This document discusses the pre-operative evaluation and planning for total knee replacement (TKR) surgery. It covers indications and contraindications for the surgery, patient evaluation including history, physical exam, and imaging, optimization of co-morbidities, surgical planning including templating and sizing, education of the patient, and potential complications of the surgery such as thromboembolism. The goal of the pre-operative process is to adequately prepare the patient and surgical team so that the TKR journey begins with the initial patient meeting and ends safely at the operating room door.

1. Arthoplasty of knee
a. Pre operative evaluation
b. complications
BY: Dr Sabir khadka
Junior resident
Department of orthopaedics

2. Preparation for aTKRjourney
STARTS BY MEETING
Starts by a meeting
ENDS AT THE DOOR OF
OPERATION ROOM Ends
at the door of Operation Room

3. Indication of TKR
• Primary indication
– Pain and loss of function of knee
• Secondary indication
– Osteoarthritis
– Rheumatoid Arthritis
– Osteochondromatosis
– Villonodular synovitis
– Metabolic arthritis
– Post traumatic arthritis

4. Contraindication
Absolute
• septic arthritis
• Chronic infection
• Extensor mechanism
dysfunction
• Severe vascular disease
• Recurvatum deformity sec.
to muscular weakness
• Presence of well functioning
arthrodesis
Relative
• Medical condition
• Inadequate soft tissue
coverage
• Morbid Obesity
• Neuropathic Arthropathy
• History of osteomyelitis
around knee joint

5. I-Patient’s meeting:
Crepitations with walking and going up and down
stairs.
Repeated knee swellings.
Mechanical symptoms ( locking)
Age, sex, level of activity , Habits: smoking,
alcohol.
Complaining of PAIN.
Deformities.
Limitation of the knee motion.
Crepitations with walking and going up and
down stairs
Repeated knee swellings.
Mechanical symptoms ( locking)

6. I-Patient’s meeting:
History of previous medications
Previous physiotherapy courses+ knee
injections.
Generalized joint disease.
Other comorbidities: D/M, renal ,
cerebrovascular.
History of UTI.
History of DVT
Mental status (dementia)
Social conditions : divorced, lives-alone
(postoperative care and rehabilitation)

7. II-Analysis of Complaints:
Age: above 50 y (55 y). Younger patients if
juvenile arthritis , post traumatic, markedly
deformed.
Gender of the patient: women have poorer
preoperative
knee flexion but better post-operative
functional scoring than men.
Level of activity: more active and high impact
sport ( jogging) ---less longevity of TKR

8. II-Analysis of Complaints:
1-Claudication pain of ischemia or spinal canalstenosis
(character and how it is relieved
2-Radiating pain form back , hip or sacroiliac joint.
1- Pain: (onset, course , duration , site , character,
severity, radiation , what increase ,
what decrease, night pain and associated
symptoms)
To be indication for TKA: DISABLING PAIN with
daily walking or stairs climbing, not relieving by
medications and rest.
NIGHT PAIN
+ Failure all previous trials of conservative
treatment.
Exclude:
1-Claudication pain of ischemia or spinal canal
stenosis
2-Radiating pain form back , hip or sacroiliac joint.

9. II-Analysis of Complaints
That’s it.
Knee deformity:( traumatic or inflammatory
can
be a younger age than 50 y.)
Expectations of the patient: should be
restored to reality
Operation will reduce your pain ,
improve function of your knee and
improve quality of life (activity and
sleeping).

10. Examination of the Joint
1-Examine knee joint : STANDING
Posture: front for coronal (varus/valgus) side for sagittal
( flexion / recurvatum)
Measurement by goniometer: Centre of patella= centre
of goniometer-- angle

11. III-Examination of the joints
aricositie.
Supine position:
Supine position:
Inspection: Skin: scars and redness,
varicosities, Swelling
Muscle wastingection: Skin: scars and
redness, v
Swelling:
Muscle wasting:
VMO

12. III-Examination of the joints
Supine position: Inspection:
iSupine position: Inspection:
Alignment: Sagittal and coronal
Flexion contracture
Skin diseases: psoriasis
Back of the knee: swellings and
scarsnment: Sagittal and coronal
Flexion contracture
Skin diseases: psoriasis.
Back of the knee: swellings and scars

13. III-Examination of the joint
2-Palpation:
Skin hotness.
Palpation:
Skin hotness
Effusion:
Bulge test
Patellar tap
Effusion: Bulge test
Patellar tap

14. III-Examination
of the joint:
Palpation: Crepitus:
Joint line
tenderness
Patellofemoral joint
tenderness: Grind
test
Patellar tendon
tenderness
Pes anserinus
tenderness

15. III-Examination of the joint:
3-Range of motion: ROM
F-Range of motion: ROM
Flex knee and measure by goniometer: N= 125-
135º (heel touches thigh)
Less than 110º = limited flexion.
Extend knee N= 0-10º hyperextension.
Lack of full extension: knee back not touching
the couch= flexion contracture
Measure degree : patella facing
to the ceiling lex knee and measure by
goniometer:
N= 125-135º (heel touches thigh)
Lessthan 110º = limited flexion.

