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British Medical Books Health Issues Computerized Tomography

Pre-Op Planning for TKR

Checklist

X-rays & templating
Prosthetic Selection

  • quality of underlying bone
    • cemented most - controversial
    • uncemented tibial component
  • presence and competence of PCL & collat. ligaments
  • functional demands of the patient
  • unconstrained - PCL retaining - ( LCS )
  • semi-constrained - posterior stabilized prosthesis ( AB II )
  • fully constrained
  • PreOP Cardiology, Dental, GI, and Urological consults
    Anesthesia Consult
    Autologous Blood / Cell Saver
    Surgical technique

Pre-operative Planning based on Exam Findings

Previous Incisions
Limb Length
Hip Deformity

  • inability to flex hip (hip fusion) is a relative contraindication to TKR
  • in RA often concomitant arthritis of both the hip and knee
    • hip arthroplasty should be performed prior to TKR
    • hip flexion is needed in order to perform a total knee arthroplasty
    • hip is more tolerant of delayed rehabilitation than is the knee

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

Knee

  • lateral subluxation (varus thrust): release popliteus tendon

varus

  • w/ OA
  • medial para-patellar approach
  • medial release
    • elevate medial capsular sleeve w/ MCL
    • resect medial osteophytes

valgus

  • lat. approach, release IT band, LCL, post. capsule
  • may need lateral retinacular release for patellar mal-tracking

flexion contracture (extension lag)

  • ST release
  • 10 mm resection of distal femoral cortex may be preferable

recurvatum

  • usually assoc. w/ limitation of full flexion
  • ST release or resection of tibial plateau

vascular status

  • if pulses are dopplerable but are not palpable, then consider proceeding with the case but avoid use of the tourniquet
  • if the pulses are not dopplerable, then the case should be delayed until a vascular consult is obtained

bilateral total knee arthroplasty

  • simultaneous vs. staged knee total knee arthroplasty offers similar results
  • studies include Morrey JBJS 1987 (N=1253), Ranawat 1994 CORR (N=155), Ritter 1987 J Arthroplasty (N=264), Fleming 1986 J Arthroplasty (N=94), Fisher 1985 CORR (N=136)
  • overall complications were all equal between simultaneous and staged groups