OT notes · Orthopaedics

Total knee replacement

Usual anaesthesia
Spinal (subarachnoid block), often with adductor canal block or local infiltration
Position
Supine, thigh tourniquet, foot rest / sandbag to hold the knee in flexion
Setting
elective

Operative note template for primary total knee replacement, with a filled example for a cemented posterior-stabilised TKR for varus osteoarthritis under spinal anaesthesia with a thigh tourniquet.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • infection of the joint needing further surgery or removal of the implant
  • stiffness or reduced bending
  • instability of the knee
  • numbness on the outer side of the scar
  • wound healing problems
  • nerve injury, especially peroneal nerve in valgus knees (foot drop)
  • fracture around the implant
  • deep vein thrombosis and pulmonary embolism
  • persistent pain, loosening and wear needing revision

Pre-operative details for this operation

  1. Side and diagnosisright / left; primary osteoarthritis, rheumatoid, post-traumatic
  2. Deformity and range of motionvarus / valgus in degrees, correctable or fixed, flexion contracture, flexion range
  3. Previous scars or surgery on the kneeposition of old incisions, previous HTO or fixation
  4. X-rays and templatingstanding AP, lateral, skyline; long-leg film if deformity; planned component sizes
  5. Blood sugar / HbA1c and skin checkno active skin infection over the knee
  6. Anticoagulant / antiplatelet statusdrug, last dose
  7. Implant system and sizes availableCruciate-retainingPosterior-stabilisedOther

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneralplus adductor canal block / periarticular infiltration if used
  2. PositionSupinefoot rest or sandbag to hold 90 degrees of flexion, lateral thigh post
  3. Tourniquetthigh; pressure in mmHg; time inflated; time deflated; total minutes; skin under cuff checked at removal
  4. Tranexamic aciddose, route, time (before inflation and before deflation if IV)
  5. Antibiotic timinggiven before tourniquet inflation; time

Operative findings

  1. Compartmentsmedial, lateral, patellofemoral: cartilage loss, eburnation, osteophytes
  2. Cruciate ligamentsACL present / absent; PCL state
  3. Bone defectssite and size; how filled (cement, bone graft, augment)
  4. Synovium and joint fluidif abnormal, sent for culture / HPE

Procedure (steps)

  1. Painting and drapingantiseptic; tourniquet inflated after limb elevation / exsanguination
  2. Skin incisionanterior midline with knee flexed, length; old scar used if any
  3. ArthrotomyMedial parapatellarMidvastusSubvastusLateral parapatellarcuff left on vastus medialis for closure
  4. Exposure and medial releasedeep MCL elevated subperiosteally; patella everted or subluxed; ACL and meniscal horns removed; osteophytes removed
  5. Distal femoral cutIntramedullary guideExtramedullary guideComputer / robot assistedvalgus angle in degrees, resection in mm
  6. Tibial cutExtramedullary guideIntramedullary guideresection in mm and side referenced, slope
  7. Femoral sizing and rotationTransepicondylar axisAP (Whiteside) axis3 degrees external to posterior condylesGap balancinganterior or posterior referencing, femoral size
  8. Chamfer cuts and box cutbox cut if posterior-stabilised; PCL excised or retained
  9. Gap balancing and soft-tissue releasespacer or tensioner; releases done (name them)
  10. PatellaResurfacedNot resurfaced, osteophytes trimmed and denervatedthickness before and after cut in mm, button size
  11. Trial reductionfull extension, flexion angle, varus-valgus stability, patellar tracking ('no thumb' test), lateral release needed?
  12. Cementingcanal plugged, pulsatile lavage, surfaces dried; cement packets; order of components; excess removed
  13. Response to cementingBP and SpO2 change, if any
  14. Insert placeddebris checked for; insert thickness in mm
  15. Tourniquet release and haemostasisbefore or after closure; geniculate vessels coagulated

Closure, drains and dressing

  1. Periarticular infiltrationdrug and volume if used
  2. DrainNoneSuction drain
  3. Capsule / retinaculumsuture material; knee flexed beyond 90 degrees to test closure
  4. Subcutaneous tissue and skinclosed with knee in about 40 degrees of flexion; sutures or staples
  5. Dressingcompression bandage
  6. Neurovascular status at enddorsalis pedis and posterior tibial pulses, capillary refill; ankle and toe dorsiflexion when block allows (peroneal nerve)

Specimens and implants

  1. Femoral componentdesign, size, side, make, lot / batch number, sticker in case sheet
  2. Tibial traysize, make, lot / batch number, sticker
  3. Polyethylene inserttype and thickness, lot / batch number, sticker
  4. Patellar buttonsize, lot / batch number, sticker; or 'not resurfaced'
  5. Bone cementnumber and weight of packets, plain or antibiotic-loaded, lot / batch, sticker
  6. Specimenssynovium / fluid for culture or HPE if sent; bone cuts discarded as biomedical waste

