Week 15 Handout Flipped Classrooms: Total Knee Arthroplasty (TKA)

Question 1

What is Total Knee Arthroplasty (TKA)?

Answer 1

Also called Total Knee Replacement (TKR). The goal is to replace damaged knee joint surfaces with prosthetic components.

Question 2

What components are used in TKA?

Answer 2

Distal Femur: Metal; Tibia: Polyethylene insert on surface.

Question 3

What are the indications for TKA?

Answer 3

Osteoarthritis, Rheumatoid arthritis, Post-traumatic deformities, Overuse injuries.

Question 4

What is osteoarthritis?

Answer 4

Degenerative cartilage loss causing pain and stiffness.

Question 5

What is rheumatoid arthritis?

Answer 5

An autoimmune disorder leading to inflammatory joint destruction.

Question 6

What are post-traumatic deformities?

Answer 6

Joint instability from prior injury or trauma.

Question 7

What are overuse injuries?

Answer 7

Common in athletes, especially runners on hard surfaces, leading to joint stress.

Question 8

What is the positioning for TKA?

Answer 8

Supine with arms extended on padded armboards; leg positioning based on surgeon’s preference.

Question 9

What should be ensured for hip positioning?

Answer 9

No pressure to peroneal nerve, adequate hip alignment, maintenance of circulation.

Question 10

What are RA patient considerations during positioning?

Answer 10

Check for cervical spine instability; may need awake fiberoptic intubation.

Question 11

What are common nerve blocks used in TKA?

Answer 11

Femoral Nerve Block, Adductor Canal Block, Sciatic Nerve Block, Combination blocks.

Question 12

What is the purpose of a Femoral Nerve Block?

Answer 12

Primary block for anterior thigh and knee.

Question 13

What is the advantage of an Adductor Canal Block?

Answer 13

Preserves motor function and provides excellent analgesia.

Question 14

Why is the Sciatic Nerve Block often avoided?

Answer 14

To prevent foot drop.

Question 15

What are the advantages of regional blocks?

Answer 15

Reduced opioid requirements, improved post-op pain control, enhanced mobility and satisfaction, better outcomes in early ambulation protocols.

Question 16

What are the steps in the surgical procedure for TKA?

Answer 16

1. Incision (anterior/anteromedial) 2. Resection of tibia, femur, patella surfaces 3. Implantation of cemented prostheses 4. Insertion of polyethylene menisci components 5. Postop care with drain.

Question 17

What are cemented prostheses?

Answer 17

They provide rigid fixation, allow early weight-bearing, may contain antibiotics, and are biocompatible with body tissues.

Question 18

What is a caution regarding cemented prostheses?

Answer 18

Exothermic curing reaction can generate heat, risking thermal injury.

Question 19

What is the recommended hemodynamic and fluid management for TKA?

Answer 19

Two large-bore IVs, maintain normotension, monitor blood loss, and use goal-directed therapy.

Question 20

What is the average estimated blood loss (EBL) during TKA?

Answer 20

200–500 mL.

Question 21

What are the transfusion triggers?

Answer 21

Hgb <7–8 g/dL or symptomatic anemia.

Question 22

What is the fluid management strategy?

Answer 22

Use goal-directed therapy, conservative crystalloid use, and consider colloids to minimize edema.

Question 23

What is the tourniquet used for in TKA?

Answer 23

Applied to thigh to maintain a bloodless field.

Question 24

What is the pressure range for tourniquet application?

Answer 24

50–100 mmHg above SBP, max 400 mmHg.

Question 25

What are the risks associated with tourniquet use?

Answer 25

Hypotension after release and reperfusion effects (lactic acid, acidosis, ↓ SVR).

Question 26

What are potential complications of TKA?

Answer 26

DVT/PE, infection, bleeding, nerve injury.

Question 27

What are the prevention strategies for complications?

Answer 27

DVT prophylaxis, infection control, proper positioning.

Question 28

What are the components of multimodal analgesia?

Answer 28

NSAIDs, acetaminophen, nerve blocks, gabapentin.

Question 29

What is the goal of opioid-sparing strategies?

Answer 29

To minimize side effects.

Question 30

What are potential complications of surgery?

Answer 30

DVT/PE, infection, bleeding, and nerve injury.

Question 31

What causes DVT/PE?

Answer 31

Due to immobility or surgery.

Question 32

What can cause infection post-surgery?

Answer 32

From wound or prosthesis.

Question 33

What is a potential complication related to blood loss?

Answer 33

Bleeding can occur during intra- or post-operatively.

