2070