Complication Of Total Knee Arthroplasty Research Articles

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.

Updated strategies to treat acute arterial complications associated with total knee and hip arthroplasty

Traditional treatment of acute arterial complications associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA) has generally included arteriography followed by open surgery. The purpose of this study was to describe our evolution from open surgery to preferential endovascular treatment for acute arterial complications of TKA and THA. We analyzed our computerized database registry and patient charts for vascular interventions associated with TKA and THA at a hospital with a large volume of orthopedic surgery to determine changing trends in endovascular intervention for these complications. Between 1989 and 2012, 39,196 TKA (26,374 total: 23,205 primary; 3169 revisions) and THA (12,822 total: 10,293 primary; 2529 revisions) were performed. Vascular surgery consultation was provided for the treatment of acute ischemia, hemorrhage, ischemia with hemorrhage, and pseudoaneurysm formation. All interventions were performed within 30 days of joint replacement. A total of 49 (0.13%) acute arterial complications occurred over the 23-year period: 37 (76%) associated with TKA and 12 (24%) with THA. Arterial injury was detected on the same day as the orthopedic procedure in 28 patients, between postoperative days 1 and 5 in 18 patients, and between postoperative days 5 and 30 in three patients. The arterial complications caused ischemia in 28 patients (58%), hemorrhage in six (12%), ischemia with hemorrhage in six (12%), and pseudoaneurysm in nine (18%). Treatment included solely endovascular intervention in 12 (25%), failed endovascular treatment converted to open surgery in one (2%), and open surgery alone in 36 (73%) patients. Before 2002, only 6% (2/32; 2 TKA) of patients were successfully treated with endovascular intervention compared with 59% (10/17; 9 TKA, 1 THA) after June 2002 (P = .0004). There was no mortality, and limb salvage was achieved in all patients. Although the majority of acute arterial complications after TKA and THA are diagnosed on the day of surgery, a high clinical awareness for acute arterial injury should also be present in the postoperative period. Although not always feasible, endovascular management is now our preferred treatment for injuries associated with TKA or THA. This offers substantially shorter time to vascular restoration, with less morbidity than open repair, and equivalent satisfactory outcomes.

Stratification of Standardized TKA Complications and Adverse Events: A Brief Communication

The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research (®), the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system. The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications. A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events. The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society. Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.

Surgical Decompression Improves Symptoms of Late Peroneal Nerve Dysfunction After TKA

Acute peroneal nerve palsy is a well-known complication of total knee arthroplasty (TKA) that causes a neurological deficit typically seen within hours or days postoperatively. Peroneal nerve dysfunction presents more subtlely than peroneal nerve palsy, with decreased knee range of motion, lateral knee pain, or both following TKA. The diagnosis of peroneal nerve dysfunction may not be suspected for weeks, months, or even years after TKA. Electromyography and nerve conduction studies can support the diagnosis. Historically, peroneal nerve palsy following TKA has been treated nonoperatively but has had an unsatisfactory rate of complete recovery. Recently, a few reports have demonstrated that patients with either peroneal nerve palsy or dysfunction after TKA have had excellent results with surgical decompression of the peroneal nerve.The authors describe a 63-year-old woman who reported transient episodes of lateral knee and leg pain for years after undergoing TKA. She eventually underwent electromyography and nerve conduction studies that indicated a diagnosis of peroneal nerve dysfunction. Approximately 10 years after the TKA, she underwent surgical decompression of the peroneal nerve and has done well since, with significant pain relief and an increased activity level.This case supports the recent literature describing peroneal nerve dysfunction as an uncommon but surgically treatable cause of lateral knee pain following TKA. Increased awareness of the condition and its facile treatment via surgical decompression may result in improved outcomes years after TKA.

Fatigue fracture of tibial arthroplasty implant masked by contralateral knee arthritis

INTRODUCTIONThe wear of polyethylene components is a well-recognised long-term complication of total knee arthroplasty. PRESENTATION OF CASEWe present a case of fatigue fracture of a geomedic tibial tray 17 years after implantation. The symptoms were masked by primary osteoarthritis of the contralateral knee. DISCUSSIONThe mode of failure in this case differs from that most commonly reported in the literature in that it occurred late as the result of prolonged use, not due to implant failure, physiological factors, or surgical technique. The case also demonstrates the incredible ‘masking’ effect of arthritic knee pain. CONCLUSIONThis case highlights the importance to clinicians of keeping a high index of suspicion for prosthesis complications in patients with unilateral joint replacement with contralateral arthropathy.

