Total Knee Replacement (TKR) – GCC Nurse Clinical Guide

Overview

Pre-operative Care

Post-operative Care

Complications

GCC Context

MCQ Practice

🦴 Total Knee Replacement — Overview

Total Knee Replacement (TKR), also called Total Knee Arthroplasty (TKA), is the surgical replacement of the damaged knee joint surfaces with prosthetic components. It is one of the most common elective orthopaedic operations globally.

Indications

Severe osteoarthritis (primary — most common indication)
Rheumatoid arthritis with severe joint destruction
Post-traumatic arthritis
Avascular necrosis of the knee
Failed conservative treatment (physiotherapy, NSAIDs, corticosteroid injections, hyaluronic acid)

Surgical Approach

Medial parapatellar approach (most common)
Components: femoral component + tibial component + polyethylene insert ± patellar resurfacing
Cemented vs uncemented fixation (cemented more common in older patients)
General anaesthesia or spinal/epidural anaesthesia (spinal increasingly preferred — reduces blood loss, faster recovery)

Enhanced Recovery After Surgery (ERAS) for TKR

Pre-operative optimisation (haemoglobin, glycaemic control, weight)
Minimise fasting time — clear fluids up to 2 hours pre-op
Perioperative analgesia (multimodal — regional blocks + paracetamol + NSAID + opioid sparing)
Early mobilisation — standing within 4–6 hours post-op; walking with physiotherapist day 1
Goal: discharge day 2–3 (vs historically 5–7 days)

📋 Pre-operative Nursing Care

Pre-operative Assessment

Full history and examination — cardiovascular, respiratory, renal status
Bloods: FBC (target Hb ≥120 g/L pre-op — anaemia increases transfusion risk), U&E, clotting, group and save
ECG (especially age >50 or cardiac history)
Urine dipstick — exclude UTI (source of post-operative prosthetic infection)
Chest X-ray if cardiorespiratory disease

Medical Optimisation

Anaemia Management

Treat iron deficiency pre-operatively: IV or oral iron
Target Hb ≥120 g/L (women) and ≥130 g/L (men) pre-op
IV ferric carboxymaltose preferred over oral iron if <4 weeks to surgery
Tranexamic acid intraoperatively reduces blood loss by 30–50%

Diabetes Management

HbA1c target ≤69 mmol/mol (≤8.5%) for elective surgery
Poorly-controlled diabetes increases infection and wound healing risk
Day of surgery: variable rate insulin infusion (VRIII) if HbA1c >69 or glucose >12
Metformin: usually held on day of surgery

Medication Management Pre-op

Medication	Action
Warfarin	Stop 5 days pre-op; check INR day before; bridge with LMWH if high risk
DOACs (rivaroxaban, apixaban)	Stop 24–48 hours pre-op (depends on renal function)
Aspirin	Usually continue for cardiovascular prophylaxis; surgeon decision
Methotrexate	Continue perioperatively (stopping increases RA flare risk)
Biologics (TNF inhibitors)	Stop 1 dosing interval before surgery; restart when wound healed (infection risk)

Patient Education Pre-op

Expected post-operative pain and management plan
Physiotherapy exercises to practise pre-op (quadriceps sets, ankle pumps)
Walking aids (frame/crutches) and how to use them
DVT prevention measures
Expected length of stay and discharge criteria
Post-discharge rehabilitation and outpatient physiotherapy plan

🏥 Post-operative Nursing Care

Immediate Post-operative Assessment (PACU/Recovery)

ABCDE assessment and vital signs every 15 minutes × 1 hour
Wound inspection: dressing intact, Redivac drain output (if used)
Neurovascular check of operated limb: capillary refill, sensation, movement, pulse in foot
Pain score: target ≤3/10 at rest before transfer to ward
Urine output: catheter usually removed day 1

Pain Management (Multimodal)

Multimodal analgesia reduces opioid requirements and enables earlier mobilisation:

Paracetamol 1g QDS (regular, scheduled)
NSAID (celecoxib or diclofenac) if renal function adequate and no contraindications
Adductor canal block (ACB) / femoral nerve block — regional anaesthesia; excellent opioid-sparing effect
Periarticular infiltration (PAI) — local anaesthetic injected into joint by surgeon
Opioids (PRN morphine/oxycodone) for breakthrough pain
Ice packs over dressing (20 min on/20 min off) — reduces pain and swelling

Physiotherapy Milestones (ERAS)

Milestone	Target Timing
Sitting out of bed	4–6 hours post-op
Standing/walking frame	Day 1 post-op (with physiotherapist)
Knee flexion 90°	Day 1–2
Stairs (one flight)	Day 2–3
Discharge from hospital	Day 2–3 (ERAS target)
Unassisted walking	6–8 weeks
Full recovery/return to activities	3–6 months

VTE Prophylaxis (CRITICAL)

TKR = HIGH VTE RISK SURGERY.
Pharmacological prophylaxis: LMWH (enoxaparin 40 mg SC daily) starting 8–12 hours post-op; continue for 14 days after TKR (28–35 days after THR)
OR DOAC: rivaroxaban 10 mg OD or apixaban 2.5 mg BD from 12 hours post-op × 14 days
Mechanical: TED stockings (both legs) + IPC during hospital stay

