Complication Of Total Knee Arthroplasty Research Articles

Acute Popliteal Artery Occlusion after Revision Total Knee Arthroplasty.

Acute arterial occlusions are a rare complication of total knee arthroplasty (TKA). However, in revision TKA, the risk of such complications is higher and these complications can lead to amputation if not adequately treated. We describe a case of acute popliteal artery occlusion 4 hours after second revision TKA in a patient with a history of several surgical procedures because of periprosthetic infection at a previous hospital. Revascularization was achieved via bypass grafting and amputation was narrowly avoided despite time lag after symptom onset to revascularization. In this case, it was possible that the arterial disease that accompanied the vascular endothelium injury such as pseudoaneurysm had existed since the previous surgery at another hospital and was destroyed by the surgical procedure, which led to the formation of thrombosis and arterial occlusion. Preoperative evaluation of the arterial condition should be considered to avoid acute arterial occlusive disease, especially in patients who had several previous surgical procedures.

Indications, outcomes, and complications of unicompartmental knee arthroplasty.

Improved prosthetic design and application of strict criteria in selection of patients have resulted in wide use of unicompartmental knee arthroplasty (UKA) in surgical treatment of damaged joints. Here, we review the contemporary indications, outcomes, and complications of procedures such as lateral and medial UKA and total knee arthroplasty (TKA), and compare the severity of these complications in UKA and TKA. Patients who received unicompartmental femorotibial osteoarthritis and patients who underwent UKA and ACL reconstruction for deficiency in anterior cruciate ligament (ACL), they all showed good clinical outcomes and survival. Reliable and successful options in the treatment of patients with isolated tibiofemoral osteoarthritis include lateral and medial UKA.

A Rare Postoperative Total Knee Arthroplasty Complication: type l complex regional pain syndrome of the foot and ankle

A Rare Postoperative Total Knee Arthroplasty Complication: type l complex regional pain syndrome of the foot and ankle

Surgical repair of chronic patellar tendon rupture in total knee replacement with ipsilateral hamstring tendons.

Patellar tendon rupture is a serious complication of total knee arthroplasty (TKA). Its reconstruction in patients with chronic ruptures is technically demanding. This article reports the results of surgical reconstruction of neglected patellar tendon rupture in TKA using autologous hamstring tendons. Nine TKA patients (six women and three men) (mean age at index surgery 68years) with chronic patellar tendon tears underwent reconstruction with ipsilateral hamstrings tendon, leaving the distal insertion in situ. The clinical diagnosis was supported by imaging (anterior-posterior and 30° flexion lateral radiographs). Insall-Salvati index, range of motion, and leg extension test were recorded preoperatively and at last follow-up. The modified Cincinnati rating system and the Kujala score were administered. The patients sustained the patellar tendon tear an average of 8weeks before the procedure. At final follow-up of 4years (range 2-8years), the median of extension lag was 5° (range 0°-15°; DS=5). The median of post-operative Insall-Salvati index was 1.4 (range 1.3-1.8; SD=0.15; p=0.002) compared to the preoperative index of 1.7 (range 1.5-2.2; SD=0.23). The mean modified Cincinnati and Kujala scores significantly increased compared with the preoperative ones (p<0.01). At final follow-up, all patients were able to walk without brace or aids, and they were satisfied with the procedure. Based on our retrospective study of nine patients, reconstruction of neglected patellar tendon rupture in TKA with autologous hamstring tendons is feasible and safe, and provides good functional recovery. Case series, Level IV.

How to interpret postoperative X-rays after total knee arthroplasty.