Combined thrombin-collagen injection for the management of an iatrogenic pseudoanuerysm in the popliteal region

Pseudoaneurysm formation is a rare but recognized complication of total knee arthroplasty (TKR), with fewer than 20 cases described in the literature. Multiple management techniques have been described for such pseudoaneurysms. As thrombin injection is an established technique, we report a case of a post-TKR tibioperoneal pseudoaneurysm successfully occluded via percutaneous injection of a dual thrombin-collagen preparation.

Paper 217: Posterior Stabilized TKA's are Less Sensitive to Implantation Tightness than PCL-Retaining Designs: A Biomechanical Study

Restricted range of motion or excessive laxity are potential complications of total knee arthroplasty (TKA). In contrast patients demand more function for daily activities. To achieve a good function after TKA is important but the aim for all patients should be a better flexion to kneel, work and live without restrictions. Hence the present study was to investigate the effects of implantation tightness on soft tissue strain during passive range of motion. Fourteen fresh frozen cadaver knee joints mounted in a passive flexion rig. Passive flexion was applied to the tibia in 15 deg increments from 0 to 150 deg of flexion. Tibiofemoral force and ligament strain of the medial and lateral collateral ligaments were measured using a custom-built force platform inserted beneath the polyethylene inlay. The standard implantation technique and two variations (2 mm tighter, 2 mm looser) were tested for four prosthesis types: fixed-bearing PCL-retaining (with and without PCL) (PFC), mobile-bearing PCL-sacrificing (LCS), posterior-stabilised (PS), posterior-stabilised with HiFlex femoral component (HF). As expected all prostheses showed a significant increase in tibiofemoral force at full extension when implantation tightness was increased. By comparison in the midrange between 15-90 deg the tibiofemoral force dropped down and was independent of variation in implantation tightness in all designs. Beyond 90 deg the fixed bearing design (PFC) and in the LCS knee were sensitive on implantation tightness. In contrast the two posterior stabilised prosthesis types (PS and HF) showed a different pattern of tibiofemoral force during flexion, with low force throughout the range of motion. As a result in full extension and deep flexion both the PFC prosthesis and the LCS knee represent sensitive designs when considering implantation tightness. Whereas posterior stabilised knee implants are associated with lower tibiofemoral force during the range of motion and more forgiving designs in relation to implantation tightness. The data also suggest that soft tissue structures other than the collaterals tighten as the knee flexes and cause an increase in tibiofemoral compressive force.

Recurrent Patella Loosening and Extra-Articular Migration after TKA

Loosening and subsequent extra-articular migration of the patella component is a rare complication of total knee arthroplasty. We report a case of recurrent aseptic loosening and extra-articular migration of a patella component. Eventually, treatment consisted of removing the patellar component without replacement.

Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society

Despite the importance of complications in evaluating patient outcomes after TKA, definitions of TKA complications are not standardized. Different investigators report different complications with different definitions when reporting outcomes of TKA. We developed a standardized list and definitions of complications and adverse events associated with TKA. In 2009, The Knee Society appointed a TKA Complications Workgroup that surveyed the orthopaedic literature and proposed a list of TKA complications and adverse events with definitions. An expert opinion survey of members of The Knee Society was used to test the applicability and reasonableness of the proposed TKA complications. For each complication, members of The Knee Society were asked "Do you agree with the inclusion of this complication as among the minimum necessary for reporting outcomes of knee arthroplasty?" and "Do you agree with this definition?" One hundred two clinical members (100%) of The Knee Society responded to the survey. All proposed complications and definitions were endorsed by the members, and 678 suggestions were incorporated into the final work product. The 22 TKA complications and adverse events include bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, medial collateral ligament injury, instability, malalignment, stiffness, deep joint infection, fracture, extensor mechanism disruption, patellofemoral dislocation, tibiofemoral dislocation, bearing surface wear, osteolysis, implant loosening, implant fracture/tibial insert dissociation, reoperation, revision, readmission, and death. We identified 22 complications and adverse events that we believe are important for reporting outcomes of TKA. Acceptance and utilization of these standardized TKA complications may improve evaluation and reporting of TKA outcomes.

