Free Total Knee Replacement Consent Form Template

Informed Consent for Total Knee Arthroplasty (TKA)

Patient Informed Consent Documentation

Patient and Surgical Information

Nature and Purpose of the Procedure

Total knee arthroplasty (TKA) is a surgical procedure performed under spinal or general anesthesia to resurface the damaged articular surfaces of the knee joint damaged by osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, or other degenerative conditions. A longitudinal incision is made over the anterior knee, and the joint is exposed. The distal femur and proximal tibia are precisely cut using resection guides and surgical jigs to accommodate metal femoral and tibial components that replicate the normal joint surfaces. A polyethylene (plastic) bearing is placed between the metal components to allow smooth, low-friction movement. A patellar button may also be implanted on the undersurface of the kneecap. The components are secured using bone cement (polymethylmethacrylate) or a press-fit porous coating that allows bone ingrowth. A surgical drain may be placed, and the incision is closed in layers. The procedure typically takes 1.5 to 2.5 hours.

Material Risks and Potential Complications

Rehabilitation and Recovery Commitment

The success of total knee replacement is substantially dependent on the patient's commitment to postoperative rehabilitation. Patients are expected to begin weight-bearing with a walker on the day of or the day following surgery. Physical therapy focused on quadriceps activation, range of motion exercises, and progressive ambulation begins within 24 hours. Formal outpatient or home physiotherapy continues for a minimum of 6 to 12 weeks. Failure to comply with the prescribed rehabilitation program significantly increases the risk of stiffness, poor functional outcomes, and the need for manipulation under anesthesia. Patients should expect full functional recovery to take 3 to 12 months.

Blood Clot Prevention Protocol

Pharmacological thromboprophylaxis will be prescribed following surgery. Options include aspirin 325 mg twice daily, enoxaparin (low molecular weight heparin) 40 mg subcutaneously daily, rivaroxaban 10 mg daily, or apixaban 2.5 mg twice daily, continuing for 14 to 35 days depending on the patient's individual risk profile. Sequential compression devices (SCDs) will be applied intraoperatively and continued until the patient is fully ambulatory. Patients are instructed to report any calf pain, limb swelling, chest pain, or breathlessness immediately.

Surgical Alternatives

Expected Benefits

The primary expected benefit of total knee arthroplasty is substantial and durable relief of knee pain that has not responded adequately to conservative measures, combined with improved functional capacity and quality of life. Studies consistently show that 80 to 90 percent of patients achieve good to excellent pain relief and restoration of daily activity function. The procedure aims to allow return to low-impact activities, improved sleep, reduced reliance on pain medications, and correction of deformity where applicable.

Operative Site Verification (Wrong-Site Prevention)

To comply with The Joint Commission National Patient Safety Goal 01.01.01 and prevent wrong-site surgery, I confirm that the operative limb has been discussed with me and will be marked by the surgeon prior to the procedure. I have verified with my surgeon that the intended operative side is documented above. I understand that I will be asked to confirm the operative side on the day of surgery during the pre-operative timeout, and I am expected to participate in this verification process.

Joint Replacement Registry Participation

Your surgery data may be submitted to the American Joint Replacement Registry (AJRR) or an equivalent national registry. Registry participation enables population-level monitoring of implant performance, complication rates, and long-term outcomes to improve care quality. Data submitted is de-identified and protected under research privacy regulations. You may opt out of registry participation by notifying your surgeon or the facility registration team before your procedure.

Right to Refuse or Withdraw Consent

You have the right to refuse this procedure or withdraw your consent at any time before the procedure begins without penalty or adverse effect on your ongoing medical care. Your surgeon will discuss non-operative alternatives with you if you choose not to proceed.

Questions and Understanding Confirmation

I confirm that I have had the opportunity to read this consent form carefully and ask questions of my surgeon. All my questions have been answered to my satisfaction. I understand the rehabilitation commitment required and the realistic timeline for recovery. I believe I am making an informed and voluntary decision.

Language Access and Interpreter Services

If English is not your primary language or if you require assistance communicating, a qualified medical interpreter is available to you at no cost. Please notify your care team if you require interpreter services before signing this document.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a signed copy of this informed consent form for my own records. I understand I may request an additional copy at any time from the facility or clinical records department.

Patient Authorization

I have been informed of the total knee replacement procedure, its expected benefits, the material risks listed above, the rehabilitation commitment required, and available alternatives. I understand that implant longevity is not guaranteed and that revision surgery may be required in the future. I consent to proceed with total knee arthroplasty on the operative side indicated above and authorize the surgeon and team to take all necessary measures to ensure patient safety.

Signatures and Verification