Today, total knee arthroplasty (TKA) is one the most commonly performed surgeries worldwide. The purpose of this article is to review the appearance of normal post-TKA roentgenographs and describe the correct sequence for their interpretation. It is unwise to depend solely on patients' symptoms when diagnosing TKA complications because serial radiographs can foresee failures well before they manifest clinically. Ideal post-TKA radiographs comprise whole lower extremity anteroposterior and lateral views taken under weight bearing conditions along with a skyline view of the patellofemoral joint. Among other things, weight bearing exposes the true alignment, ligamentous laxity and polyethylene wear. On the basis of follow-up of our TKA cases, we have drawn up a protocol for assessing postoperative X-ray films after TKAs. Following the proposed sequence, surgeon can easily decide how to proceed with follow-up and foresee complications. Careful interpretation of postoperative radiographs after TKA is essential to careful monitoring of patients and implant survival.

The Management of Extensor Mechanism Complications in Total Knee Arthroplasty

Complications involving the knee extensor mechanism and patellofemoral joint occur in 1% to 12% of patients following total knee arthroplasty and have major negative effects on patient outcomes and satisfaction. The surgeon must be aware of intraoperative, postoperative, and patient-related factors that can increase the rate of these problems. This review focuses on six of the most commonly encountered problems: patellar tendon disruption, quadriceps tendon rupture, patellar crepitus and soft-tissue impingement, periprosthetic patellar fracture, patellofemoral instability, and osteonecrosis of the patella. The goals of this report are to (1) review the relevant anatomy of the knee extensor mechanism, (2) present risk factors that may lead to extensor mechanism complications, (3) provide a diagnostic and treatment algorithm for each of the aforementioned problems, and (4) review the specific surgical techniques of Achilles tendon allograft reconstruction and synthetic mesh augmentation. Extensor mechanism disorders following total knee arthroplasty remain difficult to manage effectively. Although various surgical techniques have been used, the results in patients with a prior total knee arthroplasty are inferior to the results in the young adult without such a prior procedure. Surgical attempts at restoration of the knee extensor mechanism are usually warranted; however, the outcomes of treatment of these complications are often poor, and management of patient expectations is important.

Postoperative Falls After Total Knee Arthroplasty in Patients With a Femoral Nerve Catheter: Can We Reduce the Incidence?

A femoral nerve catheter (FNC) is often used to minimize pain following total knee arthroplasty (TKA), but complications including inpatient falls, may increase as a result, despite fall prevention protocols. We evaluated the rate of falls in 707 primary TKAs performed with an FNC at a major academic center from May 2009 to September 2012. Despite a formalized fall prevention protocol, we found 19 falls (2.7%). Three patients required further operative intervention. At a rate of 2.7%, postoperative fall is one of the most common complications of TKA at our institution. While pain control may be good with the use of FNCs following primary TKA, improvements in fall prevention strategies or the use of alternative postoperative pain control modalities may need to be considered.

Design and kinematics in total knee arthroplasty

Posterior stabilised (PS) total knee arthroplasty (TKA) design development that focused on restoring normal knee kinematics was followed by the introduction of reason-guided motion designs. Although all PS fixed-bearing knee designs were thought to have similar kinematics, reports show they have differing incidences and magnitudes of posterior femoral rollback and axial rotation. In this retrospective comparative study between two guided-motion total knee systems, we hypothesised that kinematic pattern has an influence on clinical and functional outcomes. This study represents the continuation of a previously reported clinical and kinematics analysis. We retrospectively reviewed 347 patients treated with two different TKA designs: Scorpio NRG (Stryker Orthopedics) and Journey Bi-Cruciate Stabilised (BCS) knee system (Smith & Nephew). Two hundred and eighty-one patients were assessed clinically. Patients were divided into groups according to implanted TKA. Clinical evaluation with the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire was performed. Fifteen Scorpio NRG and 16 Journey BCS patients underwent video fluoroscopy during stair climbing, chair rising/sitting and step up/down at sixmonths of follow-up. At an average 29months of clinical follow-up, patients with Journey BCS TKAs reported better clinical results. Stiffness was more frequently reported in the Journey group (5.2% vs 1.2%), whereas anterior knee pain was observed in the Scorpio NRG group (1.9%) only. Both prosthetic models reported different posterior translation of the medial and lateral contact points (CP) in all analysed motor tasks during knee flexion (BCS 10-18mm; NRG Scorpio 2-3mm). Both designs produced progressive external rotation of the femoral component relative to the tibia during flexion. Journey BCS showed statistically significant better KOOS results. The higher posterior femoral rollback observed in the kinematic assessment of this design, associated with a better patellofemoral design, may be the reason for better clinical outcome. The reported cases of stiffness and anterolateral joint pain could be attributed to excessive medial and lateral tibiofemoral posterior translation. The NRG group demonstrated good axial rotation, but this was not coupled with physiological kinematic patterns. Patellofemoral pain can be explained by a less friendly femoral-groove design. TKA clinical-functional outcome and complications were highly influenced by the bearing geometry and kinematic pattern of prosthetic designs.

