- See:
TKR Menu
- Checklist:
- considerations for alternative treatments:
steroid injection,
NSAIDS, cane, lateral heel wedges,
arthroscopy of the arthritic knee:
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risk factors for infection: are taken into consideration;
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radiographs & templating:
- ensure that the proper trial components have been assembled;
- distal femoral cutting jig (left vs right and valgus angle);
- femoral AP cutting jig size;
- box cutting jig;
- proper trial femoral component size (and right vs left);
- proximal tibial cutting jig (and posterior slope);
- misc:
- pulsed lavage gun, cement equipement, knee immobilizer;
- ensure that measures are taken to reduce infection:
- prophylactic antibiotics, minimize OR traffic, space suits, pre-scrub, iodophor adhesive drape;
- prosthetic selection:
- quality of underlying bone;
- presence and competence, of
PCL &
collateral ligaments;
- functional demands of the patient
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posterior stabilized vs
PCL retaining prosthesis;
- preop cardiology, dental, GI, and urological consults
- anesthesia consult and posting
- autologous blood / cell saver
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surgical technique:
- Pre-operative Planning based on Exam Findings:
- previous incisions:
- limb length:
-
hip deformity:
- inability to flex hip (such as hip fusion) is a relative contraindication to TKR;
- in rheumatoid arthritis, there will often be concomitant arthritis of both the hip and knee;
- generally the hip arthroplasty should be performed prior to the knee arthroplasty for the following reasons:
- hip flexion is needed inorder to perform a total knee arthroplasty;
- the hip is more tolerant of delayed rehabilitation than is the knee;
-
foot deformity:
- note deformities in hip & foot prior to proceeding w/ knee TKR;
- a valgus foot puts a valgus strain upon the knee;
- correction of ankle deformity is advised before TKR;
- if operative correction of ankle is not accepted, the final tibio-femoral angle would have to be 2 deg varus rather
than 7 deg valgus w/ the ankle w/ severe valgus;
- deformity in foot may be the cause of the deformity of knee in RA;
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vascular status:
- if pulses are dopplerable but are not palpable, then consider proceding with the case but avoid use of the tourniquet;
- if pulses are dopplerable but are not palpable in a diabetic patient, consider a vascular surgery consult;
- if the pulses are not dopplerable, then the case should be delayed until a vascular consult is obtained;
- references:
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Arterial complications of total knee replacement. The Australian experience.
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The effect of the ankle brachial pressure index and the use of a tourniquet upon the outcome of total knee replacement.
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extensor mechanism:
- w/ dificient extensor mechanism, consider medial gastrocnemius transposition flap (Jaureguito et al 1997);
- w/
quadriceps contracture (knee flexion is limited) a temporary lengthening of the extensor mechanism is required;
- an extended inverted V-Y quadricepsplasty is utilized so that the patella can be turned down anterolaterally;
- the lateral portion of this incision may be connected to a lateral retinacular release;
- clearly, these patients will require a delay in active ROM exercises;
- tibial tubercle osteotomy can be performed allowing the extensor mechanism to be retracted superiorly;
- prior to cementing of the tibial component, cerclage wires are passed along the edges of the medullary canal;
- in this manner the wires will pass around the tibial component as it is cemented in place;
- once the cement has hardened, the wires can be used to secure the tibial tubercle in place;
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knee deformity:
- lateral subluxation (varus thrust): release
popliteus tendon;
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varus deformity:
- note whether varus/valgus deformities are fixed vs flexible;
- it is important to distinguish between a fixed varus knee and a knee w/ pseudolaxity due to loss of the medial joint space;
- in the later case, the MCL may be attenuated and can easily be "overstripped" during the initial exposure (when this happens,
a larger spacer is needed to restore stability);
- w/ a fixed varus knee, further capsular elevation may be required;
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valgus deformity:
- if signicant PreOp valgus deformity has been corrected, it consider
lateral retinacular release
to allow proper patellar tracking & prevent patellar subluxation;
- consider subvastus approach to preserve
blood supply to the patella;
- release IT band,
LCL, and posterior capsule may all be necessary;
-
flexion contracture of knee:
- w/ flexion contracture, a 10 mm resection of distal femoral cortex may be preferable;
- recurvatum:
- is usually assoc w/ limitation of full flexion;
- this is relatively rare deformity in the arthritic knee;
- correction involves not only filling extension space w/ thick tibial implant, but also lengthening of the quadriceps;
- Special Situations:
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TKR following HTO;
- old diaphyseal or periarticular fractures
- remote history of infection
- patellectomy
- combined ligamentous instability
- tumors
- tibial plateau fractures:
- references:
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Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau: a minimum five-year follow-up study.
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Complications of total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau.
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Soft-tissue injury in total knee arthroplasty.
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Total knee arthroplasty in patients with a prior fracture of the tibial plateau.
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Total knee arthroplasty in post-traumatic arthrosis of the knee.
