Clinical UM Guideline


Subject: Elective Total Knee Arthroplasty
Guideline #:  CG-SURG-54 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018


This document addresses elective total knee arthroplasty (TKA) for knee damage severe enough to require replacement, when done as an elective, non-emergent procedure and not as part of the care of a congenital, acute or traumatic event such as fracture (excluding periprosthetic fracture). This procedure is also referred to as total knee replacement (TKR). Damaged cartilage and bone from the femur, tibia and sometimes the patella, is removed and replaced with new, artificial parts.

Note: This document does not address bicompartmental knee arthroplasty or unicondylar interpositional spacers. Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Elective total knee arthroplasty is considered medically necessary when criteria are met for one of the following indications:

  1. Persistent, symptomatic degenerative joint disease (DJD), rheumatoid arthritis including juvenile rheumatoid arthritis/juvenile idiopathic arthritis (JRA/JIA) or hemophilic arthropathy as indicated by all of the following:
    1. Imaging evidence of significant joint destruction and cartilage loss (for example, knee joint destruction, severe narrowing, bone deformities); and
    2. Requires treatment as a result of disabling pain; and
    3. Individual has failed at least 3 months of conservative non-surgical therapy*; and
    4. Individual has limited knee function secondary to disease that interferes with the ability to carry out age-appropriate activities of daily living (ADLs); OR
  2. Primary or metastatic tumor with limb salvage surgery.

Elective revision of a previous total knee arthroplasty is considered medically necessary when there is documentation of one or more of the following present:

  1. Component instability, loosening, or other mechanical failure (for example, dislocation of the patella or periprosthetic fracture); or
  2. Previous removal of knee prosthesis due to infection or catastrophic failure; or
  3. Progressive and substantial bone loss; or
  4. Recurrent disabling pain or significant functional disability that persists despite at least 3 months of conservative therapy* in conjunction with one of the following:
    1. An antalgic gait; or
    2. Abnormal findings confirmed by plain radiography or imaging studies.

*Note: Conservative therapy consists of an appropriate combination of:

  1. Medication (for example, non-steroidal anti-inflammatory drugs [NSAIDs], analgesics); and
  2. Physical therapy with muscle strengthening and flexibility exercises; and
  3. Activity modification, weight loss, walking aids, bracing or other interventions based on the individual's specific presentation, physical findings and imaging results.

Not Medically Necessary:

Elective total knee arthroplasty or elective revision of a previous total knee arthroplasty is considered not medically necessary when the criteria above have not been met, and for all other conditions, including any of the following:

  1. Known allergy to implant components (including cobalt, chromium, or aluminum); or
  2. Presence of a skin infection at the surgical site; or
  3. Presence of a systemic infection; or
  4. Rapidly progressive neurological disease.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Arthroplasty, knee, hinge prosthesis (eg, Walldius type)


Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)


Revision of total knee arthroplasty, with or without allograft, 1 component


Revision of total knee arthroplasty, with or without allograft, femoral and entire tibial component



ICD-10 Procedure



Replacement of right knee joint with synthetic substitute, cemented, open approach


Replacement of right knee joint with synthetic substitute, uncemented, open approach


Replacement of right knee joint with synthetic substitute, open approach


Replacement of left knee joint with synthetic substitute, cemented, open approach


Replacement of left knee joint with synthetic substitute, uncemented, open approach


Replacement of left knee joint with synthetic substitute, open approach


Revision of synthetic substitute in right knee joint, open approach


Revision of synthetic substitute in right knee joint, percutaneous approach


Revision of synthetic substitute in right knee joint, percutaneous endoscopic approach


Revision of synthetic substitute in right knee joint, external approach


Revision of synthetic substitute in left knee joint, open approach


Revision of synthetic substitute in left knee joint, percutaneous approach


Revision of synthetic substitute in left knee joint, percutaneous endoscopic approach