Patellofemoral Crepitus after Total Knee Arthroplasty: Etiology and Preventive Measures

Patellofemoral crepitus and clunk syndrome are infrequent, yet troublesome complications of total knee arthroplasty with a reported incidence of 0%-18%. They are primarily associated with implantation of posterior cruciate substituting designs. These entities are the result of peripatellar fibrosynovial hyperplasia at the junction of the superior pole of the patella and the distal quadriceps tendon which becomes entrapped within the superior aspect of the intercondylar box of the femoral component during knee flexion. When the knee extends, a crepitant sensation occurs as the fibrosynovial tissue exits the intercondylar box. Numerous etiologies have been proposed such as femoral component designs with a high intercondylar box ratio, previous knee surgery, reduced patellar tendon length, thinner patellar components, reduced patella-patellar component composite thickness, and smaller femoral components. Preventative measures include choice of femoral components with a reduced intercondylar box ratio, use of thicker patellar components, avoidance of over-resection of the patella, and debridement of the fibrosynovial tissue at the time of knee arthroplasty. Most patients with crepitus are unaware of the problem or have minimal symptoms so that no treatment is required. If significant disability is incurred, symptoms can be eliminated in a high percentage of patients with arthroscopic debridement of the fibrosynovial hyperplasia.

Prevalence of anterior knee pain among patients following total knee arthroplasty with nonreplaced patella: A retrospective study of 1778 knees

Background and objective: Anterior knee pain (AKP) may compromise the results of total knee arthroplasty in more than quarter of cases. The aim of the current work was to determine the prevalence of AKP and the severity of patellofemoral symptoms among patients who received a total knee arthroplasty with non-replaced patella in East-Tallinn Central Hospital from January 1, 2000 to December 31, 2009. Materials and methodsWe carried out a retrospective study involving 1778 consecutive total knee arthroplasties with non-replaced patella. Mean follow-up time was 68 months. We collected data by two patient-reported measures: the knee pain questionnaire and the Kujala score. ResultsWe diagnosed AKP among 20.2% of patients, 33.6% had pain in the knee from a source other than patellofemoral joint and 46.2% were pain free. In 87.3% of AKP cases the pain emerged within the first five years of knee replacement. AKP was more prevalent among patients with osteoarthritis compared to rheumatoid arthritis and among patients below 60 years. There was no difference in the prevalence of AKP in terms of gender or mobile and fixed bearing implants. The severity of patellofemoral symptoms in case of AKP was moderate. ConclusionsAKP is a frequent complication of total knee arthroplasty with non-replaced patella and patients undergoing this procedure should be apprised of the high probability of experiencing pain in the anterior part of the replaced knee.

Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty.

