What are the pre-operative, intra-operative, and post-operative management strategies for a complex total knee replacement (TKR)?

Complex Total Knee Replacement Management

For complex TKR cases, prioritize comprehensive preoperative optimization including weight reduction (target BMI <30), diabetes control, quadriceps strengthening through supervised physical therapy, and meticulous surgical planning with full-length alignment radiographs, followed by early same-day mobilization and structured postoperative rehabilitation to maximize functional outcomes and minimize complications. 1

Preoperative Management Strategies

Patient Optimization and Risk Mitigation

• Weight reduction is critical: Patients should enroll in structured weight loss programs targeting BMI reduction to ≤28-30 before surgery, as obesity increases surgical complications and may compromise outcomes 1, 2

• Diabetes control must be optimized: Achieve and maintain good glycemic control preoperatively, as poor glucose management increases infection risk and impairs healing 1, 2

• Structured physical therapy programs are essential: Implement supervised exercise programs focusing on quadriceps strengthening for 6-12 weeks preoperatively, as this improves postoperative function 1, 3

• Address psychological comorbidities: Screen for depression and anxiety, as moderate evidence shows these conditions result in less improvement in patient-reported outcomes after TKR 1

• Manage chronic pain conditions: Patients with select chronic pain syndromes have less improvement in outcomes and require realistic expectation-setting 1

• Minimize narcotic use preoperatively: Avoid chronic opioid therapy before surgery, as this complicates postoperative pain management 1

Preoperative Imaging and Planning

• Obtain standard radiographs with known magnification: Standing AP, lateral, and Merchant (skyline) views are mandatory for templating implant size, planning bone cuts, and determining tibial slope 4

• Full-length alignment radiographs are required for complex cases: Hip-to-ankle standing films assess mechanical axis alignment, particularly crucial in severe varus/valgus deformities or extra-articular deformities 2, 4

• Evaluate for bone deficiencies and ligamentous integrity: Physical examination should assess collateral ligament status and deformity severity to determine if constrained implants, metal augments, or bone graft will be needed 4

Preoperative Interventions

• Intra-articular corticosteroid injections provide temporary relief: These can offer 2 months of symptom control while awaiting surgery, though evidence for predictors of response remains unclear 1

• Assistive devices should be introduced as needed: Canes or walkers help maintain mobility and reduce pain during the preoperative waiting period 1

Intra-operative Management Strategies

Anesthesia and Pain Control

• Spinal anesthesia with regional nerve blocks is preferred: Use spinal anesthesia supplemented with adductor canal blocks to minimize opiate requirements and facilitate early mobilization 1

• Consider tourniquet use carefully: While tourniquets decrease intraoperative blood loss (strong evidence), they increase short-term postoperative pain (strong evidence) and decrease short-term function (limited evidence) 1

Blood Management

• Tranexamic acid is strongly recommended: Strong evidence supports its use to decrease postoperative blood loss and reduce transfusion necessity in patients without contraindications 1

Implant Selection and Fixation

• Component fixation choice is flexible: Strong evidence shows no difference in outcomes between cemented versus noncemented tibial components, and moderate evidence supports similar results for all-cemented versus hybrid fixation 1

• Tibial component design is surgeon preference: Strong evidence supports using either all-polyethylene or modular tibial components with no difference in outcomes 1

• Cruciate-substitution design shows equivalent results: Strong evidence demonstrates no difference in outcomes between posterior-stabilized and posterior cruciate-retaining designs 1

Patellar Management

• Patellar resurfacing decision involves trade-offs: Strong evidence shows no difference in pain or function with or without resurfacing, but moderate evidence suggests resurfacing may decrease cumulative revision surgeries after 5 years 1

Technology Considerations

• Avoid routine surgical navigation: Strong evidence supports not using intraoperative navigation as it provides no difference in outcomes or complications 1

• Do not use patient-specific instrumentation routinely: Strong evidence shows PSI offers no difference in pain or functional outcomes compared to conventional instrumentation 1