Question 34

What is a potential complication from nerve blocks?

Answer 34

Nerve injury.

Question 35

What are some DVT prophylaxis measures?

Answer 35

Early ambulation, compression stockings, and anticoagulation for high-risk patients.

Question 36

What infection control measures should be taken?

Answer 36

IV antibiotics before and after surgery and proper surgical site dressing.

Question 37

What positioning measures can prevent complications?

Answer 37

Use correct padding and alignment, and avoid excessive flexion/extension or pressure.

Question 38

What are the CRNA priorities during TKA?

Answer 38

Ensure effective nerve blocks, prepare for hemodynamic changes, practice goal-directed fluid therapy, implement multimodal analgesia, monitor for complications, facilitate early ambulation.

Question 39

Student Question: Which of the following is a primary benefit of using a femoral nerve block in total knee replacement? A) It completely anesthetizes the posterior knee B) It preserves motor function of the quadriceps C) It minimizes opioid consumption postoperatively D) It eliminates the need for general anesthesia

Answer 39

Answer: C Rationale: Regional blocks like femoral nerve block significantly reduce postoperative opioid requirements. The femoral block covers the anterior thigh and knee but not the posterior aspect. The adductor canal block, not femoral, is preferred when motor function preservation is desired. Reference: Gropper, M. A., Cohen, N. H., Eriksson, L. I., Fleisher, L. A., Leslie, K., & WienerKronish, J. P. (Eds.). (2020). Miller’s anesthesia (9th ed.). Elsevier

Question 40

Student Question: Which comorbidity most directly necessitates evaluation for cervical spine instability during TKR anesthesia planning? A) Obesity B) Rheumatoid arthritis C) Hypertension D) Diabetes mellitus

Answer 40

Answer: B Rationale: Rheumatoid arthritis can cause atlantoaxial subluxation, requiring preoperative cervical spine assessment. Reference: Jaffe, R. A., Samuels, S. I., Schmiesing, C. A., & Golianu, B. (2019). Anesthesiologist's manual of surgical procedures (6th ed.). Wolters Kluwer

Question 41

Student Question: What is the typical patient positioning for a total knee replacement surgery? A) Prone with legs dependent B) Supine with arms crossed C) Lateral decubitus with knees flexed D) Supine with arms extended on padded arm boards

Answer 41

Answer: D Rationale: Standard positioning is supine with arms extended and supported on padded boards. Leg and knee placement depends on surgeon’s preference. Reference: Jaffe, R. A., Samuels, S. I., Schmiesing, C. A., & Golianu, B. (2019). Anesthesiologist's manual of surgical procedures (6th ed.). Wolters Kluwer

Question 42

Student Question: Which of the following statements about cemented prostheses is TRUE in total knee arthroplasty? A) Cementing allows for early weight-bearing after surgery B) Cement cures endothermically and cools surrounding tissue C) Cementing causes delayed weight-bearing post-op D) Cemented implants are incompatible with body tissues

Answer 42

Answer: A Rationale: Cemented prostheses provide rigid fixation that supports early postoperative mobilization. Reference: Jaffe, R. A., Samuels, S. I., Schmiesing, C. A., & Golianu, B. (2019). Anesthesiologist's manual of surgical procedures (6th ed.). Wolters Kluwer

Question 43

Student Question: Which of the following is a potential complication after tourniquet release during TKR? A) Hyperkalemia from cement absorption B) Sudden hypertension from increased preload C) Hypotension from redistribution of blood flow D) Pulmonary edema from crystalloid overload

Answer 43

Answer: C Rationale: Tourniquet release can cause hypotension due to vasodilation caused by byproducts of metabolism (lactic acid) release. Reference: Jaffe, R. A., Samuels, S. I., Schmiesing, C. A., & Golianu, B. (2019). Anesthesiologist's manual of surgical procedures (6th ed.). Wolters Kluwer

Question 44

Student Question: Why might an adductor canal block be chosen over a femoral nerve block for TKR postoperative pain control? A) It provides complete motor blockade B) It offers superior posterior knee analgesia C) It reduces pain while preserving quadriceps strength D) It increases the need for opioids

Answer 44

Answer: C Rationale: Adductor canal block is chosen to provide pain relief while preserving motor function for early ambulation. Reference: Gropper, M. A., Cohen, N. H., Eriksson, L. I., Fleisher, L. A., Leslie, K., & WienerKronish, J. P. (Eds.). (2020). Miller’s anesthesia (9th ed.). Elsevier