16. III-Examination of the joint:
Pulses
popliteal
dorsal pedis
posterior tibial
If impaired B.V.:
No
Tourniquet.
( or inflate during
cementing)
)
-Neurovascular status: Pulses
popliteal
Dorsalis pedis
posterior tibial
If impaired B.V.:
No
Tourniquet.
Motor
knee extension - femoral nerve(L4)
foot dorsiflexion - deep peroneal (L5)
foot plantarflexion - tibial nerve (S1)

17. IV-Radiographic Evaluation
Routine views: 20 % magnification
Standing A/P in full extension:
patella facing forward
Detect:
-N=joint space more than 4 mm or
within 50% of the joint space of the
contralateral knee.
-N=lateral joint space is wider than
the medial space.
-osteophytes and subcondral bone
changes

18. AP Radiograph of the knee
• The AP view should be
obtained with the patient
in a standing position.
• Anterior posterior views
allows determination of
– Medial and lateral joint
spacing
– Articular surfaces of the
medial and lateral joint
compartments
– Femorotibial alignment

19. Lateral View
• Patellar height should be
assessed on this view using
Insall-Salvati ratio. The Insall-
Salvati is the ratio of the
patellar tendon length (LT) to
the length of the patella (LP).
• The values above 1.2 is
considered as “Patella Alta”,
while the values belove 0.8 is
considered as “Patella baja”.
• Suprapatellar and posterior
regions must be evaluated in
terms of detecting the loose
bodies.

20. Standing Orthorontgenogram
• AP view of the lower
extremities from hips to
ankles
• Mechanical axis of the
lower extremities
• Varus/valgus alignment
of the knees, leg length
discrepancy, presence
of extra-articular
deformities

21. Merchant View
• Helps to assess the
patellofemoral
alignment, trochlear
groove and articular
surface
• Congruence angle
demonstrates the
relationship of apex of
patella with trochlear
groove’s bisector

22. MRI
• MRI is used to asses the Meniscal and Ligament integrity.
• The recommended sequences are
– T1 weighted Fat suppressed spoiled gradient-echo technique
– T2 weighted fast spin-echo technique
• MRI helps in defining the avascular lesions of the knee,
determining the extent of lesion and integrity of the
overlying cartilage.

23. Radiographic Classification
To assess severity of OA:
1-Kellgren and Lawrence system Classification: standing
A/P (compare
to other healthy side!!)
• grade 0: free X-ray
• grade 1: DOUBTFUL joint space narrowing (JSN)
• grade 2: DEFINITE osteophytes and POSSIBLE JSN
• grade 3: Multiple osteophytes+ DEFINITE JSN + sclerosis,
mild bony
deformity
• grade 4: large osteophytes, marked JSN, severe sclerosis
and bony
deformity

24. Radiographic classification
II - > 4 mm joint space, but small osteophytes, slightsclerosis, or
2-IKDC (international knee
documentation committee)
Four grades in A/p view: (without
comparison)
I-No joint space narrowing, (>4 mm joint
space)
II - > 4 mm joint space, but small
osteophytes, slight sclerosis, or
femoral condyle flattening
III- 2–4 mm joint space
IV- <2 mm joint space
Osteophyte sizing from
the outer edge of the osteophyte
till the edge of sclerosed condyle in mm

25. Templating
Implant sizing: Start by lateral view and
confirm in A/P
view: Put template on x-ray films
Tibia: (anatomical axis)
choose size on lateral radiograph
ensure no overhang
aim to match native tibial slope
AP to determine medial/lateral
positioning
and ensure no overhang

26. Templating:
Implant sizing:
Femur: choose the size that.
Settle on the anterior cortex without notching.
Cover the posterior condyles not overcome it
(maintain posterior condylar offset PCO)
-Increased PCO == tight flexion gap
-Confirm by A/P to avoid overhanging

27. Templating
Implant sizing:
Put X-ray films on the template (reverse the
positions)
Draw over the X-ray films to match the selected
implants.
Write the selected sizes on the X-ray films.

28. V-Laboratory investigations:
========================================
====
ECG& Echo (above 45 y)
Chest X-ray.
BMI.
CBC, ESR, CRP.
Liver ( albumin) and kidney functions.
Random blood sugar , HbA1c(if D/M)
PT, INR
Urine analysis (with culture if pus)
MRSA screening.
ECG & Echo (above 45 y)
Chest X-ray.
BMI.

