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D. Beverland
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Drain
I last used a drain in a primary knee in 1994.
I believe that the only action that a wound drain
has is to increase the blood loss.
Anaesthesic local
injections
We now try to avoid both femoral and sciatic
nerve blocks:
➢
We use 200mls of Ropivacaine hydrochlo
ride 2mg/mL.
➢
Immediately prior to implantation of compo
nents we inject the posterior capsule with
5 eparate aliquots of 10mls each with the
knee flexed to greater than 90 degrees. Care
is taken to avoid an intra-arterial injection.
➢
Then 5ml subperiosteally into of the medial
and lateral edges of the femoral condyles.
➢
Then after implanting the components and
closing the deep fascial layer 40ml are
injected into each side of the wound.
➢
Then 30ml are injected directly into the joint.
➢
And the remaining 30ml is injected
percutaneously directly onto the femur just
above the wound.
Post-operative knee
flexion
At the end of the operation we place the knee in
a flexion jig at 90 degrees for 6 hours. We have
shown that this results in a modest but
significant decrease in blood loss [2]. However
the jig must not be left on for more than
6 hours.
Post-operative pain
management
1 gram of IV paracetamol 6 hourly for the first
24 hours. This is in combination with non-
opiate oral analgesia. An oral opioid is
prescribed for breakthrough pain. We try to
avoid parenteral opiates.
Rehab
When possible we mobilise fully weight
bearing on the day of surgery if not then on the
day following surgery. This first mobilisation
is normally done by a physiotherapist. We
have physiotherapy cover 7 days per week.
Patients are encouraged to walk to the dining
room for their meals on the first post-operative
day. When the patient has successfully
completed
stair
practice
with
the
physiotherapist they can go home. By the end
of the third post-operative day 76% of our
patients have been discharged to either their
own home or that of a relative.
We do not use CPM and once the patient leaves
hospital they do not receive any further
physiotherapy [3].
Literature
[1] Cusick LA, Beverland DE. The incidence of fatal
pulmonary embolism after primary hip and knee replacement
in a consecutive series of 4253 patients.
J Bone Joint Surg
Br. 2009 May; 91(5): 645-8.
[2] Napier RJ,
et al.
The influence of immediate knee
flexion on blood loss and other parameters following total
knee replacement.
Bone Joint J. 2014 Feb; 96-B(2): 201-9.
[3] Mockford BJ
et al.
Does a standard outpatient
physiotherapy regime improve the range of knee motion
after primary total knee arthroplasty?
J Arthroplasty. 2008
Dec; 23(8): 1110-4.