Arterial Injury in Total Knee Arthroplasty

Arterial complications associated with knee arthroplasty are relatively rare, although probably underreported, complications of knee arthroplasty that carry a risk of significant morbidity. Thorough preoperative assessment and close liaison with a vascular surgeon, combined with an appreciation of common anatomical variants or distorted anatomy, may help prevent both thromboembolic and direct injuries from occurring. Clinical features of arterial complications following knee arthroplasty may vary significantly from acute hemorrhage or ischemia in the immediate postoperative period to chronic pain and swelling presenting even months following the procedure. There is potential for diagnostic confusion and delay that may adversely affect outcome. Early diagnosis along with vascular surgical review and intervention is key to successful management.     

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundTourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes.MethodsPatients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected.ResultsVisual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent.ConclusionThis study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.     

Effects of Suture and Tourniquet on Intraoperative Kinematics in Navigated Total Knee Arthroplasty

Background

To investigate the effects of suture (soft tissue closure) and air tourniquet use on intraoperative kinematics in navigated total knee arthroplasty.

The Fragility of Tourniquet Use in Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

BackgroundPhysicians utilize P-values to interpret clinical trial data and guide patient-care decisions. Fragility analysis assesses the stability of statistical findings in relation to outcome event reversals. This study assessed the statistical fragility of recent randomized controlled trials (RCTs) investigating tourniquet use in total knee arthroplasty (TKA).MethodsWe queried PubMed, EMBASE, and MEDLINE for RCTs comparing outcomes in TKA based on tourniquet use. Fragility index (FI) and reverse fragility index (reverse FI) were calculated – for significant and nonsignificant outcomes, respectively – as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) was calculated by dividing the FI or reverse FI by the sample size. Median overall FI and FQ were calculated for all included outcomes, and sub-analyses were performed by reported significance. The literature search yielded 23 studies reporting 91 total dichotomous outcomes.ResultsOverall median FI was 4 with an interquartile range (IQR) of 3 to 6. Overall median FQ was 0.0476 (IQR 0.0291 to 0.0867). A total of 11 outcomes were statistically significant with a median FI and FQ of 2 (IQR 1.5 to 5) and 0.0200 (IQR 0.0148 to 0.0484), respectively. There were 80 outcomes that were nonsignificant with a median reverse FI of 4 (IQR 3 to 6). Loss to follow-up was greater than the median FI in 17.6% of outcomes.ConclusionAltering a small number of outcomes is often sufficient to reverse findings in RCTs evaluating tourniquet use in TKA. We recommend including fragility analyses to increase reliability in the interpretation of study conclusions.     

Optimized Tourniquet Use in Primary Total Knee Arthroplasty: A Comparative,Prospective, and Randomized Study

BackgroundThe results of recent studies investigating tourniquet (TNQ) use for knee arthroplasty are controversial. Therefore, this study aimed to compare patients undergoing total knee arthroplasty who did not have a TNQ to those in whom an optimized TNQ protocol was applied.MethodsWe prospectively evaluated 127 patients who had knee osteoarthritis who had undergone total knee arthroplasty and randomized them into two groups: “without TNQ” and “optimized TNQ” (TNQ inflation before skin incision, deflation after cementing, with pressure one hundred millimeters of mercury above the systolic blood pressure, and without articular suction drain usage). The means of surgery and TNQ duration, blood loss, number of blood transfusions, degree of pain, edema, range of motion (ROM), functional score over time, and postoperative complications were compared between the groups. Statistical significance was set at P < .05.ResultsNo significant differences were found in terms of surgical timing, blood loss, thigh and knee pain, edema, ROM, functional scores, and complications between the “without TNQ” and “optimized TNQ” groups.ConclusionThe use of an optimized TNQ in primary total knee arthroplasty presents similar clinical results to surgery without a TNQ and did not increase the incidence of postoperative complications. Its use allowed surgery to occur with the benefits of a clean and dry surgical field provided by TNQ without increasing procedure-related comorbidities.     

Radiographic Findings in Patients With Catastrophic Varus Collapse After Total Knee Arthroplasty

Background

Catastrophic varus collapse is an uncommon mechanism of failure in primary total knee arthroplasty (TKA). Varus collapse has been associated with obesity and smaller implant sizes. However, to our knowledge, preoperative radiographic characterization of this cohort has not been performed. Therefore, the following study evaluated preoperative alignment and how this correlates with the degree of eventual varus collapse identified in this patient population prior to revision.

All-Polyethylene Tibial Component Use for Elderly,Low-Demand Total Knee Arthroplasty Patients

Background

Potential advantages combined with lower cost have prompted a renewed interest in modern all-polyethylene tibial designs.

Late Tourniquet Release and Drain Clamping Reduces Postoperative Blood Loss in Total Knee Arthroplasty

Background

Many studies have investigated the effect of tourniquet release time and closed suction drainage in total knee arthroplasty (TKA). However, controversy remains as to the advisability of preclosure tourniquet release and the advisability of closed suction drain use following total knee arthroplasty.

