Complications of Total Knee Arthroplasty in Brief D. Haddad P. Kim October 4, 2005.
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Transcript of Complications of Total Knee Arthroplasty in Brief D. Haddad P. Kim October 4, 2005.
Complications of Total Complications of Total Knee Arthroplasty in BriefKnee Arthroplasty in Brief
D. HaddadD. Haddad
P. KimP. Kim
October 4, 2005October 4, 2005
TopicsTopics
thromboembolismthromboembolism anemia/blood lossanemia/blood loss infectioninfection neurovascularneurovascular wound healingwound healing intra-op MCL injuryintra-op MCL injury arthrofibrosisarthrofibrosis extensor mechanism failureextensor mechanism failure
ThromboembolismThromboembolism
increased risk:increased risk: age >40, estrogen, cancer, prolonged immobility, age >40, estrogen, cancer, prolonged immobility,
CHF, IBD, obesity, smoking , HTN DM, MICHF, IBD, obesity, smoking , HTN DM, MI
prevalence (w/o prophylaxis)prevalence (w/o prophylaxis) DVT : 40-84% DVT : 40-84%
thigh – 9-20%thigh – 9-20% calf DVT will propagate proximal in 6-23%calf DVT will propagate proximal in 6-23%
PE 10-20%PE 10-20% symptomatic 0.5 -3%symptomatic 0.5 -3% mortality up to 2%mortality up to 2%
Thromboembolism:Thromboembolism:DiagnosisDiagnosis
hi index of suspician – most asymphi index of suspician – most asymp routine screening has not proven usefulroutine screening has not proven useful venography – gold standard (97%venography – gold standard (97% duplex ultrasonographyduplex ultrasonography
sensitivity – 20-90% (multicenter study)sensitivity – 20-90% (multicenter study) >90% accurate for proximal>90% accurate for proximal
Thromboembolism:Thromboembolism: Prophylaxis Prophylaxis
recommended in all patients undergoing TKArecommended in all patients undergoing TKA
ASA – DVT rates 59%-73% ASA – DVT rates 59%-73% justification: no diff fatal PE ratesjustification: no diff fatal PE rates
mechanical (e.g. intermittent pneumatic compressive mechanical (e.g. intermittent pneumatic compressive device) – sig reduction proximal DVT device) – sig reduction proximal DVT
warfarin vs LMWH debatewarfarin vs LMWH debate LMWH slightly more effective but more transfusion and slightly LMWH slightly more effective but more transfusion and slightly
increased risk significant bleeding increased risk significant bleeding duration? – 1998 Chest MD Consensus Conference: 7-10 days, duration? – 1998 Chest MD Consensus Conference: 7-10 days,
possible incr benefit if 29-35 dayspossible incr benefit if 29-35 days
Thromboembolism: Thromboembolism: TreatmentTreatment
PE or proximal high risk DVTPE or proximal high risk DVT
IV unfract heparin (2-2.5xcontrol)IV unfract heparin (2-2.5xcontrol) LMWH (lovenox 1.5mg/kg sc od)LMWH (lovenox 1.5mg/kg sc od) coumadin (overlap until INR>2-2.5)coumadin (overlap until INR>2-2.5) IVC filterIVC filter
only if above contraindicatedonly if above contraindicated often requires LT anticoagoften requires LT anticoag not clearly shown to reduce incidence of fatal PE (OKU H and K recon 2)not clearly shown to reduce incidence of fatal PE (OKU H and K recon 2)
conventional durationconventional duration calf DVT 6 wkscalf DVT 6 wks prox DVT 3 moprox DVT 3 mo PE 6 moPE 6 mo
however indefinate Tr reduces recurrence w/ no incr bleeding risk however indefinate Tr reduces recurrence w/ no incr bleeding risk demonstrated at 2-4 y f/udemonstrated at 2-4 y f/u
Post-op Blood Loss/AnemiaPost-op Blood Loss/Anemia
estimate perioperative blood loss of 1.5L estimate perioperative blood loss of 1.5L (cemented) to 2L (uncemented)(cemented) to 2L (uncemented)
dropping tourniquet before closure and dropping tourniquet before closure and use of drain may use of drain may increaseincrease blood loss blood loss
pre-op donation and EPO, and post-op pre-op donation and EPO, and post-op blood salvage can reduce transfusion req. blood salvage can reduce transfusion req.