PurposeAlthough the analgesic effects of corticosteroids have been well documented, little information is available on periarticular injection (PI) containing corticosteroids for early postoperative pain management after total knee arthroplasty (TKA). We performed a prospective double-blind randomized trial to evaluate the efficacy and safety of an intraoperative corticosteroid PI in patients undergoing TKA.Materials and MethodsSeventy-six consecutive female patients undergoing bilateral staged TKA were randomized to receive steroid or non-steroid PI, with 3 months separating the procedures. The steroid group received PI with a mixture containing triamcinolone acetonide (40 mg). The non-steroid group received the same injection mixture without corticosteroid. During the postoperative period, nighttime pain, functional recovery [straight leg raising (SLR) ability and maximal flexion], patient satisfaction, and complications were recorded. Short-term postoperative clinical scores and patient satisfaction were evaluated at 6 months.ResultsThe pain level was significantly lower in the PI steroid than the non-steroid group on the night of the operation (VAS, 1.2 vs. 2.3; p=0.021). Rebound pain was observed in both groups at POD1 (VAS, 3.2 vs. 3.8; p=0.248), but pain remained at a low level thereafter. No significant differences were seen in maximal flexion, frequency of acute rescuer, clinical scores, and patient satisfaction. The steroid group was able to perform SLR earlier than the non-steroid group (p=0.013). The incidence of complications was similar between the groups.ConclusionPI containing a corticosteroid provided an additional pain-relieving effect on the night of the operation. In addition, corticosteroid PI did not increase the perioperative complications of TKA.

Patellar resurfacing complications in total knee arthroplasty

The ideal management of the patella during total knee arthroplasty (TKA) is still controversial. Patellar retention is generally associated with an increased rate of anterior knee pain; however, patient satisfaction is similar in cases of replacement or retention. When the patella is replaced, potential severe complications can occur. Aim of this study was to retrospectively review results of a continuous series of patients having been treated with TKA and patella resurfacing. The charts of 1,600 consecutive total knee prostheses were analysed to evaluate the rate of patellar resurfacing. All implants were posterior stabilized; 310 patients having received a patellar replacement were reviewed at follow-up (FU) examination. Complete physical examination as well as administration of the Hospital for Special Surgery (HSS) score was performed. X-rays analysis included weightbearing anteroposterior (AP) and lateral views of the injured knee and bilateral skyline views at 30° flexion. Two hundred and eighty patients were available for clinical and imaging investigation at an average FU of 96 (58-144) months. Mean age at the time of surgery was 70 (62-80) years. Mean HSS score was 85.9 ± 7.6. The overall rate of patellofemoral complications was 7% (19 cases); 13 patients claimed anterior knee pain, five had symptomatic patellar maltracking and one had patellar component loosening. Our data are in accordance with those available in the literature. Recent meta-analyses demonstrated lower risk of re-operation after patellar resurfacing. However, when complications of the resurfaced patella occur, they can be potentially catastrophic events.

Patellofemoral Crepitation and Clunk Following Modern, Fixed-Bearing Total Knee Arthroplasty

Patellar crepitation and clunk (PCC) is an important and modifiable complication of total knee arthroplasty (TKA). We calculated the incidence of PCC using a modern fixed-bearing TKA prosthesis, assessed whether PCC is associated with knee range of motion, and determined if there were any radiographic variables associated with the development of PCC in this prosthetic design. Five hundred seventy primary TKAs were evaluated after a mean follow-up of 24 months (range 12-81). Thirty-four knees developed PCC (6%); 6 required arthroscopic debridement. With each degree increase in the flexion angle, the likelihood of developing PCC increased by 4.2%. The incidence of PCC was low but increased with postoperative flexion ≥ 110°. No radiographic parameters were associated with the development of PCC.

