1. Peri-operative Care for Knee Arthroplasty
De Juan Ng

2. Pre-operative period

3. History Diagnosis Past medical history Medications correct diagnosis
pain
symptoms severe enough to warrant arthroplasty
exhausted non-operative options
Past medical history
increased risk of complications
Medications
anticoagulants

4. History Social history support from family and friends
discharge planning

5. Examination standing coronal alignment sagittal plane gait
range of movement
tenderness
ligaments – intact, correctible deformity
neurovascular status

6. Radiology
Xrays
Knee xray – AP weight bearing, lateral, skyline, Rosenberg
Long leg alignment views (3 foot standing xrays)

7. Xray assessment Coronal plane alignment – varus / valgus
Sagittal plane – alignment, tibial slope
Bone loss
Evidence of ligament deficiency
Patella tracking / femoral rotation
Metalware from previous surgery
May require CT scan for further assessment

8. Pathology / other tests
Blood tests
full blood examination
biochemistry (urea and electrolytes)
coagulation
urine microscopy and culture
Other tests
ECG
chest xray

9. Pre-operative consultation
Explanation of procedure
details about total knee replacement
picture
risks involved
Post-operative discharge plan
rehabilitation vs home
Anaesthetist review
Pre-operative antiseptic wash

10. Post-operative period

11. Antibiotics
Analgesia
Thromboprophylaxis
Xray
Blood tests
Rehabilitation

12. Antibiotic prophylaxis
Pre and post operative dose
Gram-positive bacteria cover, eg, cephazolin
1-2g <60 minutes before skin incision
1-2g, 3 doses 8-hourly post-operation

13. Analgesia
Essential to control pain for patient comfort and more effective rehabilitation
enhance functional recovery
quicker recovery of knee mobility

14. Analgesia Pre-operative Intra-operative capsular infiltration
pre-medications (eg, paracetamol, celecoxib, gabapentin)
spinal anaesthetic
nerve block – adductor canal, sciatic nerve
Intra-operative capsular infiltration
local anaesthetic
ketorolac
adrenaline

15. Analgesia Post-operative
parenteral analgesics (patient controlled analgesia)
oral analgesics
paracetamol
opioids
non-steroidal anti-inflammatory medications
local anaesthetic infusion catheters

16. Thromboprophylaxis
Following knee arthroplasty, the prevalence of venous thromboembolism (VTE) is high (up to 47% without prophylaxis)
VTE thromboprophylaxis
mechanical
compression stockings
intermittent pneumatic compression
chemical
aspirin, warfarin, enoxaparin, factor Xa inhibitors

17. Thromboprophylaxis Consider duration of prophylaxis no clear consensus
10-15 days recommended

18. Xray and blood tests Blood tests Xray – AP / lateral / (skyline)
blood count - ? need for transfusion
biochemistry
Xray – AP / lateral / (skyline)
assess position of implants, knee alignment
personal audit to assess areas for improvement

19. Rehabilitation Goal To restore knee range of movement and strength
To restore gait

20. Rehabilitation Begin 1 day post-operation adequate analgesia
sit in a chair
cold therapy to knee
compression dressing
work on range of movement, especially knee extension in the early period
walking (full weight bearing) with walking aid (frame or crutches)
muscle strength – quadriceps, gluteals

21. Summary Pre-operative Post-operative
history and examination to ensure procedure is appropriate
optimize patient’s medical health
planning to ensure surgery is performed well
Post-operative
prophylactic thromboprophylaxis and antibiotics
adequate analgesia
early (day 1) rehabilitation