Revision Total Knee Arthroplasty after Severe Notching of the Anterior Femoral Cortex

Anterior femoral cortex notching is a known complication of total knee arthroplasty (TKA). In severe cases, notching may alter the mechanical properties of the distal femur. We report a patient with significant femoral notching and malpositioning of the femoral prosthesis after TKA, leading to unresolved postoperative pain, decreased range of motion, and functional disability. The severity of this lesion required the use of augments and an offset femoral stem for improved alignment during revision arthroplasty, which is described in this brief technical note.

Patellar Fracture After Total Knee Arthroplasty for Rheumatoid Arthritis

Patellar fracture is one of the most challenging complications of total knee arthroplasty, but relatively, little is known about it in patients with rheumatoid arthritis. We retrospectively analyzed 329 total knee arthroplasties performed in 230 female patients with rheumatoid arthritis to identify the incidence and risk factors for postoperative patellar fractures. The mean age was 61.8 years, and the mean follow-up period was 6.2 years. Patellar resurfacing was performed in all cases. Five postoperative patellar fractures (1.51%) were identified, and a thin residual patellar thickness and the use of posterior-stabilizing components were identified as significant risk factors, although the number of fractures was small in both groups. There was also tendency of higher age and greater joint line change observed in patients with fracture compared with those without fracture.

Complications in Total Knee Arthroplasty After High Tibial Osteotomy

The outcome of total knee arthroplasty (TKA) after high tibial osteotomy remains uncertain. Compared with primary TKA, the results in some studies are not significantly different. Others report adverse effects on the outcome. The purpose of this study was to determine (1) the middle- and long-term survival of TKA performed after high tibial osteotomy, (2) their clinical and radiographic results, and (3) what complications could be expected in this group of patients.The study group comprised 31 patients (34 knees) undergoing cemented TKA after high tibial osteotomy. Average follow-up was 8 years (range, 6-213 months). Survival of the TKA was estimated using the Kaplan-Meier method. Outcomes were documented using the Hospital for the Special Surgery score. The results showed that the Kaplan-Meier survival rate was 82% at 5 years and 76% at 10 years. Excellent and good clinical results were obtained in 67% of patients. Complications occurred in 12 (35%) knees: stiffness in 4, aseptic loosening in 2, patellofemoral subluxation in 1, instability in 1, inexplicable pain in 1, and deep infection in 3.Great care with technical details is necessary when high tibial osteotomy is indicated because a future conversion to TKA may occur.

A Comparison of Patellar Vascularity Between the Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty

A complication of total knee arthroplasty is patellar avascular necrosis. Surgical approaches for total knee arthroplasty include the medial parapatellar approach (MPa) and, less commonly, the subvastus approach (SVa). The argument that SVa retains better patellar vascularity than the MPa was investigated on 20 participants, (SVa, n = 10; MPa, n = 10) 18 months postoperatively. Outcomes were a radionuclide bone imaging technique, a new bone vascularity scale, and an anterior knee pain numerical assessment scale. Results indicated no significant difference between groups on imaging (P = .935), the components of the bone vascularity scale, or anterior knee pain (P > .999). The SVa appears to offer no benefit over the MPa in terms of patellar vascularity or anterior knee pain.

Influence of gender on the outcome of total knee arthroplasty

Total knee arthroplasty (TKA) is a common treatment for osteoarthritis. Recently, there has been interest in the anatomical differences between male and female knees and possible effects on outcome. The purpose of this study is to analyze whether gender influenced on clinical outcome, radiographic findings, revision rate, or complications of TKAs performed with unisex components. Six hundred eighty-one patients (28% male and 72% female) treated with TKA were evaluated. Similar patient age, body mass index, International Knee Society (IKS) knee score, range of motion, and stage of osteoarthritis were noted in both groups pre-operative. IKS function score and activity level were higher in the male group. At a mean of 2.3 years post-operative, both groups demonstrated similar increases in IKS scores. Function scores and activity levels remained higher in the male group. No differences in radiologic findings or revision rates were noted. Slightly higher infection rates were noted in the male group.

