Total Knee Arthroplasty (TKA)
Right [left] knee osteoarthritis, end-stage, not responsive to conservative management
Same
Right [left] total knee arthroplasty, [implant manufacturer/model, e.g., Zimmer Persona / Stryker Triathlon]
[***, MD/DO]
[Resident/PA name]
Spinal [/ general endotracheal] with [adductor canal block / femoral nerve block]
The patient is a [age]-year-old [male / female] with end-stage right [left] knee osteoarthritis presenting with [X]-year history of medically refractory knee pain, functional limitation, and radiographic joint space loss (Kellgren-Lawrence grade [3/4]). Conservative measures including physical therapy, NSAIDs, and corticosteroid injections for at least [3] months have failed. The risks, benefits, and alternatives — including infection, stiffness, instability, periprosthetic fracture, need for revision, and thromboembolic events — were discussed. Informed consent was obtained.
The knee joint demonstrated [tricompartmental / medial compartment / lateral compartment] articular cartilage loss with eburnated bone. The [medial / lateral] meniscus was [absent / degenerate]. The ACL was [absent / attenuated / intact]. Alignment was [varus / valgus / neutral] preoperatively. Component sizing was confirmed on trial reduction. Final implants: femoral component size [X], tibial tray size [X], polyethylene insert [X mm], [patellar component [X mm]].
The patient was positioned supine with the operative leg in a leg holder. Tranexamic acid [1 g IV] was administered prior to tourniquet inflation. A thigh tourniquet was applied and inflated to [200–250] mmHg (limb occlusion pressure-based or SBP + 100–150 mmHg) after exsanguination with an Esmarch bandage. A midline anterior knee incision was made from [X] cm proximal to the patella to the tibial tubercle. A medial parapatellar arthrotomy was performed. The patella was [subluxated / everted].
The distal femur was prepared with the intramedullary guide set to [5–6°] valgus. Distal femoral resection was performed. Femoral rotation was set to [3°] external rotation relative to the posterior condylar axis [confirmed with Whiteside's line and the surgical transepicondylar axis]. Femoral anterior-posterior, chamfer, and box cuts were made for size [X].
The proximal tibia was resected perpendicular to the tibial mechanical axis at [9] mm depth from the less-worn (lower) tibial plateau with [3–5°] posterior tibial slope. The tibial size was determined and the keel prepared. The PCL was [retained / sacrificed per posterior-stabilized design].
The patella was [resurfaced with a [X]-mm poly button / not resurfaced]. Patellar circumferential electrocautery denervation was performed. Trial components were placed and range of motion, alignment, and soft tissue balance assessed: [flexion X°, extension X°, stable in varus/valgus stress]. Gap balance was [symmetric in flexion and extension / required [medial / lateral] soft tissue release for balance].
The tibial tray and femoral component were cemented in place with [Palacos / Simplex] antibiotic-loaded cement. The poly insert was impacted and locked. The tourniquet was deflated. Hemostasis was achieved. The wound was irrigated. The arthrotomy was closed with [#1 Vicryl] figure-of-eight sutures. Subcutaneous tissue closed with [2-0 Vicryl]. Skin was closed with [staples / 3-0 Monocryl].
None
Femoral and tibial cartilage/bone specimens sent to pathology [if indicated]
[X] mL (tourniquet used, actual blood loss underestimated)
None [Routine closed-suction drains are not recommended for primary TKA per current evidence]
The patient was taken to the PACU in stable condition. Weight-bearing as tolerated was permitted immediately. DVT prophylaxis (aspirin 81 mg BID x 35 days [/ rivaroxaban / enoxaparin] per protocol) was initiated. Physical therapy was initiated on postoperative day 1.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left knee osteoarthritis, end-stage, KL grade ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left TKA, *** implant
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal + adductor canal block
INDICATIONS: .PTAGE-year-old .PTSEX with end-stage *** knee OA (KL grade ***), failed *** months of conservative management (PT, NSAIDs, injections). Consent obtained.
FINDINGS: *** compartment cartilage loss, eburnate bone. Meniscus ***. ACL ***. Alignment ***. Implants: femoral size ***, tibial tray size ***, poly *** mm[, patella *** mm].
PROCEDURE:
Supine. TXA 1 g IV administered. Tourniquet *** mmHg (LOP-based) after exsanguination. Midline incision. Medial parapatellar arthrotomy. Patella subluxated/everted. Distal femur resected at ***° valgus. Femoral rotation ***° ER relative to PCA (confirmed TEA/Whiteside). Femoral cuts size ***. Proximal tibial resection perpendicular to mechanical axis, *** mm from less-worn plateau, ***° posterior slope. PCL ***. Patella [resurfaced *** mm / not resurfaced; patellar denervation performed]. Trials: ROM ***, gaps symmetric, balanced [/ released ***]. Cemented with antibiotic cement. Poly locked. Tourniquet deflated; hemostasis. Arthrotomy closed #1 Vicryl. Subcutaneous 2-0 Vicryl. Skin closed.