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitals and limb checkpulse, BP, distal pulses, toe movement and sensation, dressing soakage; hourly for 4 hours then 4-hourly
  2. Limb positionfoot on a pillow with knee straight, no pillow under the knee
  3. Check X-rayAP and lateral of the knee
  4. Analgesiamultimodal: drug, dose, frequency; block top-up if catheter
  5. Tranexamic acidfurther dose if ordered
  6. Physiotherapyquadriceps exercises, range of motion from POD 0 or 1; walk with walker, weight bearing as tolerated
  7. Thromboprophylaxisas per unit protocol; calf pump exercises
  8. Drain and dressingdrain removal time if placed; dressing change day
  9. Hb and blood sugarHb on POD 1; sugar charting in diabetics
  10. Suture removal and follow-upat about 2 weeks; knee flexion target at discharge

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. L.M., 64 years, bilateral knee osteoarthritis, right worse, varus 12 degrees correctable, fixed flexion 10 degrees, flexion to 100 degrees, planned for elective right TKR.

Case details

Date: 09/09/2026. Elective arthroplasty list. OT 4 (laminar flow).

In OT 08:30. Spinal given 08:45. Tourniquet inflated 09:12. Skin incision 09:15. Tourniquet deflated 10:28. Skin closed 10:45.

Surgeon: Dr C. (consultant). First assistant: Dr A. (3rd-year resident, Orthopaedics), did the exposure and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: right knee tricompartmental osteoarthritis, Kellgren-Lawrence grade 4, pain limiting walking to 200 m despite 1 year of medical treatment and physiotherapy.

Templated: femur size 3, tibia size 3. HbA1c 6.4 percent. Skin over knee healthy. Hb 12.1 g/dl.

Consent: general, procedure-specific and anaesthesia consent taken in Gujarati from patient, husband as witness. Infection, stiffness, numbness lateral to scar and foot drop explained.

Right knee marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:00, before tourniquet inflation. Inj tranexamic acid 1 g IV at 08:52, 20 min before inflation.

Anaesthesia and position

Spinal anaesthesia with right adductor canal block. Supine, foot rest set for 90 degrees of knee flexion, lateral thigh post.

Parts painted with chlorhexidine-alcohol and draped. Limb elevated and thigh tourniquet inflated to 300 mmHg at 09:12.

Procedure

Anterior midline incision 14 cm with knee flexed. Medial parapatellar arthrotomy, leaving a cuff on vastus medialis.

Deep MCL elevated subperiosteally to the posteromedial corner. Patella everted. Findings: full-thickness cartilage loss medial compartment and patellofemoral joint, lateral compartment grade 2 changes. ACL deficient. Large medial osteophytes. Synovium normal.

ACL and anterior horns of menisci excised. Osteophytes removed.

Femoral canal entered with the intramedullary rod a few mm medial to midline, anterior to PCL origin. Distal femoral cut at 5 degrees valgus, 9 mm resection.

Tibial cut with extramedullary guide, perpendicular to mechanical axis, 2 mm below the worn medial plateau (10 mm off the lateral side).

Femur sized 3 with anterior referencing. Rotation set parallel to the transepicondylar axis, checked against the AP axis. Chamfer and box cuts done. PCL excised. Posterior horns of menisci and posterior osteophytes removed.

Extension and flexion gaps equal and balanced with a 10 mm spacer after release of the posteromedial capsule. No further release needed.

Patella 23 mm thick, cut to 14 mm, 35 mm button trial placed medially.

Trials: femur 3, tibia 3, 10 mm insert. Full extension, flexion to 125 degrees, stable in extension and at 90 degrees. Patella tracking central with 'no thumb' test. No lateral release.

Femoral canal plugged with a bone plug. Cut surfaces washed with pulsatile lavage and dried. Two packets (40 g each) of plain bone cement. Tibia cemented first, then femur and patella. Excess cement removed. Knee held in extension with trial insert till cement set. No change in BP or SpO2 at cementing.

Joint checked for debris. Final 10 mm posterior-stabilised insert locked.

Tranexamic acid 1 g IV at 10:13. Tourniquet deflated at 10:28 (total 76 min). Knee packed and haemostasis secured, lateral inferior geniculate vessels coagulated. Skin under cuff normal.

Closure

Periarticular local anaesthetic infiltration given as per unit protocol; drug and volume recorded on the anaesthesia chart.

