Peri-operative Care for Knee Arthroplasty De Juan Ng

Pre-operative period

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

History Social history support from family and friends discharge planning

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

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

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

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

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

Post-operative period

Antibiotics Analgesia Thromboprophylaxis Xray Blood tests Rehabilitation

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

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

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

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

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

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

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

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

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

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