29. Laboratory investigations:
Additional:
25 (OH) vit D.
HIV screening.
Nicotine level. (if smoker)
Pre-requisites: (against infection and wound
problems)
Hg > 12g/dl
• HbA1C < 7
• Albumin >3.5mg/dl
• Transferrin >200mg/dl
• Total Lymphocyte count 1200-1500 cells/ mm3
• BMI <40
• 25-Hydroxy vitamin D >30 ng/ml

30. Optimization of the patient forTKR
you can deal with them.

31. Optimization of the patient
How to deal with modifiable factors:
1-Poor Dentition
Send to dentist for evaluation and management.
2-• BMI >40
Setup with Nutritionist---Weight loss strategy
development
Bariatric surgery evaluation Last resort
Why ? BMI >40 associated with
DVT/PE, Infection, Readmissions. Post-op
mortality
3-Smoking:-- vascular constriction –infection
rate: cessation of smoking
6 weeks before and 6 weeks after surgery.

32. Optimization of the patient .
Decreases lymphocyte count <1200 cells/ mm3
4 HbA1c >7.0
increased risk
Stroke, PE
Infection
Mortality
5- Malnutrition: Albumin <3.5 g/dL & lymphocytes < 1200
cells/mm3
Nutritionist consult ,
malnutrition---- Impairs wound healing
Hinders fibroblast proliferation
Decreases collagen synthesis
Prolongs inflammation
Decreases lymphocyte count <1200 cells/ mm3
Impairs body’s ability to fight infection
Increased risk of pneumonia

33. Optimization of the patient
Spread between people is by skin contact (shaking hands, etc.), on
2. No chronic intravenous device is present ( PICCline, etc.), and urinary
6-MRSA: STAPH AUREUS
Decolonization procedure MRSA:
1. All active skin infection sites must be resolved
before decolonization . Boils
must be drained. Antibiotics may be needed.
2. No chronic intravenous device and urinary
catheters should be avoided.
3. Colonization eradication should be attempted at
home, not in the hospital.
4. Chlorhexidine or hexachlorophene antiseptic
soap:

34. Optimization of the patient
5. Mupirocin 2% ointment
• Apply inside each nostril twice daily for 7 days, using a
cotton tipped
swab• Duration: 7 days
6. Oral antibiotics:
• Are not required for decolonization
• May be used to decrease gastrointestinal colonization,
and may
include clindamycin, doxycycline.
7. Encourage treatment of all household members

35. Optimization of the patient
obstruction (prostate)
Treat UTI prior to surgery if:
Obstructive symptoms ( retention)OR
Dysuria and bacterial count >1000 CFU/mL
Urinary tract infection (UTI)
Consider urine analysis and urine culture if:
Symptoms suggestive of urinary tract infection
OR
No symptoms, but risk factors for infection
(prostate , DM )
Proceed with surgery if:
Urine analysis not suggestive of UTI OR
Urinary tract infection, but bacterial count <1000
CFU/mL without
obstruction (prostate)
Treat UTI prior to surgery if:
Obstructive symptoms ( retention)OR
Dysuria and bacterial count >1000 CFU/mL

36. Optimization of the patient
Supraventricular arrhythmias (including atrial fibrillation) with heart rate of
>100 beats/min at rest
Symptomatic bradycardia
Severe valvular disease
Cardiac problems: cardiac consultation (ECG for ALL)
Delay surgery after coronary stenting for 1 year
Renal problems: (nephrology consultation)
If creatinine > 1.5 mg/dl or creatinine clearance < 100 ml/min.
Anaemia:
Increased risk of infection in patients with preoperative Hb < 10
g/dl
Vit D deficiency: !!
Normal > 30 ng/ ml
Less than 20 nm/ml= increased risk of aseptic loosening and
infection

37. Optimization of the patient
Drugs:
methotrexate therapy
5-Other disease-modifying antirheumatic drugs
Hydroxychloroquine considered safe to continue in perioperative period
Leflunomide, sulfasalazine, and azathioprine generally held until normal bowel/renal
function postoperatively
Drugs:
1- Dual antiplatelet therapy ( Aspirin and clopidogrel :
Stop 7 days before surgery ( after cardiologist).
2-NSAIDs: 7 days before surgery Stop taking all NSAIDs such as
naproxen , ibuprofen.
3-Stress-dose steroids (SDS) for patients on steroids
If <7.5 mg/day or any dose for <3 wks, only use typical daily dose
perioperatively
If > 7.5 mg/day individualized by the physician.
4-Methotrexate
Considered safe to continue in the perioperative period
Reasonable to hold for 2-4 weeks preoperatively if patient can
tolerate withdrawal of
methotrexate therapy
5-Other disease-modifying antirheumatic drugs
Hydroxychloroquine considered safe to continue in perioperative
period
Leflunomide, sulfasalazine, and azathioprine generally held until
normal bowel/renal
function postoperatively