sig post-op hematoma uncommonsig post-op hematoma uncommon consider holding anticoag consider holding anticoag
Vascular InjuryVascular Injury
RARE (0.03-0.2%) RARE (0.03-0.2%) 14 cases reported in UK from 147 surgeons14 cases reported in UK from 147 surgeons
3 direct trauma (pop a. or branches) – good recovery3 direct trauma (pop a. or branches) – good recovery 11 thrombosis (fem/pop) – 6 required 11 thrombosis (fem/pop) – 6 required amputationamputation no cases of thrombosis without tourniquetno cases of thrombosis without tourniquet
pre-op critical assessment of vascularity importantpre-op critical assessment of vascularity important prev sx, claudication, Ca’n vessels, pulsesprev sx, claudication, Ca’n vessels, pulses
noninvasive vasc studies and vasc. sx consultation noninvasive vasc studies and vasc. sx consultation when indicatedwhen indicated abi < 0.9=consult, <0.5=need for revasc before TKAabi < 0.9=consult, <0.5=need for revasc before TKA
post-op assessment vascularity in all patients – post-op assessment vascularity in all patients – emergent angio/sx if pulses absentemergent angio/sx if pulses absent
Neurological InjuryNeurological Injury
almost synonymous w/ peroneal n. injuryalmost synonymous w/ peroneal n. injury 0.3-4%0.3-4% usually after correction of FFD or fixed valgus (e.g. RA)usually after correction of FFD or fixed valgus (e.g. RA) RF – previous lumb, lumbar laminectomy, severe valgus, RF – previous lumb, lumbar laminectomy, severe valgus,
epidural, previous HTOepidural, previous HTO Tr: release dressing completely and flex knee, AFO if Tr: release dressing completely and flex knee, AFO if
persists; observepersists; observe
OUTCOMEOUTCOME Asp and Rand – 50% pts recovered at 5 y. f/u (more Asp and Rand – 50% pts recovered at 5 y. f/u (more
common in incomplete palsies)common in incomplete palsies) OKU – most partial palsies recover completelyOKU – most partial palsies recover completely Krackow 4/5 pts completely recovered after delayed Krackow 4/5 pts completely recovered after delayed
decompression (5-45 mo)decompression (5-45 mo)
Wound Healing Wound Healing
RF: RF: prior: incisions, direct ant. knee trauma, infectn, prior: incisions, direct ant. knee trauma, infectn,
burns, radiationburns, radiation use of azothioprine, short acting RA medsuse of azothioprine, short acting RA meds immunosuppressionimmunosuppression obesityobesity subcut skin closure w/ polydioxanone (PDS)subcut skin closure w/ polydioxanone (PDS) probs w/ microciruclation (DM,RA)probs w/ microciruclation (DM,RA) prolonged corticosteroidprolonged corticosteroid correction severe deformity (skin on concave side)correction severe deformity (skin on concave side)
PreventionPreventionmain blood supply medialmain blood supply medial anastamoses at fascial levelanastamoses at fascial level less oxygen tension in lateral flap less oxygen tension in lateral flap
as move medialas move medial use of midline incision is use of midline incision is
recommendedrecommended raise flaps raise flaps underunder fascia if necc fascia if necc use of most lateral incision use of most lateral incision
recommended if multiple recommended if multiple incisionsincisions
if new incision if new incision skin bridge 7 skin bridge 7 cmcm
if contracted – consider soft if contracted – consider soft tissue expanderstissue expanders
consider full thickness flap pre-op consider full thickness flap pre-op
TreatmentTreatment
agressively treat early signs of infectionagressively treat early signs of infection low threshold to aspirate kneelow threshold to aspirate knee hold ABic until deep cultures availhold ABic until deep cultures avail early I&Dearly I&D
once prosthesis exposed – aggressive st once prosthesis exposed – aggressive st reconstruction reconstruction excise abnormal skin, gastroc/soleus/free flapexcise abnormal skin, gastroc/soleus/free flap
InfectionInfection
1-2% prevalence1-2% prevalence best preventedbest prevented when diagnosed should be treated when diagnosed should be treated
aggressivelyaggressively RF: immunosuppression, diabetes, RF: immunosuppression, diabetes,
smoking, prior surgery, obesity, smoking, prior surgery, obesity, hinged/highly constrained implanthinged/highly constrained implant
reduced w/ laminar flow; prophylactic reduced w/ laminar flow; prophylactic antibiotics, antibiotic impreg cementantibiotics, antibiotic impreg cement
DefinitionsDefinitions