Haemophilic arthropathy: Long-term outcomes in 107 primary total knee arthroplasties

BackgroundArthropathy of the knee is a frequent complication in patients with severe bleeding disorders leading to considerable pain and disability. Total knee arthroplasty (TKA) provides marked pain relief. However, a modest functional outcome and a high number of complications due to prosthetic infection and loosening are reported. Data on long-term outcomes are scarce, and most case series include few patients. We have studied clinical outcomes and complications of TKAs with special emphasis on prosthetic survival and periprosthetic infection. MethodsA consecutive series of 107 TKAs in 74 patients with haemophilic arthropathy were retrospectively reviewed. Follow-up was mean 11.2years (range 0.8–33.1years). ResultsFive- and 10-year survival rates, with component removal for any reason as the end point, were 92% and 88%, respectively. Twenty-eight TKAs were removed after median 10years (range 0.8–28years). The most common cause of failure was aseptic loosening (14 knees) and periprosthetic infection (seven knees). The overall infection rate was 6.5%. The mean postoperative drop in haemoglobin levels was 4.3g/dL (range 0.5–9.4) with a significant difference between haemophilia A patients with and without inhibitor (6.3g/dL (range 3.6–9.4) versus 3.7g/dL (range 0.5–8.1) (p<0.001). A painless knee was reported in 93% of the TKAs at the latest follow-up. ConclusionsThe medium and long-term results of primary TKA in a large haemophilic population show good prosthetic survival at five and 10years with an excellent relief of pain. Periprosthetic infection is still a major concern compared to the non-haemophilic population. Level of evidenceLevel IV.

Reply to the Letter to the Editor: Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society

To the editor: Thank you for your thoughtful consideration of our work on complications of TKA. We agree that pain is an unfavorable outcome following TKA, as TKA is generally proposed in order to relieve pain. We did not include pain in our project because we do not have a generally accepted, standardized definition for pain following TKA, and we did not believe we should develop this definition. Our principal reasons for this belief included: (1) there is no standardized reporting for pain, and unlikely to be one anytime soon because of difference among patients’ perceptions of that symptom, and (2) pain is a symptom, but tells us little about its cause, which can range from aseptic loosening to infection to untreated depression. As you suggest, pain following TKA has been underreported by surgeons. One patient’s severe pain is another patient’s mild discomfort and another patient’s annoyance. Perhaps we should have included pain in our list of exclusions in the Methods and Materials section. Careful evaluation of TKA outcomes notes a higher level of pain than previously recognized and accepted. However, patients’ perception of pain following TKA is not standardized. One patient’s pain level of nine may be another patient’s pain level of one, and both patients report pain. As you note, the incidence of pain following TKA can range from 10% to 34%. The prevalence of pain following could be lower or higher, depending on the population surveyed and the level of pain defined as important enough to measure. Stedman’s Medical Dictionary defines complication as a “morbid process or event that occurs during the course of a disease that is not an essential part of that disease, although it may result from it or from independent causes.” Pain is a symptom that can be caused by a complication or by issues unrelated or related to the TKA. Tachycardia is also a symptom that can be caused by venous thromboembolic disease, but we do not include tachycardia as a complication of TKA. Pain is considered the fifth vital sign, and is an indication of patient outcome. It can be used as an objective standard for judging progress of an individual patient, but is a poor comparator among different patients. At this time, we do not believe that pain following TKA is an easily reported complication which will fit in the TKA complication stratification system. Our work is the first step in understanding and codifying complications and adverse events following TKA. Our patients will teach us more about their complications and adverse events during the next decade. As we continue to listen to our patients, perhaps our list of standardized complications for TKA will be revised.

Amputation after failure or complication of total knee arthroplasty: prevalence, etiology and functional outcomes

ObjectiveIdentify the etiology and incidence, as well to assess functional outcomes of patients, undergoing lower limb amputation after failure or complication of total knee arthroplasty. These patients were treated at the Center for Knee Surgery at the National Institute of Traumatology and Orthopedics (INTO), during the period of January 2001 to December 2010. MethodsThe patients were interviewed and their charts were retrospectively analyzed to evaluate their functional outcome. ResultsThe incidence of amputation due to failure or complication of total knee arthroplasty was 0.41% in 2409 cases. Recurrent deep infection was the cause of amputation in 81% of cases, being Staphylococcus aureus and Pseudomonas aeruginosa the most frequent germs. Vascular complications and periprosthetic fracture associated to metaphyseal bone loss were also causes of amputation. In our study, 44% of amputees patients were using orthesis and 62.5% have had the ability to walk. ConclusionIncidence of 0.41%, being the main cause recurrent infection. The functional outcome is limited, and the fitting achieved in 44% of patients and only 62.5% are ambulatory.