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rheumatoid arthritis
- considerations for the
rheumatoid cervical spine
- ensure that anesthesia is prepared for possible need for bronchoscopic intubation;
- ref:
Predictors of Paralysis in the Rheumatoid Cervical Spine in Patients Undergoing Total Joint Arthroplasty.
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juvenile rheumatoid arthritis:
- Cementless total knee arthroplasty in juvenile onset rheumatoid arthritis.
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hemophilia:
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Total knee arthroplasty for the treatment of chronic hemophilic arthropathy.
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Total knee arthroplasty in hemophilia.
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Total knee arthroplasty in chronic hemophilic arthropathy.
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Total knee arthroplasty in classic hemophilia.
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stiff / ankylosed knees (Aglietti et al, J Arthroplasty, 1989)
- 20 stiff (range of motion less than 50 degrees) and 6 ankylosed (no motion) knees were replaced
with posterior stabilized condylar prosthesis and followed up at an average of 4.5 years.
- results: 81% good to excellent, 11.5% fair, and 7.5% poor using the Hospital for Special Surgery knee rating system
- total range of motion increased from an average of 32 degrees to 78 degrees.
- flexion contracture decreased from 28 to 7 degrees and average flexion increased from 60 degrees to 85 degrees.
- less motion was achieved in the ankylosed knees.
- a modified Coonse and Adams quadricepsplasty was utilized in 11 cases.
- ref:
Considerations in total knee arthroplasty following previous knee fusion.
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bilateral total knee arthroplasty:
- multiple reviews have demonstrated that simultaneous vs. staged knee total knee arthroplasty offers similar results with lower overall costs.
- prominent studies include Morrey JBJS 1987 (N=1253), Ranawat 1994 CORR (N=155), Ritter 1987 J Arthroplasty (N=264), Fleming 1986 J Arthroplasty (N=94),
and Fisher 1985 CORR (N=136).
- the above studies all demonstrated that overall complications were all equal between simultaneous and staged groups except Fisher et al that demonstrated
lower complications in the simultaneous bilateral TKA group.
- the rate of infection and pulmonary embolism was equal in both groups of all studies mentioned.
- blood loss and transfusion requirements were approximately equal in Ritter’s and Fleming’s studies.
- Ranawat’s study demonstrated increased drain output in the simultaneous group (1500 cc) vs. the staged group (1000 cc) and higher homologous
blood requirements in the simultaneous group (60%) vs. the staged group (30%).
- all studies demonstrated that costs and overall hospital stays were significantly less with the simultaneous group.
- Morrey’s 1987 study demonstrated that mortality and loosening rates were equal.
- Ranawat’s 1994 study demonstrated that mortality was equal between the two groups and medical risk is not a factor.
- the aforementioned data suggests that simultaneous bilateral TKA is a cost-effective strategy for willing patients who understand that
rehabilitation will be more demanding and painful initially.
- these procedures should probably be reserved for centers where a large volume of total knee arthroplasty is performed.
- additionally, patients with substantial deformity, where persistent unilateral deformity would delay the rehabilitation of the corrected extremity,
are the most likely to gain from simultaneous procedures.
- references:
-
Successive bilateral total knee replacement.
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Complications and mortality associated with bilateral or unilateral total knee arthroplasty.
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Intraoperative monitoring for safety of bilateral total knee replacement.
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Simultaneous bilateral total knee arthroplasties: who decides?
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Is obesity a contraindication to bilateral total knee arthroplasties under one anesthetic?
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Paget's disease:
- tibial and femoral bowing associated with Paget disease often necessitates extramedullary cutting guides;
- arthritic knee pain must be differentiated from pain caused by Paget disease;
- arthritic knee is confirmed as source of pain if that pain is relieved after intra-articular local anesthetic injection or
ineffectively relieved following diphosphonate or
calcitonin therapy.
- exposure is often difficult in these patients;
- if there has been femoral involvement, then IM alignment rods should not be used;
- extramedullary alignment rods should generally be used in the tibia;
- references:
- Total knee arthroplasty in Paget's disease: technical problems and results. PA Schai MD et al. Orthopedics. Jan 1999. Vol 22. No 1. p 21.
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Total knee arthroplasty for osteoarthrosis in patients who have Paget disease of bone at the knee.
- Orders:
- NPO p Midnight x Meds
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ATB and PreOp ATB
- Hiboclens Shower and Bactroban to nares q12 hrs until OR
- IVF D5W 1/2 NS c 20 KCL at 100 ml/hr to begin at Midnight
- Foley (w/ Septra) or Void Prior to OR
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Diabetes (1/2 NPH dose) + S.S. - Dextrose Stick in AM and on call
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Musculoskeletal Labs:
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EKG, CXR, UA
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Type & Cross 2 units pRBC and/or
FFP
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DVT Prophylaxis:
- Cleocin solution 300 mg per 100 ml NS q6hr as mouth wash;
Alternatives to Total Knee Replacement: Autologous Hamstring Resurfacing Arthroplasty