Complex Case Considerations

• Have constrained implants available: Severe deformities, ligamentous insufficiency, or bone deficiencies may require semi-constrained or constrained prostheses 4

• Prepare metal augments and bone graft: Complex cases with significant bone loss necessitate these materials in the surgical armamentarium 4

Postoperative Management Strategies

Early Mobilization Protocol

• Initiate rehabilitation on the day of surgery: Strong evidence supports that same-day mobilization reduces hospital length of stay, and moderate evidence shows it reduces pain and improves function compared to starting on postoperative day 1 1

• Implement full weight-bearing immediately: Twice-daily physical therapy with full weight-bearing should begin on the day of surgery 1

• Target discharge by postoperative day 3: With appropriate early mobilization protocols, most patients can be safely discharged within 3 days 1

Structured Rehabilitation

• Supervised exercise programs are mandatory for first 2 months: Strong evidence demonstrates that supervised physical therapy during the first 8 weeks improves physical function, and limited evidence suggests it decreases pain 1, 5

• Prescribe outpatient therapy 3 times weekly: Structured programs with progressive strengthening and functional exercises optimize long-term outcomes 1, 5

• Include both land and aquatic therapy options: Aquatic activities can be beneficial components of rehabilitation programs, particularly for patients with multiple comorbidities 5

Interventions to Avoid

• Do not use continuous passive motion machines: Strong evidence shows CPM after TKR does not improve outcomes 1

• Cryotherapy devices are not beneficial: Moderate evidence demonstrates that cryotherapy devices after knee arthroplasty do not improve outcomes 1

• Avoid routine surgical drains: Current evidence does not support the use of postoperative drains 1

Anticoagulation Management

• Resume anticoagulation when hemostasis is established: For patients on apixaban or similar agents, resumption typically occurs 12-24 hours postoperatively when adequate hemostasis is confirmed 6, 7

• Use appropriate VTE prophylaxis: For patients not on chronic anticoagulation, apixaban 2.5 mg twice daily for 5 weeks is recommended for hip procedures; knee replacement protocols may differ 7

Monitoring and Follow-up

• Monitor hemoglobin levels: Postoperative hemoglobin should be checked; transfusion is typically unnecessary with levels >9.0-9.6 mg/dL when using tranexamic acid 1

• Assess renal function postoperatively: Surgical stress may affect kidney function, particularly relevant for patients on anticoagulation 6

• Annual weight-bearing radiographs for long-term surveillance: These detect subclinical wear and allow early identification of complications 1

Common Pitfalls and Caveats

Patient Selection Errors

• Do not delay surgery arbitrarily once criteria are met: Patients have already attempted prolonged conservative treatment; unnecessary 3-month delays are not recommended 2

• Avoid operating on inadequately optimized patients: While lack of resources to modify risk factors should not be an absolute contraindication, counsel patients about increased complications with obesity, poor glycemic control, and nicotine use 2

Surgical Planning Failures

• Underestimating complexity leads to inadequate preparation: Severe coronal deformities, bone deficiencies, and extra-articular deformities require additional measures including constrained implants and augments 4

• Inadequate preoperative templating: Failure to obtain proper radiographs with known magnification compromises surgical planning 4

Postoperative Management Mistakes

• Delaying mobilization compromises outcomes: Starting rehabilitation on postoperative day 2 or later increases length of stay and may worsen pain and function 1

• Inadequate duration of supervised therapy: Stopping structured physical therapy before 2 months postoperatively reduces functional gains 1

• Premature discontinuation of VTE prophylaxis: For hip procedures, the full 5-week course of anticoagulation is necessary 7

Outcome Expectations

• 89% of patients achieve good or excellent outcomes: At 3 months, most patients ambulate independently without assistive devices, require no pain medications, and achieve 0-120° range of motion 1, 2

• Revision rates vary but are generally low: Studies with ≥5 years follow-up report revision rates of 0-13%, though younger patients face higher lifetime revision risk 2, 8