What advice should be given to a patient undergoing total knee arthroplasty (TKA)?

From the Guidelines

For patients undergoing knee replacement surgery, I strongly recommend following a comprehensive pre and post-operative care plan to ensure optimal recovery, as outlined in the most recent guidelines from 2023 1. Before surgery, it is crucial to complete all pre-operative medical evaluations, follow medication instructions (especially regarding blood thinners), and prepare your home by removing tripping hazards and arranging a first-floor living space if possible. After surgery, adhere strictly to your prescribed pain management regimen, which typically includes a combination of opioids (like oxycodone) for 1-2 weeks, NSAIDs (like celecoxib 200mg twice daily), and acetaminophen (1000mg every 6 hours). Begin physical therapy as soon as recommended, usually within 24 hours after surgery, and continue for 6-12 weeks. The exercises will focus on range of motion, strengthening, and gradually increasing weight-bearing activities. Use assistive devices like walkers or canes as instructed. Watch for signs of infection (increased pain, redness, warmth, drainage, or fever) or blood clots (calf pain, swelling, or shortness of breath) and report these immediately. Most patients can return to light activities within 6 weeks and more normal function by 3 months, though complete recovery may take up to a year as the new joint fully integrates with your body's tissues and your muscles regain strength.

Some key points to consider:

• The use of tranexamic acid is supported by strong evidence to decrease postoperative blood loss and reduce the necessity of postoperative transfusions following total knee arthroplasty (TKA) in patients with no known contraindications 1.
• Early postoperative mobilization and postoperative physical therapy are helpful for achieving the best outcomes 1.
• The decision to proceed with TJA should be based on a shared decision-making process between the patient and their physician, taking into account the unique risks and benefits of the procedure for the individual patient 1.
• Patients who have medical or surgical risk factors should be counseled as to their increased risks, and preoperative attempts to modify these risk factors through efforts such as weight loss, glycemic control, or smoking cessation should be encouraged 1.

It is essential to prioritize the patient's individual needs and circumstances when making decisions about their care, and to provide them with ample resources to assist with modifying their risk factors 1.

From the Research

Preoperative Care

• Patients undergoing total knee arthroplasty (TKA) should be aware of the importance of strong pain assessment and reassessment skills with an understanding of multimodal pain management to benefit pain control and patient recovery from TKA surgery 2.
• Nursing interventions that prevent complications from infections or thromboembolism will reduce never events from occurring 2.

Thromboprophylaxis

• Guidelines recommend the use of multiple pharmacologic agents and/or mechanical compressive devices for prevention of venous thromboembolism (VTE) 3.
• Aspirin, enoxaparin, and rivaroxaban are commonly used for thromboprophylaxis after TKA, with varying degrees of efficacy and safety 3, 4, 5, 6.
• Enoxaparin and aspirin have been found to confer similar bleeding risks, and both exhibit less bleeding than patients who receive rivaroxaban 3, 4.
• Fondaparinux has been found to be as safe as aspirin for risk of wound complications 4.
• New oral antithrombotic agents, such as apixaban, dabigatran, and rivaroxaban, have demonstrated efficacy in prophylaxis against VTE following TKA while preserving safety 5.

Postoperative Care

• Safe mobilization and therapy techniques that reflect evidence-based practice will keep patients safe 2.
• Patients should be monitored for postoperative bleeding, and the choice of pharmacologic prophylaxis should be made based on a balance of the risk/benefit profile of each medication 3, 6.
• The risk of VTE and bleeding-related complications should be carefully considered when selecting a thromboprophylaxis regimen 6.