Infection Following Total Knee Arthroplasty

For most orthopedists, total knee arthroplasty (TKA) has been regarded as the most effective surgery for patients with severe knee diseases. Though seldom occur, postoperative infection certainly remains one of the most devastating and dreaded complications of TKA. Thus, careful and early diagnosis is needed. After diagnosis, categorize the infection type and choose a rightful and sequential step of treatment are recommended.

Bilateral Distal Femoral Flexion Deformity After Total Knee Arthroplasty in a Patient with Rheumatoid Arthritis: 在一位患有類風濕性關節炎的病人，進行了兩邊全膝關節置換術後逐漸形成股骨遠端屈曲畸形

Rheumatoid arthritis is an autoimmune systemic disease with predominant peripheral polyarthritis, often leading to severe joint destruction. This is a case report of an 81-year-old woman with long-standing severe rheumatoid arthritis requiring multiple orthopaedic operations for joint destruction since 2000. These operated joints improved her functional mobility until recently, when she found that her knees were fixed at around 70° of flexion with limited motion. There was chronic progressive flexion deformity of bilateral distal femurs, which was an extremely rare complication of total knee arthroplasty.

Amputação após falha ou complicação de artroplastia total de joelho: incidência, etiologia e resultados funcionais

ObjectiveIdentify the etiology and incidence, as well to assess functional outcomes of patients, undergoing lower limb amputation after failure or complication of total knee arthroplasty. These patients were treated at the Center for Knee Surgery at the National Institute of Traumatology and Orthopedics (INTO), during the period of January 2001 to December 2010. MethodsThe patients were interviewed and their charts were retrospectively analyzed to evaluate their functional outcome. ResultsThe incidence of amputation due to failure or complication of total knee arthroplasty was 0,41% in 2409 cases. Recurrent deep infection was the cause of amputation in 81% of cases, being Staphylococcus aureus and Pseudomonas aeruginosa the most frequent germs. Vascular complications and periprosthetic fracture associated to metaphyseal bone loss were also causes of amputation. In our study, 44% of amputees patients were using orthesis and 62.5% have had the ability to walk. ConclusionIncidence of 0.41%, being the main cause recurrent infection. The functional outcome is limited, and the fitting achieved in 44% of patients and only 62.5% are ambulatory.

Treatment Failure Among Infected Periprosthetic Patients at a Highly Specialized Revision TKA Referral Practice.

Deep infection is a serious and costly complication of total knee arthroplasty (TKA), which can increase patient morbidity and compromise functional outcome and satisfaction. Two-stage revision with an interval of parental antibiotics has been shown to be the most successful treatment in eradicating deep infection following TKA.We report a large series by a single surgeon with a highly specialized revision TKA referral practice.We identified 84 patients treated by a two-stage revision. We defined “successful two-stage revision” as negative intraoperative cultures and no further infection-related procedure. We defined “eradication of infection” on the basis of negative cultures and clinical diagnosis.After a mean follow up of 25 months, eradication of the infection was documented in 90.5% of the patients; some had undergone further surgical intervention after the index two-stage procedure. Successful two-stage revision (e.g. no I&D, fusion, amputation) was documented only in 63.5% of the patients. We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision.Factors affecting the high failure rate included multiple surgeries prior to the two-stage revision done at our institution, and high prevalence of MRSA present among failed cases.The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice. Thus increasing the prevalence of patients with previous failed attempts at infection eradication and delayed care as well as more fragile and immune compromised hosts.