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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.

                              
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