38. VII-Patient Education: JOINT CLASS
Exercise: continue up to day of surgery.
Diet:
• Drink plenty of fluids.
• Eat more fiber to help avoid constipation.
• Eat foods rich in iron.
• getting enough calcium.
Inside the house:
Bathroom
• Elevated commode seat

39. Patient Education:
chips, gum, or mints are
NOT allowed.
• Do NOT use lotions or powders.
• Do NOT shave before surgery.
• Do NOT shower the morning of your surgery.
The Day before Surgery:
Do
• Remove nail polish.
• Shower and wash your hair the night before. Use the
antibacterial soap
• Sleep in clean pajamas or clothes on freshly laundered
linens.
• Get a good night’s sleep.
Do Not
• Do NOT eat or drink anything after the time you were
instructed;
chips, gum, or mints are
NOT allowed.
• Do NOT use lotions or powders.
• Do NOT shave before surgery.
• Do NOT shower the morning of your surgery

40. Complication
• Thromboembolism
– The overall prevalence of DVT after TKR without any form
of mechanical or pharmaceutical prophylaxis is 40-84%
– Correlated with other co-morbidities
– Mechanical compression boots and foot pumps helps in
prevention
– Warfarin prophylaxis usually begin on the evening before
or after surgery, adjusted according to PT ( INR 2.0-3.0)
– LMWH
– Chemical prophylaxis for at least 14days in patient without
previous DVT and upto 6 weeks in patient with history of
DVT

41. Infection
• Dreadful complication, 2-3%
• Pre-operative factors: Rheumatoid arthritis(Sero
+,Male), Skin ulceration, previous knee surgery,
use of hinged knee prosthesis, obesity ,
consistent UTI, Steroid use, DM, poor
nutrition,malignancy, psoriasis
• Organism : Staph aureus, Staph epidermidis,
Strep Species
• Usually treated with 1st Generation
Cephalosporin if resistant Vancomycin

42. Polyethyelene Wear
• Most prevalent cause of eventual prosthesis
failure
• Wear of liner creates debris and stimulates
foreign body reaction
• Leads to synovitis and osteolysis
• With progressive wear asymmetric joint space
narrowing
• Eventual metal on metal contact

43. Patellofemoral complication
• Patellofemoral instability
• Patellar fracture
• Patellar component failure
• Patellar component loosening
• Patellar clunk syndrome
• Extensor mechanism rupture

44. • Patellofemoral instability
– Extensor mechanism imbalance
– Mispositioned patellar, femoral or tibial components
– Patellar subluxation
• Patellar fracture
– Uncommon, 1%
– Excessive patellar resection
– Vascular compromise secondary to lateral release
– Patellar maltracking secondary to component malposition
– Excessive joint line elevation
– Knee flexion more than 115degrees
– Trauma, thermal necrosis
– Revision TKR

46. • Patellar component failure
– Fatigue fracture pf the metal baseplate from the
fixation lugs
– Delamination of the polyethyelene from the base
plate
• Patellar component loosening
– 0.6-2.4%
– Predisposing factors: deficient bone stock, component
malposition and subluxation, patellar fractures,
osteonecrosis of the patella, loosening of other
components

47. Patellar clunk Syndrome

48. • Extensor mechanism rupture
– Rupture of Quadriceps or patellar tendon- 0.1-
0.55%
– Quadriceps rupture may be related to lateral
release in part
– Patellar tendon release is associated with previous
knee surgery,knee manipulation,distal
realignment procedure of the extensor
mechanism

49. Neurovascular complication
• Aterial compromise after TKA is a rare but
devastating complication that occurs in 0.03-
0.02% of patients, with 25% resulting in
amputation
• Peroneal nerve palsy- 1-2%

50. Periprosthetic fractures
• Supracondylar fracture of the femur occur
infrequently after TKA ( 0.3 to 2%)
• Related risk fracture include anterior femoral
notching, osteoporosis, rheumatoid arthritis,
steroid use, female gender, revision
arthroplasty and neurological disorders
• Tibial fractures are uncommon

52. Aseptic failure of primary TKA
• Component loosening
• Polyethylene wear with osteolysis
• Ligamentous laxity
• Periprosthetic fracture
• Arthrofibrosis
• Patellofemoral complications

53. REFERENCES
• CAMPBELL’S OPERATIVE ORTHOPAEDICS, 13TH
EDITION
• APLEY & SOLOMON’S SYSTEM OF
ORTHOPAEDICS AND TRAUMA, 10TH EDITION