Wound Care

Sterile dressing change at 48–72 hours (if no signs of infection or drainage)
Staples/clips removed at 10–14 days
Monitor for signs of infection: erythema, warmth, increasing pain, discharge, fever
Waterproof dressings allow early showering

⚠️ Complications of TKR

Early Complications

Complication	Signs/Symptoms	Action
DVT/PE	Calf pain, leg swelling; sudden dyspnoea	Doppler USS; CTPA; anticoagulate
Wound infection (superficial)	Erythema, warmth, oozing; fever	Wound swab; antibiotics; ortho review
Periprosthetic joint infection (PJI)	Persistent pain, fever, elevated CRP/WBC; joint aspiration positive	Surgical washout or prosthesis removal; prolonged antibiotics
Haemarthrosis	Tense, painful swollen joint; significant drain output	Aspiration if tense; re-operation if haematoma
Neurovascular injury	Foot drop (peroneal nerve); foot ischaemia	Urgent ortho/vascular review

Late Complications

Aseptic loosening (most common cause of revision — prosthesis loosens from bone)
Stiffness (adhesions limiting flexion — target >90° flexion at 6 weeks)
Periprosthetic fracture (trauma to implanted knee)
Instability (ligamentous laxity post-surgery)
Chronic pain (up to 20% have persistent pain post-TKR)

Periprosthetic Joint Infection (PJI) — Nurse Alert

Any patient with a prosthetic knee joint who develops fever, joint pain/swelling, or wound breakdown must be assessed urgently for PJI. PJI can present:

Early (<3 months): surgical site infection spreading to joint
Late (>3 months): haematogenous seeding from dental procedures, UTI, skin infections

Dental prophylaxis (amoxicillin 2g 1 hour before dental work) recommended for first 2 years post-TKR.

Signs of Neurovascular Compromise — Hourly Checks

The "5 Ps": Pain (disproportionate), Pallor, Pulselessness, Paraesthesia, Paralysis
Any of these: inform orthopaedic team immediately — compartment syndrome or vascular injury

🌍 GCC-Specific Context

TKR Burden in GCC ▼

High rates of obesity and T2DM in GCC directly increase osteoarthritis risk → large TKR volumes
Kuwait and Saudi Arabia have among the highest arthroplasty rates in the Middle East region
Private hospitals (Cleveland Clinic Abu Dhabi, Mediclinic Middle East, NMC Healthcare) and government hospitals (KFSH, KAUH) all perform high-volume TKR
Poorly-controlled diabetes increases infection and wound healing risk — pre-operative HbA1c optimisation particularly important in GCC diabetic population
Obese patients (BMI >40): increased infection, loosening, and PE risk — some centres recommend weight loss before surgery

SCFHS / DHA / QCHP Exam Focus ▼

TKR VTE prophylaxis: 14 days post-TKR (28–35 days post-THR)
Target Hb pre-op: ≥120 g/L (anaemia = transfusion risk)
Multimodal analgesia: paracetamol + NSAID + regional block + PRN opioid
Early mobilisation: sit out day 1, walk day 1 with physio (ERAS)
Neurovascular checks: 5 Ps — Pain, Pallor, Pulselessness, Paraesthesia, Paralysis
TKR knee flexion target: 90° by discharge
Periprosthetic joint infection: dental prophylaxis recommended for 2 years post-TKR
Most common cause of TKR revision: aseptic loosening
Stop biologics (TNF inhibitors) 1 dosing interval before TKR — infection risk

📝 MCQ Practice

1. A patient is 6 hours post-total knee replacement. The nursing assessment finds the foot cold and pale with absent dorsalis pedis pulse and the patient reports numbness. What is the MOST appropriate action?

✅ C — Cold, pale limb + absent pulse + paraesthesia = multiple Ps of neurovascular compromise (pulselessness, pallor, paraesthesia). This could indicate compartment syndrome or vascular injury — a limb-threatening emergency. The orthopaedic surgeon must be called IMMEDIATELY. Never delay when multiple Ps are present.

2. How long should VTE prophylaxis with LMWH or DOAC continue after total knee replacement?

✅ B — VTE prophylaxis should continue for 14 days after total knee replacement. Note: total HIP replacement requires 28–35 days (longer duration). This is a commonly tested distinction in orthopaedic nursing exams.

3. Under ERAS (Enhanced Recovery After Surgery) protocols, when should a patient typically first mobilise after total knee replacement?

✅ C — ERAS protocols mandate early mobilisation: sitting out within 4–6 hours post-op, walking with frame/crutches under physiotherapy supervision on day 1. Early mobilisation reduces VTE risk, preserves muscle strength, reduces delirium, and enables earlier discharge. Bed rest INCREASES VTE risk.

4. A patient 3 months post-TKR develops fever, severe knee pain and swelling. CRP is 187 mg/L. What is the priority investigation?

✅ C — Fever + severe knee pain/swelling + markedly elevated CRP at 3 months post-TKR = periprosthetic joint infection (PJI) until proven otherwise. Joint aspiration for synovial fluid microscopy and culture is the key diagnostic investigation. PJI requires surgical intervention (washout or two-stage revision) and prolonged targeted antibiotics.