What are the evidence‑based orthopedic care guidelines for 2026?

Orthopedic Guidelines 2026: Evidence-Based Care Recommendations

Critical Evidence Quality Assessment

The majority of commonly performed orthopedic procedures lack high-quality evidence supporting their clinical effectiveness, with most recommendations based on observational data rather than definitive randomized controlled trials. 1 This fundamental limitation means clinical decisions must balance available evidence with practical considerations, acknowledging that absence of trial data does not necessarily mean procedures are ineffective—some interventions may have such overwhelming observational evidence that randomized trials would be considered unethical. 1

Hip Osteoarthritis Management

Non-Pharmacological First-Line Interventions

• Land-based cardiovascular and resistance exercise supervised by a physical therapist combined with manual therapy is strongly recommended for all patients with hip OA. 2
• Aquatic exercise programs are equally strongly recommended as an alternative modality. 2
• Weight loss is mandatory for overweight or obese patients, as this directly impacts mechanical loading and disease progression. 2
• Walking aids (canes, walkers) should be provided based on functional assessment to reduce joint loading. 2
• Education and self-management programs must be implemented for all patients, including regular disease education and self-management strategies. 2

Pharmacological Management Algorithm

1. Start with acetaminophen up to 4g/day as first-line oral analgesic for mild-to-moderate pain. 2
2. Add or substitute NSAIDs when acetaminophen provides inadequate response, using the lowest effective dose for the shortest duration. 2
3. Prioritize topical NSAIDs before oral NSAIDs, particularly in patients with cardiovascular, renal, or gastrointestinal comorbidities. 2
4. Consider opioid analgesics (tramadol) only when NSAIDs are contraindicated, ineffective, or poorly tolerated. 2
5. Intra-articular corticosteroid injections may be used for acute flares unresponsive to analgesics and NSAIDs, guided by ultrasound or fluoroscopy. 2

What NOT to Use

• Glucosamine and chondroitin are not recommended based on current evidence. 2
• Intra-articular hyaluronic acid (viscosupplementation) is not recommended for hip OA, as evidence does not support its use. 2
• Electroacupuncture is not recommended. 2

Surgical Indications

• Joint-preserving procedures (osteotomy) should be considered for young adults with symptomatic hip OA, especially with dysplasia or varus/valgus deformity. 2
• Total hip replacement is indicated for patients with radiographic evidence of hip OA who have refractory pain and disability despite conservative management. 2
• For elderly patients with poor bone quality, cemented femoral fixation reduces periprosthetic fracture risk. 2

Knee Osteoarthritis Surgical Management

Preoperative Optimization

• Preoperative risk mitigation and rehabilitation are critical for optimal surgical outcomes. 1
• Modern anesthesia techniques and blood management protocols should be implemented. 1

Tranexamic Acid Use

• Tranexamic acid is strongly recommended to decrease postoperative blood loss and reduce transfusion necessity following total knee arthroplasty (TKA) in patients without contraindications. 1

Unicompartmental vs Total Knee Arthroplasty

• For isolated medial arthritis, both UKA and TKA have advantages and disadvantages. 1
• Limited evidence supports UKA may decrease risk of deep vein thrombosis and manipulation under anesthesia. 1
• Moderate evidence supports TKA decreases the number of revision surgeries compared to UKA. 1

Intraoperative Technical Decisions

• Tourniquet use has mixed evidence: moderate evidence shows it decreases intraoperative blood loss, but strong evidence demonstrates it increases short-term postoperative pain. 1
• Patellar resurfacing remains controversial with no clear consensus. 1
• No single fixation option demonstrates strong advantage over others. 1
• No demonstrable advantages exist for patient-specific instrumentation (PSI) or surgical navigation for routine TKA. 1

What NOT to Use

• Antibiotic-loaded bone cement is not supported by current evidence for routine use. 1
• Surgical drains are not recommended. 1
• Continuous passive motion (CPM) machines are not recommended. 1

Postoperative Management

• Early postoperative mobilization is essential for achieving best outcomes. 1
• Postoperative physical therapy is strongly recommended. 1

Venous Thromboembolism Prophylaxis

Multimodal Approach Components

Despite persistent lack of international consensus on specific agents 3, the following multimodal strategy demonstrates efficacy:

• Early mobilization by postoperative day 2 is critical, as failure to ambulate by day 2 significantly increases VTE risk (OR = 0.3 for those who ambulate early). 4
• FDA-approved pharmacological prophylaxis significantly reduces VTE (OR = 0.5) compared to suboptimal dosing or mechanical prophylaxis alone. 4
• Pneumatic compression devices combined with knee-high elastic stockings should be used. 5
• Mechanical prophylaxis alone is insufficient and associated with increased VTE risk. 4

Chemical Prophylaxis Options

• For elective hip and knee replacement, non-vitamin K antagonist oral anticoagulants (NOACs) have equal value to low molecular weight heparins (LMWH) or fondaparinux (strong recommendation). 6
• For hip fracture surgery, LMWH or fondaparinux is recommended. 6
• Duration should be 4-6 weeks postoperatively. 5

High-Risk Scenarios

• Bilateral simultaneous TKA significantly increases VTE risk (OR = 4.2) and requires heightened vigilance. 4
• Morbid obesity alone is NOT an independent predictor of VTE and does not require dose adjustment of standard prophylaxis. 4

Glenohumeral Osteoarthritis

Surgical Decision-Making

• Total shoulder arthroplasty is moderately recommended over hemiarthroplasty for glenohumeral OA. 1
• Total shoulder arthroplasty should NOT be performed in patients with irreparable rotator cuff tears. 1
• Surgeons performing fewer than two shoulder arthroplasties per year should avoid performing these procedures to reduce immediate postoperative complications (weak recommendation). 1
• Keeled or pegged all-polyethylene cemented glenoid components are weakly recommended. 1

Non-Surgical Options

• Injectable viscosupplementation has weak supporting evidence. 1
• Physical therapy and pharmacotherapy options are extrapolated from hip and knee OA literature but lack specific high-quality evidence for shoulder application. 1

Fracture Management: Secondary Prevention

Colles Fracture Protocol

• Every patient aged 50+ with a Colles fracture must be systematically evaluated for subsequent fracture risk. 7
• Immediate finger motion must begin after casting or surgery to prevent edema and stiffness. 7
• Aggressive finger and hand motion exercises are essential immediately after cast removal. 7

Osteoporotic Vertebral Compression Fractures

• Avoid prolonged bed rest, as this accelerates bone loss, muscle weakness, and increases DVT risk. 8
• Gentle range-of-motion exercises should begin within the first few days. 8
• MRI is required to distinguish acute from chronic fractures for treatment planning. 8

Pharmacological Secondary Prevention

• Oral bisphosphonates (alendronate 70mg weekly or risedronate 35mg weekly) should be initiated immediately, reducing vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51%. 8, 7
• Calcium 1000-1200mg/day plus vitamin D 800 IU/day is essential, reducing non-vertebral fractures by 15-20% and falls by 20%. 8, 7
• Avoid high-pulse dosages of vitamin D, as these increase fall risk. 7
• Treatment duration is typically 3-5 years, longer if high risk persists. 7

Rehabilitation Requirements

• Early postfracture physical training focusing on muscle strengthening and balance training must be implemented. 8, 7
• Balance training must continue long-term to prevent future falls. 7
• Comprehensive fall prevention strategies reduce fall frequency by approximately 20%. 8

Post-Operative Mobilization Protocols

Early mobilization interventions accelerate return of body function and minimize medical complications. 9 Five evidence-based approaches include:

• Motion interventions to increase range of motion. 9
• Progressive Muscle Relaxation (PMR) to reduce pain, increase muscle strength, and address kinesiophobia. 9
• Weight-bearing interventions to reduce stiffness and pain. 9
• Positioning interventions to reduce postoperative blood loss and increase range of motion. 9
• Neuromuscular Electrical Stimulation to increase muscle strengthening. 9

Motion-based and PMR interventions show significantly better results with range of motion recovery within six weeks post-surgery. 9

Critical Implementation Gaps

Evidence Limitations

• Barely any data exist to guide non-surgical treatment of glenohumeral OA. 1
• Most orthopaedic procedures lack definitive randomized controlled trials comparing them to no treatment or placebo. 1
• When high-level evidence shows non-operative care is equivalent to surgery, surgery should be considered second-line treatment after non-surgical measures have failed. 1

Quality Improvement Priorities

• Urgent need exists to prioritize research for procedures with limited evidence bases through definitive randomized controlled trial designs. 1
• Properly conducted definitive trials are more difficult with orthopaedic interventions than with drugs due to labor intensity, expense, late response times, and potential for crossover between arms. 1
• Problems with recruitment, blinding, and quality of reporting contribute to low-quality standards in orthopaedic trials. 1