Patient education is an effective method of managing expectations and has been associated with reduced anxiety and length of stay in addition to improved pain control in the postoperative period. It may be provided by specialist nurses and can be on a one-to-one basis [7] or in a group. It includes details of the surgical procedure, expectation and goal setting, symptom management, discharge date and the perioperative care plan. Various educational resources can be employed including booklets, care plans and educational videos. Other considerations include the organisation of postoperative support and psychological and organisational preparedness.

There is some evidence to suggest that preoperative exercise may help improve functional capacity and physiological reserve [8]. However, a recent meta-analysis did not show any significant effect on functional recovery after joint replacement, although the limitations stated included low therapeutic validity of the exercises and the studies included in the review were somewhat heterogeneous [9]. There would appear to be some face validity to the concept of improving muscle bulk, power and control preoperatively in order to speed recovery, although exercises may be limited by the patient’s knee condition and general health.

The nutritional status of the patient plays a role in postoperative recovery and wound healing [10] and identification and treatment of patients who are at risk can be undertaken using the Malnutrition Universal Screening Tool [11]. Similarly, anthropometric measures including triceps skinfold can be used which has been shown to have an inverse relationship to postoperative infection after TKA [12]. Low biochemical markers such as serum transferrin, albumin and total lymphocyte count have also been associated with longer recovery times and length of stay after TKA [13, 14]. Individuals who are deemed to have a nutritional deficit can be provided with appropriate nutritional supplements, and those who are at a higher risk of nutritional deficiency should be referred to a dietician prior to surgery.

Preoperative Anemia has the potential to increase postoperative transfusion rates, infection and LOS [15–17]. As such, preoperative iron therapy or erythropoietin may help reduce these unfavourable outcomes [18, 19].

Minimising bleeding and blood loss are important in reducing transfusion rates and the potential risks associated with this in addition to reducing costs and maintaining blood stores. Transfusion rates in TKA can be as high as 20 % and can therefore have a significant impact. Strategies aimed at reducing blood loss can be initiated at the preoperative assessment to identify patients at increased risk. Intraoperatively, bleeding can be minimised by meticulous surgical technique and haemostasis in addition to specific anaesthetic techniques. Similarly, postoperative measures can also be valuable.

Patients undergoing TKA are at a significantly increased risk of venous thromboembolism. The incidence of symptomatic VTE is as high as 10 %, and the incidence of asymptomatic VTE is as high as 40–60 % [38, 39]. Despite this there remains controversy as to the ideal thromboprophylaxis measures. Thromboprophylaxis measures include both mechanical and pharmacological strategies and can be instituted at the preoperative stage. All patients should undergo a VTE risk assessment. Based on patient- and surgery-related factors, patients can then be assigned as low, intermediate or high risk, and this can be balanced against the risk of bleeding or other complication. All patients should receive basic measures including avoidance of dehydration, early mobilisation and lower limb range of motion exercises. The National Institute for Health and Care Excellence (NICE) in the UK has produced comprehensive guidelines (Fig. 5.3) for VTE prevention in orthopaedic surgery [40, 41]. Mechanical VTE prophylaxis should be combined with pharmacological means and for elective TKA the latter should be continued for 10–14 days. Pharmacological VTE prophylaxis can include either low molecular weight heparin (LMWH), fondaparinux, dabigatran or rivaroxaban. The choice of pharmacological prophylaxis is often determined by local policies.

One of the great challenges in arthroplasty is the prevention, diagnosis and management of prosthetic joint-associated infections. Prosthetic joint infection (PJI) and its consequences have a considerable impact on patients and lead to physical disability, significant emotional morbidity and increased mortality [47].

It places an enormous burden on health service provision along with a huge economic impact. The key to avoiding the consequences of infection in TKA is prevention.