- See:
TKR Menu
- Checklist:
- considerations for alternative treatments:
steroid injection,
NSAIDS, cane, lateral heel wedges,
arthroscopy of the arthritic knee:
-
risk factors for infection: are taken into consideration;
-
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
-
posterior stabilized vs
PCL retaining prosthesis;
- preop cardiology, dental, GI, and urological consults
- anesthesia consult and posting
- autologous blood / cell saver
-
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;
-
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.
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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;
-
knee deformity:
- 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 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;
-
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:
-
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.
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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.
-
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.
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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.
-
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.
-
Complications and mortality associated with bilateral or unilateral total knee arthroplasty.
-
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.
-
Total knee arthroplasty for osteoarthrosis in patients who have Paget disease of bone at the knee.
- 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
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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;
Medial Gastrocnemius Transposition Flap for the Treatment of Disruption of the Extensor Mechanism after TKR.
J.W. Jaureguito MD, C.M. Dubois, S.R. Smith MD, L.J. Gottlieb MD, and J.A. Finn MD
JBJS Vol 79-A No 6. June 1997.
