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Pre-Admission Assessment Questions: Total Knee Replacement (TKA)

1. Reason for Surgery / Knee History

• Which knee is being replaced? (laterality confirmation)
• How long have you had knee pain/arthritis?
• What makes the pain worse — walking, stairs, rest, at night?
• Rate your pain on a scale of 0–10.
• What non-surgical treatments have you tried? (PT, injections, bracing, medications)
• Have you had any prior knee surgeries on this knee?
• Do you use any assistive devices (cane, walker, brace)?
• How far can you walk before stopping due to pain?

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2. Medical History / Comorbidities

• Do you have diabetes? If so, how well is it controlled? (last HbA1c)
• Do you have hypertension, heart disease, or heart failure?
• Any history of blood clots (DVT or pulmonary embolism)?
• Do you have kidney disease, liver disease, or COPD/asthma?
• Any history of stroke or TIA?
• Do you have obesity? (BMI is a key risk factor for complications)
• Any history of anemia or bleeding disorders?
• Any autoimmune or inflammatory conditions (RA, lupus)?
• Do you have any active infections anywhere in your body?

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3. Medications

• What prescription medications are you currently taking?
• Do you take blood thinners? (warfarin, rivaroxaban, aspirin, clopidogrel — ask about last dose)
• Do you take NSAIDs regularly? (when did you last take them?)
• Are you on steroids or immunosuppressants?
• Do you take any diabetes medications or insulin?
• Any herbal supplements or over-the-counter medications?
• Have you been told to hold any medications before surgery?

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4. Allergies

• Do you have any drug allergies? (especially antibiotics — cefazolin is standard prophylaxis)
• Any allergy to latex, iodine, or contrast dye?
• Any prior reactions to anesthesia?

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5. Anesthesia & Surgical History

• Have you had surgery or anesthesia before?
• Any complications with past anesthesia? (nausea/vomiting, difficult airway, malignant hyperthermia family history)
• Do you have a personal or family history of problems with anesthesia?
• Have you had any prior joint replacements? Any complications?

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6. Cardiovascular / Respiratory Assessment

• Any chest pain, shortness of breath, or palpitations?
• Can you climb a flight of stairs or walk on level ground without stopping?
• Do you get short of breath lying flat? (orthopnea)
• Do you snore heavily or have sleep apnea? Do you use a CPAP?
• Any recent cardiac workup or stress tests?

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7. VTE Risk Assessment

• Any personal or family history of DVT or PE?
• Are you currently on anticoagulation?
• Are you on hormonal contraceptives or HRT?
• Are you a smoker?

TKA carries high VTE risk — this informs thromboprophylaxis choice postoperatively. — Morgan and Mikhail's Clinical Anesthesiology, 7e

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8. Nutritional & Metabolic Status

• Have you lost weight recently without trying?
• Do you have a good appetite?
• Any difficulty swallowing?
• Do you drink alcohol? How much? How often?
• Do you smoke? How many pack-years?
• Do you use recreational drugs?

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9. Functional / Social History

• Who will be caring for you at home after discharge?
• Do you live in a house with stairs? Can you manage them?
• Do you have a shower/tub setup that's safe for post-op?
• Have you arranged for home PT or rehab?
• What is your occupation and activity goals after surgery?

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10. Preoperative Instructions Compliance

• Have you been NPO (nothing by mouth) since midnight / per instructions?
• Did you shower with chlorhexidine soap before admission?
• Did you complete preoperative blood work and imaging (X-rays)?
• Have you signed informed consent?
• Do you understand what to expect from the surgery and recovery?

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11. Mental Health / Expectations

• Do you have a realistic expectation of recovery time and outcomes?
• Any history of anxiety, depression, or chronic pain conditions?
• Are you on any psychiatric medications?
• Do you have concerns about the surgery you'd like to discuss?

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Key Clinical Notes

• Pain control: TKA produces more severe and longer-lasting pain than THA; multimodal analgesia and nerve blocks are key. — Morgan and Mikhail's Clinical Anesthesiology, 7e
• Anesthesia preference: Neuraxial (spinal/epidural) anesthesia is preferred over general anesthesia for TKA due to lower rates of infection, AKI, PE, and falls.
• Blood conservation: Ask about autologous donation or tranexamic acid use — standard protocol to reduce surgical bleeding.
• Active infection: Any active infection (even dental/skin) is a contraindication to proceeding with implant surgery.

