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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;
- tranexamic acid
- 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 gastrocnemius transposition 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 advanced 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