Sample Consent Form Total Knee Replacement or Revision

I ,_____________________________________ , agree to have the following operation: TOTAL KNEE REPLACEMENT OR REVISION.

1. The nature and purpose of the operation listed above, alternative method(s) of treatment, the material risks involved, and the possibility of complications have been fully explained to me to my satisfaction. I understand that the most common risks and complications associated with a Total Knee Replacement or Revision include, but are not limited to:

a. Blood clots in the leg, fatal pulmonary embolism, dislocation of the prosthesis, intraoperative and postoperative fracture of the femur, infection, failure of the prosthesis or grafting materials, complications from anesthesia, reactions to blood transfusion, postoperative leg length inequality, instability of the Knee replacement, nerve damage or injury, vascular injury, delayed wound healing, other injury or even death.

b. I understand that infections following a Total Knee Replacement or Revision are very rare; however, infections are a known complication of surgery. If an infection does occur, additional surgery(ies) are generally necessary and may even require removal of the knee replacement.

c. I understand that temporary or permanent numbness on the skin lateral to the incision can be a complication unique to total knee surgery, and that kneeling can be painful after knee replacement surgery.

d. I understand that after undergoing a Total Knee Replacement or Revision, I may still have pain or disability.

2. No guarantee or assurance has been made as to the results that may be obtained from the Total Knee Replacement or Revision. I understand that this is a complex and technically demanding operation. The success of this operation in part depends upon the mechanical devices, which are going to be implanted in my body. I fully understand that these devices can fail or malfunction, and may need to be repaired or replaced. I also understand that there are no guarantees as to the longevity of this device or its parts and that it or its parts could fail prematurely.

3. I understand that during the course of surgery, my surgeon may need to use bone graft from deceased donors, or blood from live donors, and that any bone graft or blood used will be carefully screened for communicable diseases, including AIDS, hepatitis, Jakob-Creutzfeldt, or other diseases. I understand that despite the screening procedures, there is a small chance that I could contract one of these diseases.

4. I understand that I am responsible to follow completely and fully all of my surgeon’s advice and recommended treatments, and that my recovery and result will depend on my doing so.

5. I understand that I will be given anesthesia before and during the Total Knee Replacement or Revision procedure. I understand that there are risks associated with anesthesia, and I understand that these risks, along with alternatives, will be explained to me by the anesthesiologist.

6. I hereby authorize and direct Dr. _____________________ to perform the operation of Total Knee Replacement or Revision, including whatever incidental procedures and/or additional service involving anesthesia, radiology, pathology, administration of medications, and the like, may be necessary, including such other and further operations, treatments or procedures, which may not be presently contemplated, but which my physician

By signing this Informed Consent, I certify that I have read the contents of this form or the contents have been read to me. The information contained in this form has been explained to me and I understand its contents. I further certify that I have read the patient information given to me about the procedure.

Any questions I have concerning the Informed Consent have been answered to my satisfaction. I fully understand the possible risks, which may result from a Total Knee Replacement or Revision. My decision to proceed with the Total Knee Replacement or Revision has been voluntarily and freely given.

Signature of Patient or Person Authorized to Sign for Patient


Physician’s Signature

Date and Time _______________________________

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