Revision of synthetic substitute in left knee joint, external approach



ICD-10 Diagnosis



All diagnoses

Discussion/General Information

Knee replacement surgery is one of the five most frequently performed inpatient procedures in the United States. In 2010, an estimated 693,400 TKAs were performed on individuals aged 45 or older. This number is expected to grow as the population ages. The vast majority of cases of TKAs are due to degenerative joint disease; osteoarthritis (OA) is the most common form of this condition. Approximately 14% of U.S. adults will be affected by OA during their lifetime. The rate of affected adults jumps up to 33.6% in those aged 65 years and older. However, OA does not always progress to the point where surgery is recommended; the need for surgery is limited to symptomatic cases. OA is a progressive joint disease, and although disease progression cannot be reversed, conservative treatment can frequently slow or mitigate the progression of the disease. While hemophilia is not a common condition, the knee is the most common joint affected by the disease. Bleeding into joints causes progressive damage to the articular cartilage leading to cartilage loss, pain and loss of function. These changes may ultimately lead to knee arthroplasty if conservative measures fail to alleviate symptoms. 

Rheumatoid arthritis is a chronic inflammatory and progressive disease characterized by symmetrical joint involvement, which causes pain, swelling, stiffness, and loss of function in the joints. If left untreated, it may lead to joint destruction and progressive disability. Rheumatoid arthritis affects 2.1 million Americans usually striking people between the ages of 20 and 60, and people in their mid to late fifties are especially vulnerable. Rheumatoid arthritis is three times more common in women than in men. The traditional nonsurgical approach consists of non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain, swelling, and inflammation, plus a disease-modifying antirheumatic drug (DMARD) such as methotrexate to slow the course of the disease and prevent joint and cartilage destruction, physical therapy, or assistive devices. Total knee arthroplasty is considered for individuals who have exhausted other conservative treatment options (AAOS, 2014).

Juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis (JRA), commonly occurs in children between ages 7 and 12 years old. It affects an estimated 294,000 children in the United States and approximately two-thirds of these children have knee involvement (Heyse, 2014). In a study examining the arthroplasty rates between 1991 and 2005, Mertelsmann-Voss and associates (2014) noted that the rates of arthroplasty in the JIA population have significantly decreased. The authors suggest this decrease might be due to the effectiveness of DMARDs and biologic agents in preventing end-stage joint destruction if initiated early in the disease process. TKA procedures in this population can be complex, structural abnormalities may exist, bone quality is frequently compromised, multiple joint involvement is common and due to the small size of the knees, custom devices may be needed (Heyse, 2014). This may contribute to poorer long term outcomes. A retrospective study by Heyse and colleagues (2014) reported that long term (20 years) TKA survivorship rates were lower for individuals with JIA versus the long term TKA survivorship rates for individuals with osteoarthritis.

There is general agreement that TKA improves clinical outcomes, such as pain and mobility and overall quality of life, when this intervention is applied to an appropriate population. As TKA is an invasive procedure, the surgery does carry some inherent risks. Approximately 0.5-1.0% of individuals will die within the 90-day post-operative period. The risks of developing a serious complication range from 0.1-1.0%. These complications include deep venous thrombosis, pulmonary embolus, deep prosthetic infection, or peri-prosthetic fracture. An additional approximately 20% of those who undergo TKA will continue to experience residual pain for 6 or more months following surgery. A number of conservative interventions have been shown to be effective in controlling the symptoms of OA. For these reasons, conservative treatment options should be exhausted prior to considering TKA.

There are a number of specialty medical societies who have published guidelines regarding the use of TKA. The OA Research Society International (OARSI) published recommendations in 2014 on the treatment of osteoarthritis. OARSI recommended orthopaedic surgical intervention after more conservative treatment options had been exhausted. Recommendations are based upon the extent of OA present and existing comorbidities. These conservative treatments include pharmacological interventions, such as capsaicin, acetaminophen, topical and oral non-selective NSAIDS, oral COX-2 inhibitors, and intra-articular glucocorticoids. OARSI recommended several core treatments appropriate for all individuals which included, but was not limited to:

The American Academy of Orthopaedic Surgeons (AAOS) 2013 guidelines for the nonsurgical treatment of osteoarthritis of the knee include a number of recommendations which are rated based upon the strength of the evidence, applicability and risk of harm of the intervention. Interventions are rated as strong, moderate, limited, inconclusive or consensus.





Recommendations published by the American College of Rheumatology (ACR) parallel those of OARSI and AAOS. In addition to a number of conditional recommendations, ACR strongly recommends cardiovascular (land based or aquatic) and resistance exercise as well as weight loss in those who are overweight. ACR conditionally recommends the use of one of the following: oral or topical NSAIDS, acetaminophen, Tramadol, or intra-articular corticosteroid injections in those individuals who have failed full-dose acetaminophen therapy.

