PreOp Planning for TKR    


- See: TKR Menu

- Checklist: 
    - surgical risk assessment
            - preop cardiology, dental, GI, and urological consults
            - risk factors for infection: are taken into consideration;
            - anesthesia consult and posting
                     - Pulmonary embolism prophylaxis in more than 30,000 total knee arthroplasty patients: is there a best choice?
                     - autologous blood / cell saver / transamic acid

    - radiographs & templating:
    - surgical technique
             - ensure that the proper trial components have been assembled; 
             - pulsed lavage gun, cement equipement, knee immobilizer;
             - 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
                      - posterior stabilized vs PCL retaining prosthesis;


- Pre-operative Planning based on Exam Findings:

    - spine pathology
            - references:
                    - Patient-reported outcomes after total knee replacement vary on the basis of preoperative coexisting disease in the lumbar spine and other nonoperatively treated joints: the need for a musculoskeletal comorbidity index.
                    - Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block.
                    - Influence of low back pain on total knee arthroplasty outcome.
                    - Total knee replacement in patients with concomitant back pain results in a worse functional outcome and a lower rate of satisfaction.

    - 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;
    - knee deformity: 
           - previous incisions:  
           - lateral subluxation (varus thrust): release popliteus tendon;
           - 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 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;
          - valgus deformity:
                   - w/ valgus deformity 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; 
          - references:
                   - Preoperative Malalignment Increases Risk of Failure After Total Knee Arthroplasty
                   - Magnitude of limb lengthening after primary total knee arthroplasty.
          - 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; 
          - 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; 
                   - references:
                             - Medial gastroc flap for the treatment of disruption of the extensor mechanism after total knee arthroplasty. 
                             - Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty.
                             - Quadriceps strength and the time course of functional recovery after total knee arthroplasty
                             - Quadriceps strength in relation to total knee arthroplasty outcomes.

    - 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 preop correction of ankle is not accepted, final tibio-femoral angle would have to be 2 deg varus rather than 7 deg valgus
                     w/ ankle w/ severe valgus;
          - deformity in foot may be the cause of the deformity of knee in RA; 
          - references:
                 - Persistent hindfoot valgus causes lateral deviation of weightbearing axis after total knee arthroplasty.
                 - Correlation of Knee and Hindfoot Deformities in Knee OA: Compensatory Hindfoot Alignment and Where It Occurs
                 - Dynamic foot function changes following total knee replacement surgery.
                 - Stress fracture of the fifth metatarsal bone as a late complication of total knee arthroplasty.
                 - Stress fracture of the first metatarsal after total knee arthroplasty: two case reports using gait analysis
                 - Calcaneal stress fracture: an adverse event following total hip and total knee arthroplasty: a report of five cases.
                 - Is gait normal after total knee arthroplasty? Systematic review of the literature
                 - Evaluation of knee and hindfoot alignment before and after total knee arthroplasty: a prospective analysis
                 - Gait analysis before and after unilateral total knee arthroplasty. Study using a linear regression model of normal controls -- women without arthropathy.
                 - Persistent hindfoot valgus causes lateral deviation of weightbearing axis after total knee arthroplasty.
                 - Hindfoot alignment at one year after total knee arthroplasty.
                 - Effect of Deformities Below the Ankle on TKA
                 - Alteration of hindfoot alignment after total knee arthroplasty using a novel hindfoot alignment view
                 - The planovalgus foot: a harbinger of failure of posterior cruciate-retaining total knee replacement.

    - 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:
                - Arterial complications of total knee replacement. The Australian experience.
                - The effect of the ankle brachial pressure index and the use of a tourniquet upon the outcome of total knee replacement
                - The Value of Immediate Preoperative Vascular Examination in an At-Risk Patient for Total Knee Arthroplasty
                - Total knee arthroplasty after ipsilateral peripheral arterial bypass graft: acute arterial occlusion is a risk with or without tourniquet use.




- Special Situations:
    - TKR following HTO 
    - old diaphyseal or periarticular fractures
    - remote history of infection
    - patellectomy
    - combined ligamentous instability
    - tumors
    - tibial plateau fractures 
          - references:
               - Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau: a minimum five-year follow-up study.
               - Complications of total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau.
               - Soft-tissue injury in total knee arthroplasty.
               - Total knee arthroplasty in patients with a prior fracture of the tibial plateau.
               - Total knee arthroplasty in post-traumatic arthrosis of the knee. 
    - obesity
               - The impact of pre-operative obesity on weight change and outcome in total knee replacement: a prospective study of 529 consecutive patients.
               - Complications Following Total Knee Arthroplasty in the Superobese, BMI>50

    - 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.
    - juvenile rheumatoid arthritis:
            -
Cementless total knee arthroplasty in juvenile onset rheumatoid arthritis.
    - hemophilia:
            - Total knee arthroplasty for the treatment of chronic hemophilic arthropathy.
            - Total knee arthroplasty in hemophilia.
            - Total knee arthroplasty in chronic hemophilic arthropathy.
            - Total knee arthroplasty in classic hemophilia.
    - stiff / ankylosed knees (Aglietti et al, (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.
            - references:
                    - Considerations in total knee arthroplasty following previous knee fusion
                    - Arthroplasty for the stiff or ankylosed knee

    - bilateral total knee arthroplasty 
    - 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.  
                   - Total knee arthroplasty for osteoarthrosis in patients who have Paget disease of bone at the knee.
    - Gout:
           - Greater Wound and Renal Complications in Gout Patients Undergoing Total Joint Arthroplasty.



- Orders:
      - NPO p Midnight x Meds
      - 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
      - Diabetes (1/2 NPH dose) + S.S. - Dextrose Stick in AM and on call
      - Musculoskeletal Labs 
      - EKG, CXR, UA
      - Type & Cross 2 units pRBC and/or FFP
      - DVT Prophylaxis 
      - Cleocin solution 300 mg per 100 ml NS q6hr as mouth wash



Chronic Opioid Use Prior to Total Knee Arthroplasty



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Saturday, May 21, 2016 12:46 pm