Total Knee Arthroplasty Operative Report

Date of Surgery: [Date]

Patient: [Patient full name] — [MRN]

Laterality: [Right / Left] (Must be explicitly stated; never inferred.)

Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s) and role(s)] (Omit line if none.)

Facility/OR: [Facility name and OR number]

(Laterality, tourniquet use, patella resurfaced status, fixation strategy, and insert constraint type must always be explicitly documented. If implant details are pending from scanning/inventory systems, include placeholder "Implant details pending from implant log" and do not finalize note until complete. If a complication occurred, describe recognition, management, and residual concern. Document what was done and found, not what was intended.)

Diagnoses and Procedure

Preoperative Diagnosis: [Primary diagnosis and relevant comorbid factors]

Postoperative Diagnosis: [Diagnosis post-procedure]

Procedure Performed: [Full procedure name including laterality]

Anesthesia and Perioperative Details

Anesthesia Type: [General / Spinal / Epidural / Combined]

Regional Blocks: [Block type(s), laterality, agent, volume] (Include only if performed.)

Antibiotic Prophylaxis: [Agent(s), dose(s), timing relative to incision]

Tranexamic Acid: [Route, dose, timing] (Include only if administered.)

Indications

[Brief narrative (2–4 sentences) summarizing primary diagnosis, failed nonoperative treatments, functional limitations, and preoperative deformity (varus/valgus, flexion contracture) if present.]

Operative Findings

[Concise description of compartmental involvement and cartilage loss pattern, bone quality, ligament status (MCL/LCL competence, PCL integrity), patellar cartilage status, pre-resection deformity severity, and any unexpected findings.]

Procedure

Positioning and Preparation: [Patient position, limb support devices, prepping and draping. Include statement that time-out was performed confirming correct patient, procedure, laterality, and implants.]

Tourniquet: [Tourniquet used / Tourniquet not used] (Must be explicitly stated.)

• Pressure: [mmHg] (If used.)
• Inflation time: [timestamp] (If used.)
• Deflation time: [timestamp] (If used.)
• Total tourniquet time: [minutes] (If used.)
• Antibiotic infusion completed prior to inflation: [Yes / No] (If used.)

Approach: [Skin incision location and length; arthrotomy type (medial parapatellar / midvastus / subvastus / other); patellar management for exposure (everted / subluxed); additional exposure maneuvers if required.]

Alignment and Instrumentation: [Method: conventional (intramedullary femur/extramedullary tibia) / navigation / robotic / patient-specific instrumentation. Alignment philosophy if relevant: mechanical / kinematic / adjusted mechanical.]

Femoral Preparation:

• Distal femoral resection: [Valgus angle relative to mechanical axis; resection thickness]
• Femoral sizing: [Size selected]
• Femoral rotation reference: [Posterior condyles / Transepicondylar axis / Whiteside's line / Gap-balanced / Combined references]
• Box/notch preparation: [Performed / Not required] (Describe if PS or constrained design.)

Tibial Preparation:

• Tibial cut method: [Extramedullary / Intramedullary / Navigation / Robotic / Patient-specific]
• Alignment achieved: [Varus/valgus relative to mechanical axis]
• Posterior slope: [Degrees]
• Tibial component size: [Size]
• Tibial rotation reference: [Tibial tubercle / Akagi line / Anterior tibial crest / Other]

Gap Balancing and Stability:

• Balancing technique: [Measured resection / Gap balancing / Hybrid]
• Flexion and extension gaps: [Symmetry and thickness; mediolateral balance]
• Soft tissue releases: [Structure(s) released and rationale / None performed]
• PCL management: [Retained / Recessed / Sacrificed]
• Insert constraint type: [CR / PS / VVC / Constrained condylar] (Must be explicitly stated.)
• Stability with trials: [ROM achieved; varus/valgus stability in extension and at 90° flexion; AP stability as applicable]

Patellar Management: [Patella resurfaced / Patella not resurfaced] (Must be explicitly stated.)

• Component type and size: [Type, size, fixation] (If resurfaced.)
• Patellar tracking: [Central / Mild lateral tilt / Required correction]
• Lateral release: [Performed with rationale / Not performed]

Final Implantation and Fixation:

• Fixation strategy: [Cemented / Cementless / Hybrid] (Must be explicitly stated.)
• Cement details: [Cement type; antibiotic-loaded if applicable; bone preparation (lavage, drying); cementation sequence] (If cemented.)
• Insert thickness: [mm]; locking mechanism confirmed engaged
• Final ROM and stability: [ROM achieved; stability confirmed]

Closure:

• Irrigation: [Solution(s) and volume]
• Hemostasis: [Method(s)]
• Drain: [Type and location / No drain placed]
• Arthrotomy closure: [Technique and suture]
• Skin closure: [Technique and materials]
• Dressing: [Type applied]
• Counts correct

Implants

(List all implanted components. If details pending from inventory system, note "Implant details pending from implant log" and complete prior to finalization.)

• Femoral component: [Manufacturer], [System/Brand], Size [size], Lot/Serial/UDI [identifier]
• Tibial baseplate: [Manufacturer], [System/Brand], Size [size], Lot/Serial/UDI [identifier]
• Polyethylene insert: [Constraint type (CR/PS/VVC/CC)], [Thickness mm], [Manufacturer/System], Lot/Serial/UDI [identifier]
• Patellar component: [Manufacturer], [System/Brand], Size [size], [Cemented / Cementless], Lot/Serial/UDI [identifier] (Include only if resurfaced.)
• Stems/Augments: [Component, dimensions, Manufacturer/System, Lot/Serial/UDI] (Include only if used.)
• Cement: [Manufacturer/Type], [Antibiotic-loaded: Yes/No], Lot [number(s)] (Include only if used.)
• Bone graft/Topical antibiotics: [Material, amount, location applied] (Include only if used.)

Operative Summary

EBL: [mL]

Specimens/Cultures: [List specimens or cultures obtained / None]

Complications: [None / Description including recognition, management, and residual concerns] (Must be explicitly stated.)

Postoperative Plan

• Weight-bearing: [Weight-bearing as tolerated / Partial weight-bearing / Non-weight-bearing]
• ROM/PT mobilization: [Knee ROM goals; PT initiation timing]
• DVT prophylaxis: [Mechanical measures] + [Pharmacologic agent, dose, duration]
• Antibiotics: [Postoperative duration]
• Pain management: [Multimodal regimen; regional catheter if applicable]
• Wound care: [Dressing management and showering instructions]
• Follow-up: [Timing and clinic]
• Imaging: [Postoperative radiographs / None ordered]
• Pathway deviations: [Deviations and rationale / None] (Include only if applicable.)

Disposition

[Patient condition at end of case; neurovascular status; destination (PACU / floor / extended recovery); specific monitoring concerns.]