TKR – Total Knee Replacement

Knee replacements can be considerably more painful than hip replacements. The recipe is very similar, with the addition of an adductor canal block.

Pre-op

• Paracetamol PO

Intra-op

• 16G cannula, using lidocaine
• Spinal
  • 2.5ml heavy 0.5% bupivicaine
  • No opioids
• Propofol TCI for sedation, if necessary. ~1 mcg/ml
• Adductor canal block (ACB)
• Prophylactic antibiotics according to local guidelines
• Tranexamic acid
• Prophylactic anti-emetics including dexamethasone
• Local infiltration of anaesthetic (LIA) into joint
• Avoid use of tourniquet

Post-op

• Analgesia
  • Regular paracetamol
  • Regular NSAID (unless given regular aspirin)
  • Oral opioid for breakthrough pain
• VTE prophylaxis
• Early return to oral intake
• Avoid post-op IV fluids

Out of fashion

• Pre-op carbohydrate drinks – don’t accelerate discharge or reduce complications
• Opiates in spinal – although they reduce pain scores and analgesic use, benefit might be outweighed by risk of urinary retention, pruritis and respiratory depression
• Tourniquets – do not reduce total blood loss, but do cause swelling and impair early functional recovery
• Gabapentin – evidence currently lacking for pain reduction