Patient has exhausted all medical, surgical and lifestyle modification options in treating advanced degenerative arthritis of the knee and seeks discussion with orthopaedic surgeon of further options (total knee replacement). TABLE 1. CURRENT DECISION-MAKING PROCESS IN END-STAGE DEGENERATIVE ARTHRITIS OF THE KNEE Orthopaedic surgeon recommends total knee arthroplasty as a treatment option Orthopaedic surgeon does not recommend total knee arthroplasty and suggests an alternative PATIENT CONSIDERS SURGEON’S RECOMMENDATION Patient chooses to proceed with total knee replacement Patient chooses not to proceed with total knee replacement

KNOWN OA OR CONSIDERATION FOR TKA Bernini Kantor Lynch Mayor Shirreffs Sparks Tomek PROBLEM WITH EXISTING KNEE ARTHROPLASTY Bernini Kantor Scudder Shirreffs Sparks Tomek PROBLEM AFTER ACL SURGERY Carr Peterson Sparks KNOWN MENISCUS TEAR Age < 40 Carr Sparks Age > 40 Lynch Sparks Tomek KNOWN ACL OR PCL TEAR OR SPORTS INJURY Carr Karlson Peterson Shirreffs Sparks PATELLOFEMORAL PAIN Karlson Peterson Scudder Shirreffs KNEE IN PATIENT UNDER 18 YEARS Carney Athletes: Carr Karlson Peterson Sparks KNEE PAIN NYD Peterson Scudder Shirreffs PAIN AFTER FRACTURE OR TRAUMATIC DISLOCATION Within last 6 mo Cantu Koval More than 6 mo ago Bernini Kantor Lynch Mayor Scudder Shirreffs Sparks Tomek TABLE 2. KNEE PATIENT TRIAGE ALGORITHM Additional Notes: Patients should always be offered the option of an appointment with the provider that they have seen previously. Hemophilia patients should continue to be referred to Dr. Bernini

Patient decides to proceed with total knee replacement TABLE 3. EVENTS LEADING UP TO TOTAL KNEE REPLACEMENT AND THE POST-HOSPITAL COURSE A standard battery of preoperative labs is performed including complete blood count, chem-7 profile, electrocardiogram and chest x-ray Appointment is made with primary care provider (usually an internist) for medical clearance Patient attends total knee replacement class Patient admitted to DHMC, has total knee replacement and is discharged to home or to extended care facility Regularly-scheduled follow-up with orthopaedist at 6 weeks, 12 weeks, 6 months and one year. Radiographs, interval history, exam and standardized radiographs are obtained at each visit.

Patient has exhausted all medical, surgical and lifestyle modification options in treating advanced degenerative arthritis of the knee and seeks discussion with orthopaedic surgeon of further options (total knee replacement). TABLE 4. PROPOSED DECISION-MAKING PROCESS IN END- STAGE DEGENERATIVE ARTHRITIS OF THE KNEE Orthopaedic surgeon recommends total knee arthroplasty as a treatment option Orthopaedic surgeon does not recommend total knee arthroplasty and suggests an alternative PATIENT CONSIDERS SURGEON’S RECOMMENDATION Patient chooses to proceed with total knee replacement Patient chooses not to proceed with total knee replacement SHARED DECISION - MAKING AID