Flexion Contracture Following Primary Total Knee Arthroplasty: Risk Factors and Outcomes

Function and satisfaction after total knee arthroplasty (TKA) are partially linked to postoperative range of motion (ROM). Fixed flexion contracture is a recognized complication of TKA that reduces ROM and is a source of morbidity for patients. This study aimed to identify preoperative risk factors for developing fixed flexion contracture following TKA and to quantify the effect of fixed flexion contracture on outcomes (Oxford knee score 12-60 and patient satisfaction) at 2 years. Pre-, intra-, and postoperative data for 811 TKAs were retrospectively reviewed. At 2 years postoperatively, the incidence of fixed flexion contracture was 3.6%. Men were 2.6 times more likely than women to have fixed flexion contracture (P=.012), and patients with preimplant fixed flexion contracture were 2.3 times more likely than those without to have fixed flexion contracture (P=.028). Increasing age was associated with an increased rate of fixed flexion contracture (P=.02). Body mass index was not a risk factor (P=.968). Incidence of fixed flexion contracture for those undergoing computer navigated TKA was 3.9% compared with 3.4% for those having conventional surgery (P=.711). Patients with fixed flexion contracture had poorer outcomes with a median [interquartile range] Oxford Knee Score of 25 [15] compared with 20 [11] for those without (P=.003) and lower patient satisfaction (P=.036). These results support existing literature for incidence of fixed flexion contracture after TKA, risk factors, and outcomes, indicating that these figures can be extrapolated to a wide population. They also clarify a previously contentious point by excluding body mass index as a risk factor.

General and specifi c complications in total knee arthroplasty with and without patellar resurfacing

The need to replace the patella in total knee arthroplasty is still a subject of debate among orthopedic surgeons. Existing studies show heterogeneous and even contradictory results. А study of 249 patients with unilateral knee osteoarthrosis , who underwent total knee arthroplasty with (group I) and without (group II) patellar resurfacing in the orthopaedic department of National Medical Surgical Center named N.I.Pirogow was carried out. Group I included 128 patients (51.4%), and group II included 121 patients (48,6%), Posterior Stabilized Sigma (DePuy Johnson&Johnson) implants were used. We studied the rate and structure of general and specifi c (patellofemoral), complications and the revision rate related to patellofemoral complications after total knee replacement with and without patellar resurfacing. On the basis of the study results, we concluded that, with the design of prosthesis used in our study, in patients with primary knee osteoarthrosis, similar results may be achieved with and without patellar resurfacing.

Knee Region Coverage with Reversed Gracilis Pedicle Flap (GReSP Flap).

To treat severe soft-tissue complications of total knee arthroplasty, we used an extended reversed gracilis flap based on secondary pedicles (the GReSP flap). Locate the gracilis and pedicles, then debride the wound bed. Expose the superficial aspect of the muscle, while protecting the saphenous vein and nerve. Temporarily clamp the main vascular pedicle to ensure blood supply when perfused only by the secondary pedicles. Transect the proximal tendon of the gracilis muscle to provide maximal length for the muscle flap and ligate the main vascular and nerve pedicles. Suture the flap in place and cover with skin graft. Immobilize the knee for two weeks; follow with rehabilitation to restore range of motion. We treated three patients who had an infection at the site of a total knee arthroplasty and exposure of the implant. IndicationsContraindicationsPitfalls & Challenges.

Pseudo-Patella Baja after total knee arthroplasty

SummaryBackgroundOne of the complications of total knee arthroplasty (TKA) which has not yet been directly addressed is pseudo-patella baja (PPB). True patella baja (PB) is present when the length of the patellar tendon becomes shorter. PPB is present when the patella tendon is not shortened, but the level of the joint line is elevated. This study was conducted to assess PPB in TKA.Material/MethodsSixty patients who had had a primary TKA at our center between 1995 and 2005 were included. The average follow-up was 27.5 months. The Knee Society Scoring (KSS), lateral knee x-rays and the Blackburne-Peel index were used for assessments.ResultsOut of the 60 patients, 43 (72%) demonstrated no joint line elevation or patellar tendon shortening (group A). Fifteen patients (25%) had joint line elevation (group B), and both PB and PPB were present in 2 (3%) patients (group C). KSS was lower in groups B and C compared with group A, but this difference was not statistically significant. The average range of motion (ROM) in group A was significantly higher compared with either group B or C, and patients in groups B and C showed significantly more severe pain compared with group A (P<0.001).ConclusionsPPB is not an uncommon finding after TKA and is associated with a statistically significant decrease in ROM and an increase in pain. Furthermore, KSS in the PPB group was less than in patients without PPB, although the difference was not statistically meaningful.