The World Federation of Hemophilia 2012 guidelines for the management of hemophilia recommend a similar treatment plan for those affected with chronic hemophilic arthropathy. Recommended conservative therapies include analgesics such as COX-2 inhibitors, physiotherapy to preserve strength and function, casting, bracing, orthotics, walking aids or home or activity modifications. If conservative treatment fails, joint replacement surgery might be needed for severe disease.

Obesity is an independent risk factor for multiple diseases including joint deterioration (Perry, 2016). Excessive body weight increases the major mechanical load on the knee and contributes to changes in the composition, structure, and mechanical properties of articular cartilage. Zhou and colleagues evaluated the impact of BMI on the risk of knee OA in a meta-analysis of 12 studies (2014). The authors discovered a significant non-linear dose-response association between BMI and the risk of OA. When compared with a baseline BMI of 22.5 kg/m2, at 25 kg/m2, the relative risk (RR) increase was 1.59 (95% confidence interval [CI], 1.34-1.81). A BMI of 30 kg/m2 increased RR by 3.55 (95% CI, 2.51-5.11), at a BMI of 35 kg/m2 the RR was 7.45 (95% CI, 4.19-13.13) (p=0.000).Within the overall population, the increase in the incidence of total joint arthroplasty parallels the rising rate of obesity (Werner, 2015). There is a general consensus that the risk of short term post-operative complications increases as weight increases, including wound infections, component malposition and in-hospital mortality (D'Apuzzo, 2015; Perry, 2016). In a retrospective analysis, D'Apuzzo and colleagues (2015) suggested that obesity itself is not an independent risk factor for in-hospital complications and that the multiple comorbidities associated with obesity are significant confounders in many studies. In addition, there is conflicting evidence regarding whether obese individuals benefit from improved clinical outcomes in the long term. There does appear to be an increased revision rate for overweight or obese individuals five or more years following the initial surgery although this risk appears to be only moderately higher (Kerkhoffs, 2012; Perry, 2016; Si, 2015). Obese individuals have reported equivalent or superior clinical outcome satisfaction scores (Chen, 2016; McElroy, 2013; Perry, 2016). There appears to be few options for those individuals with DJD who are overweight or obese. Smith (2016) noted that those individuals with OA are at a greater risk of gaining weight due to reduced activity. While the authors of many of the studies recognized the increased complexity related to performing TKAs on this population, the majority of studies recommended not withholding joint replacement surgery for overweight or obese individuals (Chen, 2016; McElroy, 2013; Kerkhoffs, 2012; Perry, 2016; Suleiman, 2012). The American Association of Hip and Knee Surgeons (2013) notes that TKA may be considered in obese individuals and states “expectations are for a steady, but slower improvement in the severe obese compared to non-obese patients post operatively”.

Exercise and muscle strength building programs have been shown to be effective in alleviating some of the symptoms of knee OA including restoring range of motion, alleviating pain, and increasing ability to perform ADLs (Golightly, 2012; Jorge, 2015; Lange, 2008; Latham, 2010; Tanaka, 2013).

A recent randomized, assessor blinded, controlled trial (RCT) conducted by Skou and colleagues (2015) compared the outcomes of participants with moderate to severe knee OA who were assigned to either undergo total knee replacement (n=50) followed by 12 weeks of non-surgical treatment or 12 weeks of non-surgical treatment only (n=50). Non-surgical treatment consisted of exercise, education on the disease and self-help strategies, dietary counseling, use of insoles and pain medication. Participants were followed for 12 months. At 12 months, the difference in change of the mean score on four Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales from baseline was calculated. In the intention-to-treat analysis, the surgically treated group reported a significantly greater improvement in KOOS score compared to the non-surgical group (32.5; 95% CI, 26.6 to 38.3 versus 16.0, 95% CI, 10.1 to 21.9) with an adjusted mean difference of 15.8 (95% CI, 10.0 to 21.5). Both groups did report clinically relevant improvements. The surgical group also reported significantly greater improvement in scores in secondary outcomes which assessed function, mobility and perceived quality of life. In the non-surgical group, 26% (13/50) had undergone a total knee replacement prior to the 12 month follow-up and 2% (1/50) of the surgical group had not undergone total knee replacement at 12 months. These individuals were included in the intention-to-treat analysis. Serious adverse events were significantly higher in the surgical group versus the non-surgical group (8 versus 1; p=0.05 in the treated knee and 24 versus 6, p=0.005 overall). Adverse events included deep venous thrombosis and stiffness requiring manipulation under anesthesia. While the surgical group did show a greater improvement in decreasing pain and improving function and quality of life, the risk of serious adverse events is also increased. The non-surgical group was also found to have substantial improvement in most outcomes. While the results of this study did support that total knee replacement does provide improved outcomes over non-surgical treatment in those with moderate to severe OA, the surgery is not without risks. Non-surgical treatment should be pursued prior to elective surgery in order to maximize any potential benefits while minimizing risks.