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Physical Examination of the Knee

1. GENERAL INSPECTION (Patient Standing & Walking)

Standing

• Alignment: Look for varus (bow-legged) or valgus (knock-kneed) deformity — both are common findings in OA patients heading for TKA
• Limb length discrepancy
• Muscle wasting: Quadriceps atrophy (especially VMO)
• Skin changes: Scars from previous surgeries, erythema, sinuses

Gait Analysis

• Antalgic gait (shortened stance phase on affected side)
• Vaulting or circumduction suggesting stiffness
• Thrust: Varus/valgus thrust during weight-bearing

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2. INSPECTION (Patient Supine on Bed)

• Swelling: Diffuse (effusion) vs. localized (bursitis)
• Deformity: Fixed flexion contracture, hyperextension
• Skin: Bruising, erythema, sinuses, scars
• Muscle bulk: Quadriceps wasting compared bilaterally

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3. PALPATION

Temperature & Skin

• Increased warmth suggests inflammation or infection
• Compare with the contralateral knee

Effusion Tests

Specific Tenderness Points

• Medial joint line → OA, medial meniscus tear, MCL injury
• Lateral joint line → OA, lateral meniscus, LCL injury
• Medial femoral condyle → OA, avascular necrosis
• Tibial tubercle → Osgood-Schlatter (young patients), patellar tendon insertion
• Patella margins → Patellofemoral OA
• Pes anserine bursa (anteromedial proximal tibia) → Bursitis, common in OA
• Popliteal fossa → Baker's cyst, DVT, popliteal aneurysm

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4. RANGE OF MOTION (ROM)

• Crepitus: Feel for during ROM — coarse crepitus suggests significant cartilage loss
• Pain arc: Note at which point in ROM pain is provoked

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5. NEUROVASCULAR ASSESSMENT

• Distal pulses: Popliteal, posterior tibial, dorsalis pedis (critical pre-TKA)
• Capillary refill of toes
• Sensation: Light touch L3–S1 dermatomes
• Motor: Quadriceps (L3–L4), hamstrings (L5–S1), tibialis anterior (L4–L5)

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6. SPECIFIC LIGAMENT TESTS

Anterior Cruciate Ligament (ACL)

• Patient supine, knee at 20–30° flexion
• Stabilize femur with one hand; pull tibia anteriorly with the other
• Positive: Increased anterior tibial translation or soft end-point
• Graded: 1+ (0–5 mm), 2+ (5–10 mm), 3+ (>10 mm)

• Hip at 45°, knee at 90° flexion, foot stabilized
• Pull tibia forward; compare with opposite knee
• Positive: Anterior translation > contralateral side
• Less sensitive than Lachman

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Posterior Cruciate Ligament (PCL)

• Knee at 90° flexion, foot stabilized
• Push tibia posteriorly with smooth backward force
• Positive: >5 mm posterior displacement or soft end-point

• Hips and knees both flexed to 90° while supine
• Positive: Tibia visibly sags backwards relative to femur → PCL insufficiency

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Collateral Ligaments

• Test at both 0° and 30° flexion
• Valgus stress (medial force) → tests MCL
• Varus stress (lateral force) → tests LCL
• At 30° flexion: isolated collateral injury
• Laxity in full extension = combined cruciate + collateral injury

• Grade I: Pain, no laxity
• Grade II: Pain + marked laxity, firm end-point
• Grade III: Complete laxity, no end-point

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7. MENISCAL TESTS

• Patient supine, knee hyperflexed
• Examiner: one hand on foot, one hand on knee palpating joint line
• Flex/extend knee while simultaneously rotating tibia internally (lateral meniscus) and externally (medial meniscus) + apply varus/valgus stress
• Positive: Palpable/audible click along the joint line, pain, or locking

• Patient prone, knee at 90° flexion
• Apply downward compression + internal/external rotation
• Positive: Pain with compression = meniscal pathology
• Compare: pain relieved with distraction = meniscal (not ligament) origin
• Relatively specific but not sensitive

• Patient stands on affected leg, knee at 20° flexion
• Rotates body medially and laterally three times
• Positive: Medial or lateral joint line pain, or sense of locking

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8. PATELLOFEMORAL TESTS

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9. EXTENSOR MECHANISM

• Straight Leg Raise: If unable to actively lift leg with extended knee → extensor mechanism disruption (quad tendon, patellar, patellar tendon rupture)
• Palpate: Quad tendon, patella, patellar tendon for gaps/defects

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10. HIP EXAMINATION (Never Forget)

• Hip ROM (especially internal rotation)
• FABER / FADIR tests to screen for hip joint pathology
• Thomas test for hip flexor contracture

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Summary Table: Key Special Tests