deep infection=deep to fascia w/ joint deep infection=deep to fascia w/ joint involvementinvolvement
early infection (<6 mo) – early infection (<6 mo) – contamination/wound probcontamination/wound prob
late – heamatogenous seedinglate – heamatogenous seeding more useful in directing Tr: duration of more useful in directing Tr: duration of
symptoms (< or > 2wks)symptoms (< or > 2wks)
DiagnosisDiagnosis
ESR, CRP, bone/wbc scans variably ESR, CRP, bone/wbc scans variably usefuluseful
aspirate all joints suspected of infectionaspirate all joints suspected of infection 100% sensitivity, specificity, and accuracy in 100% sensitivity, specificity, and accuracy in
one study (43 knees)one study (43 knees) AB’ics must be stopped for 10-14 daysAB’ics must be stopped for 10-14 days
TreatmentsTreatments repeated aspirations and AB’icsrepeated aspirations and AB’ics
poor op candidate, dx in 48 hours, pen sensitive organismpoor op candidate, dx in 48 hours, pen sensitive organism component retention w/ I and D and poly exchangecomponent retention w/ I and D and poly exchange
acute post-op (w/in 4/52) or <2 wks (?5 days,?30 days) of symptomsacute post-op (w/in 4/52) or <2 wks (?5 days,?30 days) of symptoms prosthesis exchangeprosthesis exchange
2 stage is standard2 stage is standard remove components/cementremove components/cement aggressive debridement aggressive debridement AB’ic depot AB’ic depot
(articulated spacer)+ IV AB’ics(articulated spacer)+ IV AB’ics insert revision TKA insert revision TKA duration b/w stages controversial – 6 wks and downward trend CRP/ESRduration b/w stages controversial – 6 wks and downward trend CRP/ESR
fusionfusion failure of tr, inad skin/st, resistant organisms, immunocompetentfailure of tr, inad skin/st, resistant organisms, immunocompetent 90% success eradication and fusion90% success eradication and fusion
resection arthroplastyresection arthroplasty non-ambulator/salvagenon-ambulator/salvage
amputationamputation life threatening sepsis or ultimate last resort after all other Tr failedlife threatening sepsis or ultimate last resort after all other Tr failed
Intra-op MCL RuptureIntra-op MCL Rupture
traditionally treated with change to constrained traditionally treated with change to constrained implantimplant
best tr: intra-op repair and continue w/ planned best tr: intra-op repair and continue w/ planned implantimplant
Leopold et al JBJS 2001Leopold et al JBJS 2001 16 pts w/ intra-op MCL injury16 pts w/ intra-op MCL injury all treated primarily with repair or reattachment and all treated primarily with repair or reattachment and
6/52 bracing w/ no ROM restrictions6/52 bracing w/ no ROM restrictions unconstrained implantsunconstrained implants good results re var/val stability,ROMgood results re var/val stability,ROM
StiffnessStiffness
common source of failurecommon source of failure ““remains unsolved problem”remains unsolved problem” best predictor post-op ROM: pre-op ROMbest predictor post-op ROM: pre-op ROM
inconsistent predictors – diagnosis, keloid, prev plateau #, inconsistent predictors – diagnosis, keloid, prev plateau #, prev sxprev sx
intra-op causes (“overstuffing”)intra-op causes (“overstuffing”) improper flexion-extension gap balancing, malpositioning or
oversizing of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, or incompletely resected posterior osteophytes.
post-op causespost-op causes patient motivation and compliance, deep infection,
arthrofibrosis, patellar comp, CRPS, HO
TreatmentTreatment JAAOS 2004JAAOS 2004
Extensor Mechanism FailureExtensor Mechanism Failure
quads rupture – extremely rarequads rupture – extremely rare patellar tendon (ligament) rupturepatellar tendon (ligament) rupture
one of most dreaded complicationsone of most dreaded complications <1%<1% intraop- everting stiff ext mechintraop- everting stiff ext mech postop – trauma, chronic attritionpostop – trauma, chronic attrition best TR is preventionbest TR is prevention Tr unreliable and generally unsatisfying resultTr unreliable and generally unsatisfying result
Tr: Tr: acute: primarily if avulsion and intact periosteal sleeve (+/- acute: primarily if avulsion and intact periosteal sleeve (+/-
semiT augment)semiT augment) chronic: reconstruction w/ Achilles allograft preferred Tr for most chronic: reconstruction w/ Achilles allograft preferred Tr for most
authors @ presentauthors @ present
Patellar FracturePatellar FractureJAAOS 2003JAAOS 2003
Peace OutPeace Out