The use of knee arthroplasty to reconstruct a knee following the diagnosis of a primary or metastatic tumor has largely replaced amputation as the treatment of choice. In appropriate candidates, arthroplasty can allow the individual to retain a higher level of function. In a systematic review, Thambapillary and colleagues (2013) evaluated the longevity, complications and functional outcomes associated with proximal femoral arthroplasty to treat primary or metastatic tumors of the femur. The authors noted that in those with high-grade localized or metastatic disease, knee arthroplasty provided a relief of pain and good functional capacity and tended to outlive the individual. In those with low-grade pathology, the limb salvage rate was reported at over 90% following curative resection margins surgery.

A number of considerations are involved in the decision for TKA surgery. While TKA has been established as an effective treatment for appropriate candidates, it is a major surgical procedure with its concomitant risks. In addition, prosthetic devices have limited life spans. For this reason, there is some debate regarding the optimal time to perform TKA, as the need to maintain a good quality of life is balanced with the need to postpone TKA and minimize the risk of reoperation due to prosthetic device failure. In the past, surgery was not encouraged prior to the age of 50 as there was concern about the need to replace a device; however, TKA is now routinely being performed on younger individuals.

While the rate of TKA revisions has held steady at approximately 8-12%, the overall number of cases has risen as the number of initial surgeries has increased. Complications can occur at any time during the post-operative period. Early failure may be the result of infection while later failures are due to device failure. As the mean life expectancy increased, the number of individuals outliving their device has increased. Individuals undergoing TKA at age 47 are two times as likely to require revision as to die. In contrast, individuals greater than 77 years old at the time of TKA had a 90% chance of dying prior to requiring revision due to device failure (Hamilton, 2015). The most common causes of revision surgery, after device failure, are aseptic loosening, and infections. Revision surgery varies in terms of the extent of revision needed. The procedure may involve a relatively minor secondary patellar resurfacing and exchange of the tibial insert, or may require implantation of constrained linked and mega prostheses. However, due to potential extenuating circumstances, revision surgery is often more costly and complex than the original surgery (Hamilton, 2015).


Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Arthroplasty: Surgical replacement of all or part of a joint.

Degenerative joint disease (DJD): A progressive disorder of the joints caused by gradual loss of cartilage.

Osteoarthritis(OA): Also known as osteoarthrosis, is a form of DJD.

Range of motion (ROM): Measurement of the extent to which a joint can go through all its normal spectrum of movements.

Rheumatoid arthritis: A chronic inflammatory arthritis, the synovium thickens; causing swelling and produces chemical substances that attaches and destroys the articular cartilage covering the bone.


Peer Reviewed Publications:

  1. Bi W, Wang W, Han G, et al. Osteosarcoma around the knee treated with neoadjuvant chemotherapy and a custom-designed prosthesis. Orthopedics. 2013; 36(4):e444-450.
  2. Buttgereit F, Burmester GR, Bijlsma JW. Non-surgical management of knee osteoarthritis: where are we now and where do we need to go? RMD Open. 2015; 1(1):e000027.
  3. Chen JY, Lo NN, Chong HC, et al. The influence of body mass index on functional outcome and quality of life after total knee arthroplasty. Bone Joint J. 2016; 98-B (6):780-785.
  4. Coyte PC, Hawker G, Croxford R, et al. Variation in rheumatologists' and family physicians' perceptions of the indications for and outcomes of knee replacement surgery. J Rheumatol. 1996; 23(4):730-738.
  5. D'Apuzzo MR, Novicoff WM, Browne JA. The John Insall Award: Morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin Orthop Relat Res. 2015; 473(1):57-63.
  6. Escobar A, Quintana JM, Aróstegui I, et al. Development of explicit criteria for total knee replacement. Int J Technol Assess Health Care. 2003; 19(1):57-70.
  7. Frink SJ, Rutledge J, Lewis VO, et al. Favorable long-term results of prosthetic arthroplasty of the knee for distal femur neoplasms. Clin Orthop Relat Res. 2005; 438:65-70.
  8. Golightly YM, Allen KD, Caine DJ. A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis. Phys Sportsmed. 2012; 40(4):52-65.
  9. Goodman SM, Johnson B, Zhang M, et al. Patients with rheumatoid arthritis have similar excellent outcomes after total knee replacement compared with patients with osteoarthritis. J Rheumatol. 2016; 43(1):46-53.
  10. Haidukewych GJ, Langford J, Liporace FA. Revision for periprosthetic fractures of the hip and knee. J Bone Joint Surg Am. 2013; 95(4):368-376.
  11. Hamilton D, Henderson GR, Gaston P, et al. Comparative outcomes of total hip and knee arthroplasty: a prospective cohort study. Postgrad Med J. 2012; 88(1045):627-631.
  12. Hamilton DF, Howie CR, Burnett R, et al. Dealing with the predicted increase in demand for revision total knee arthroplasty: challenges, risks and opportunities. Bone Joint J. 2015; 97-B(6):723-728.
  13. Heyse TJ, Ries MD, Bellemans J, et al. Total knee arthroplasty in patients with juvenile idiopathic arthritis. Clin Orthop Relat Res. 2014; 472(1):147-154.
  14. Hu YC, Lun DX. Application of artificial prosthesis reconstruction techniques in malignant tumors around the knee joint. Orthop Surg. 2012; 4(1):1-10.
  15. Jorge RT, Souza MC, Chiari A, et al. Progressive resistance exercise in women with osteoarthritis of the knee: a randomized controlled trial. Clin Rehabil. 2015; 29(3):234-243.
  16. Katz JN. Parachutes and preferences--a trial of knee replacement. N Engl J Med. 2015; 373(17):1668-1669.
  17. Kerkhoffs GM, Servien E, Dunn W, et al. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012; 94(20):1839-1844.
  18. Latham N, Liu CJ. Strength training in older adults: the benefits for osteoarthritis. Clin Geriatr Med. 2010; 26(3):445-459.
  19. McElroy MJ, Pivec R, Issa K, et al. The effects of obesity and morbid obesity on outcomes in TKA. J Knee Surg. 2013; 26(2):83-88.
  20. Mertelsmann-Voss C, Lyman S, Pan TJ, et al. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014; 66(6):1432-1439.
  21. Perry KI, MacDonald SJ. The obese patient: a problem of larger consequence. Bone Joint J. 2016; 98-B(1 Suppl A):3-5.
  22. Ricci WM. Periprosthetic femur fractures. J Orthop Trauma. 2015; 29(3):130-137.
  23. Rodriguez-Merchan EC. Total joint arthroplasty: the final solution for knee and hip when synovitis could not be controlled. Haemophilia. 2007; 13 Suppl 3:49-58.
  24. Si HB, Zeng Y, Shen B, et al. The influence of body mass index on the outcomes of primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015; 23(6):1824-1832.
  25. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015; 373(17):1597-1606.
  26. Smith TO, Aboelmagd T, Hing CB, MacGregor A. Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis. Bone Joint J. 2016; 98-B(9):1160-1166.
  27. Suleiman LI, Ortega G, Ong'uti SK, et al. Does BMI affect perioperative complications following total knee and hip arthroplasty? J Surg Res. 2012; 174(1):7-11.
  28. Tanaka R, Ozawa J, Kito N, Moriyama H. Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2013; 27912):1059-1071.
  29. Thambapillary S, Dimitriou R, Makridis KG, et al. Implant longevity, complications and functional outcome following proximal femoral arthroplasty for musculoskeletal tumors: a systematic review. J Arthroplasty. 2013; 28(8):1381-1385.
  30. Werner BC, Kurkis GM, Gwathmey FW, Browne JA. Bariatric surgery prior to total knee arthroplasty is associated with fewer postoperative complications. J Arthroplasty. 2015; 30(9 Suppl):81-85.