EBL: *** mL (tourniquet)
COMPLICATIONS: None
DISPOSITION: WBAT. DVT prophylaxis *** x 35 days. PT POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
Posterior-stabilized (PS) design
Given PCL deficiency or PCL release required for deformity correction, a posterior-stabilized design was selected. The PCL was excised. The femoral box cut was made with the PS jig to accommodate the post-cam mechanism. The PS tibial post and femoral cam provide anteroposterior stability in place of the PCL. Indications include PCL insufficiency, severe varus/valgus deformity requiring extensive soft tissue releases, prior patellectomy, and revision cases.
Unicompartmental knee arthroplasty (UKA)
Indications: single-compartment arthritis (medial or lateral), intact ACL, correctable deformity (<10–15°), flexion contracture <10–15°, absent inflammatory arthropathy. A mini-arthrotomy is used (midvastus or subvastus approach; not a full medial parapatellar arthrotomy). Medial femoral and tibial surfaces are prepared with UKA-specific instrumentation. The lateral and patellofemoral compartments are inspected and must be relatively preserved. Fixed- or mobile-bearing poly insert options are design-dependent. UKA preserves bone stock, proprioception, and ACL function with faster early recovery.
Robotic-assisted TKA
Robotic assistance does not add RVUs to the claim regardless of capital equipment cost. Document use of robotic guidance in the operative note, including system name, registration process, dynamic or static reference array, and intraoperative real-time feedback used for bone cuts.
Revision TKA
Revision technique differs substantially from primary TKA: component extraction (osteotomes, Gigli saw, specialized extractors), cement removal, assessment of bone loss, and reconstruction with stems, augments, sleeves, cones, or porous metal metaphyseal fixation. Document the specific components explanted, bone defect classification (AORI grade), and reconstruction method. Increased-service reporting may be appropriate for unusually complex revisions when total operative time and specific challenges are documented.
Charting Tips
- Document implant manufacturer, model, and sizes (femoral size, tibial tray size, poly insert thickness, patellar component size if resurfaced) in the operative note. FDA UDI documentation is mandatory — record UDI for each component. A note that states 'TKA performed' without implant specifications is inadequate for registry, FDA adverse event reporting, and future revision planning.
- Document tourniquet time and pressure. Use limb occlusion pressure-based inflation (SBP + 100–150 mmHg, typically 200–250 mmHg) rather than a fixed high pressure (275 mmHg) — high fixed pressures are associated with quadriceps injury and wound complications per current evidence. Document total tourniquet time; times exceeding 90 minutes are associated with increased wound complications. Document tourniquet deflation and hemostasis confirmation before closure.
- Document posterior tibial slope. Tibial slope (typically 3–7°, design-specific) affects flexion kinematics and PCL tension. Failure to set appropriate slope is a source of stiffness or instability. Document: 'proximal tibial resection performed with [X]° posterior tibial slope.'
- Document intraoperative gap balance and soft tissue releases on trial components. Record flexion gap, extension gap, varus/valgus stability at 0° and 90°, and any releases performed (medial soft tissue release, lateral release, PCL release). This is the surgeon's intraoperative quality check and justifies final implant selection. It also provides documentation if stiffness or instability develops postoperatively.
- Document failed conservative treatment for medical necessity. Payer audits for TKA commonly focus on: duration of conservative treatment (minimum 3 months typically required), specific interventions (physical therapy, NSAIDs, corticosteroid injections, viscosupplementation), radiographic evidence of joint space loss (Kellgren-Lawrence grade 3 or 4), and functional limitations. 'Failed conservative management' without specific detail is insufficient for many payer LCD requirements.
Documentation & Reimbursement Considerations
- Report Total Knee Arthroplasty (TKA) as the primary service when it is the definitive operation performed.
- Implant design does not change the code. Document the specific design rationale (PCL retained vs. sacrificed, degree of constraint) and implant specifications.
- Document unicompartmental vs. total to ensure correct reporting selection.
- Verify payer-specific bilateral modifier conventions. Staged bilateral within 90 days of the first TKA global period: bill the second knee with unrelated-procedure reporting during the postoperative period (unrelated procedure during global period) if the second TKA is truly independent, or staged-or-related-procedure reporting (staged) if planned as staged at time of first surgery.
- Related unplanned return-to-the-operating-room reporting does not reset the global period — the remaining global days of the primary TKA continue.
- Implant documentation: FDA UDI tracking is mandatory for knee prostheses (Class III devices). Record manufacturer, model, lot number, component sizes, and UDI for femoral component, tibial baseplate, polyethylene insert, and patellar component. AJRR reporting is voluntary, not a state mandate. Document implant details in the operative note — 'TKA performed' without specifications is inadequate for registry, FDA adverse event reporting, and future revision planning.