No drain. Arthrotomy closed with interrupted polyglactin 910 (Vicryl) No. 1; knee flexed to 110 degrees to test the repair. Subcutaneous tissue with Vicryl 2-0 and skin with staples, knee in 40 degrees of flexion.

Sterile dressing and compression bandage.

Specimens and implants

Posterior-stabilised cemented knee: femoral component size 3 right, tibial tray size 3, insert 10 mm, patellar button 35 mm. Bone cement 2 x 40 g, plain.

Make and lot / batch numbers as on the stickers. All 6 stickers pasted on the implant page of the case sheet and entered in the OT implant register.

No specimen. Bone cuts discarded as yellow category biomedical waste.

End of procedure

Estimated blood loss 300 ml (mostly after deflation). No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Right foot warm, dorsalis pedis and posterior tibial pulses palpable, capillary refill under 2 seconds. Ankle and toe movement to be checked as spinal wears off.

Shifted to recovery in stable condition. Pulse 76/min, BP 130/80 mmHg.

Post-op orders

Pulse, BP, distal pulses and toe movement hourly for 4 hours, then 4-hourly. Report any foot drop at once.

Foot on a pillow with knee straight. No pillow under the knee.

Analgesia as per acute pain team (drug, dose and times written on the drug chart).

Thromboprophylaxis as per unit protocol. Ankle pump exercises hourly.

Check X-ray AP and lateral right knee. Hb and blood sugar on POD 1.

Quadriceps exercises and bending from POD 1. Walk with walker, weight bearing as tolerated, from POD 1.

Staples out at 2 weeks.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 09/09/2026, 11:00.

Must document for this operation

  • Tourniquet pressure, time of inflation and deflation, and total time. Needed if the patient develops a nerve palsy or skin injury under the cuff, and for audit of long tourniquet times.
  • Antibiotic and tranexamic acid (TXA) doses with times in relation to tourniquet inflation. The antibiotic must reach the tissue before the limb is isolated, and TXA timing is part of blood-loss audit.
  • Every component with size, make and lot / batch number, with stickers pasted. Revision surgeons often cannot find the primary implant details; the sticker page is the fastest record and is needed for recall and the registry.
  • Cruciate-retaining or posterior-stabilised design, insert thickness, and patella resurfaced or not. The revision plan, and even the choice of a simple insert exchange, depend on these.
  • Soft-tissue releases done and final stability in extension and flexion. They explain later instability or stiffness and guide the next surgeon.
  • Cement packets and lot number, and any BP or SpO2 change at cementing. Cement is an implant, and a reaction must be recorded for anaesthetic and audit review.
  • Distal pulses and peroneal nerve function at the end. Foot drop after correction of a valgus deformity must be picked up early, and the note must show the starting state.

Common mistakes in these notes

  • Writing 'TKR done' without component sizes, insert thickness or design.
  • Not writing tourniquet inflation and deflation times.
  • Giving the antibiotic after the tourniquet is inflated, or not recording its time.
  • Stickers not pasted or only the femoral sticker pasted.
  • Not stating whether the patella was resurfaced.
  • No record of foot and toe movement when the block wears off.

Indian practice and paperwork

  • Record the batch and serial number of every component and the cement in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • Under AB PM-JAY, primary TKR is package SB039A (HBP 2022) with the TKR implant mapped separately. The op note should state the anaesthesia and technique so they match the booked package. (SACHIS HBP-2022 master and NHA HBP 2.2 user guidelines)
  • The Indian Joint Registry of the Indian Society of Hip and Knee Surgeons (ISHKS) is voluntary; its form asks for implant details, so a complete sticker page makes entry easy. (ISHKS registry reports (AAHKS news 2019; PMC3796925))
  • In a Stanford audit of revision arthroplasty (first author also affiliated with a Pune hospital), the primary op note was available in 47 percent and implant stickers in 32 percent of cases. (Electricwala AJ et al., Open Orthop J 2016;10:725-731)

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; copyright 2027, Ch 8 Arthroplasty of the knee: anaesthetic options, pain management, tranexamic acid, surgical technique for primary TKA (Techniques 8.1 to 8.11), wound closure, postoperative management, pp. 426-448.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Techniques 3 and 4: total knee arthroplasty, standard midline approach and bone preparation; component implantation (Mihalko WM), pp. 12-18.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; text: the whole dose should be infused before a tourniquet is inflated (one TKA study found no SSI difference). Redose after 4 h. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 8, printed p. 428: tranexamic acid IV 10-15 mg/kg or 1 g, 20 min before tourniquet inflation and repeat about 15 min before deflation; topical 1.5-3 g in 100 ml saline for 5 min before deflation.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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