  31. Zhou ZY, Liu YK, Chen HL, et al. Body mass index and knee osteoarthritis risk: a dose-response meta-analysis. Obesity (Silver Spring). 2014; 22(10):2180-2185.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Orthopaedic Surgeons (AAOS). Surgical Management of Osteoarthritis of the Knee: Evidence-Based Clinical Practice Guideline. Adopted December 4, 2015. Available at: Accessed on June 1, 2018.
  2. American Academy of Orthopaedic Surgeons (AAOS). The diagnosis of periprosthetic joint infections of the hip and knee. Guideline and evidence report. June 2010. Available at: Accessed on June 1, 2018.
  3. American Academy of Orthopaedic Surgeons (AAOS). Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline 2nd Edition. Adopted May 18, 2013. Available at: Accessed on June 1, 2018.
  4. Cahaba Government Benefit Adminstrators®, LLC. Jurisdiction Alabama. Local Coverage Determination for Surgery: Major Joint Replacement (Hip and Knee) (L32971). Revised 10/01/2015. Available at: Available at: Accessed on June 1, 2018.
  5. First Coast Service Options, Inc. Jurisdiction J-N. Local Coverage Determination for Major Joint Replacement (Hip and Knee) (L32078). Revised 03/02/2016. Available at: Available at: Accessed on June 1, 2018.
  6. Hochberg MC, Altman RD, April KT, et al; American College of Rheumatology. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012; 64(4):465-474.
  7. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014; 22(3):363-388.
  8. National Government Services, Inc. Jurisdiction Illinois. Local Coverage Determination for Total Joint Arthroplasty (L36039). Revised 12/01/2015. Available at: Accessed on June 1, 2018. 
  9. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum. 2014; 43(6):701-712.
  10. Osmon DR, Berbari EF, Berendt AR, et al.; Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013; 56(1):e1-e25.
  11. United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Knee Replacement Procedures. Third Edition, 2014. Rosemont, IL. Available at Accessed on June 1, 2018.
  12. Wallny TA, Strauss AC, Goldmann G, et al. Elective total knee arthroplasty in haemophilic patients. Proposal for a clinical pathway. Hamostaseologie. 2014;34 Suppl 1:S23-S29.
  13. World Federation of Hemophilia. Guidelines for the management of hemophilia: 2nd edition. 2012. Available at: Accessed on June 1, 2018.
  14. Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee.. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty. 2013; 28(5):714-721.
  15. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008; 16(2):137-162.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo: Arthritis of the knee. June 2014. Available at: Accessed on June 1, 2018.
  2. American College of Rheumatology (ACR). Juvenile Arthritis. Updated April 2017. Available at: . Accessed on June 1, 2018.
  3. Arthritis Foundation. Living with Arthritis. Available at: Accessed on June 1, 2018.
  4. Centers for Disease Control and Prevention (CDC). Arthritis. Last reviewed February 21, 2018. Available at: Accessed on June 1, 2018.
  5. Hemophilia Federation of America (HFA). Joint Damage. Available at: Accessed on June 1, 2018.
  6. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Arthritis: Joint Replacement Surgery. Last reviewed on August 30, 2016. Available at: Accessed on June 1, 2018.
  7. U.S. National Library of Medicine Medline Plus. Knee Replacement. Bethesda, MD. Last reviewed on March 15, 2016. Available at: Accessed on June 1, 2018.
  8. U.S. National Library of Medicine Medline Plus. Osteoarthritis. Bethesda, MD. Last updated on April 30, 2018. Available at: Accessed on June 1, 2018.

Total Knee Arthroplasty
Total Knee Replacement

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Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Websites sections.



MPTAC review. Updated header language from “Current Effective Date” to “Publish Date.”Updated References and Websites sections.



MPTAC review. Updated Discussion, References and Websites sections.



MPTAC review. Revised medically necessary clinical indications for elective revision of a previous total knee arthroplasty. Removed injection (steroid) from conservative therapy indications for elective revision of a previous total knee arthroplasty. Added juvenile rheumatoid arthritis to the medically necessary indications. Updated formatting in position statements. Updated References and Websites sections.



MPTAC review. Updated References and Websites sections.



MPTAC review. Initial document development.