Questions/Purposes

The aim of the study was to investigate if there is a benefit of performing tourniquet release after skin closure, along with drain clamping, for the first 6h following TKA.

Methods

Ninety-six patients underwent TKA between May 2009 and April 2010. Fourteen of these were excluded because of systemic diseases and simultaneous bilateral TKA. Twenty-nine of these were excluded due to use of a patellar component and posterior cruciate ligament (PCL)-sacrificing systems. Thus, 53 patients that underwent PCL-retaining cemented TKA were reviewed retrospectively. In the control group (group C), the tourniquet was released before skin closure, an attempt at hemostasis was made, and a compressive bandage was applied. The drain was not clamped in these patients. The test group of 23 patients (group T) had tourniquet release after skin closure and after the compressive bandage was applied. The drain was clamped for the first 6h after surgery. The two groups were compared as to the amount of drained blood, postoperative change in hemoglobin, postoperative complications, and knee function.

Results

We found that drained blood and hemoglobin drop were significantly lower in group T compared with group C. There was no difference regarding postoperative complications and knee function.

Conclusion

We conclude that tourniquet release after skin closure and compressive dressing followed by 6h of drain clamping reduces postoperative blood loss in TKR surgery.     

The Role of Patient Characteristics on the Choice of Unicompartmental versus Total Knee Arthroplasty in Patients With Medial Osteoarthritis

Background

Medial unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are both viable treatment options for medial osteoarthritis (OA). However, it remains unclear when to choose for which arthroplasty treatment. Goals of this study were therefore to (1) compare outcomes after both treatments and (2) assess which treatment has superior outcomes in different patient subgroups.

Lower Extremity Arterial Calcification on Preoperative Knee Radiographs as a Predictor of Postoperative Cardiovascular Events After Primary Total Knee Arthroplasty

Background

A cross-sectional study of total knee arthroplasty (TKA) patients was conducted to determine the association of lower-extremity arterial calcification (LEAC) with acute perioperative cardiovascular events (CVEs).

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty

BackgroundTo determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient.MethodsRetrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed.ResultsThe cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2).ConclusionThe LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient’s first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge.Level of EvidenceLevel 3-retrospective cohort study.     

Unicompartmental Knee Arthroplasty vs Total Knee Arthroplasty for Medial Compartment Arthritis in Patients Older Than 75 Years: Comparable Reoperation,Revision, and Complication Rates

Background

Prior studies comparing unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) in the elderly are limited by heterogeneity in arthritic disease patterns and patient selection. We report the results of UKA and TKA in patients 75 years and older with isolated medial compartmental arthritis, with special emphasis on immediate postoperative recovery, complications, reoperation rates, and implant survivorship at midterm follow-up.

Improved Radiographic Outcomes With Patient-Specific Total Knee Arthroplasty

Patient-specific guides can improve limb alignment and implant positioning in total knee arthroplasty, although not all studies have supported this benefit. We compared the radiographs of 100 consecutively-performed patient-specific total knees to a similar group that was implanted with conventional instruments instead. The patient-specific group showed more accurate reproduction of the theoretically ideal mechanical axis, with fewer outliers, but implant positioning was comparable between groups. Our odds ratio comparison showed that the patient-specific group was 1.8 times more likely to be within the desired + 3° from the neutral mechanical axis when compared to the standard control group. Our data suggest that reliable reproduction of the limb mechanical axis may accrue from patient-specific guides in total knee arthroplasty when compared to standard, intramedullary instrumentation.     

Total Knee Arthroplasty Combined With Medial Patellofemoral Ligament Reconstruction for Osteoarthritic Knee With Preoperative Valgus Deformity and Chronic Patellar Dislocation

We report a challenging case of a 44-year-old woman who had osteoarthritis in the lateral compartment of her right knee with severe valgus deformity and chronic lateral patellar dislocation. Total knee arthroplasty was performed for the knee. However, persistent patellar dislocation remained during the surgery; and therefore, medial patellofemoral ligament (MPFL) reconstruction was additionally performed at the time of the surgery. Stable patellar tracking was obtained after the MFPL reconstruction; and during the 2-year follow-up, her knee functioned well, and no recurrent patellar dislocation was observed. This clinical case indicates the usefulness of MPFL reconstruction for obtaining stable patellar tracking during total knee arthroplasty when a tendency for lateral patellar dislocation remains.     

Effect of Different Tourniquet Pressure on Postoperative Pain and Complications After Total Knee Arthroplasty: A Prospective,Randomized Controlled Trial

BackgroundTourniquet pressure inflation is commonly selected between 100 and 150 mm Hg above the systolic blood pressure (SBP). Given the lack of evidence to support a given inflation pressure, our study aimed to ascertain the lowest tourniquet pressure that facilitated total knee arthroplasty (TKA) and resulted in the least postoperative pain and complications.MethodsIn a double-blind, randomized controlled trial of patients scheduled for unilateral primary TKA, 150 were assigned to use tourniquet pressures of SBP + 75 mm Hg (group I), SBP + 100 mm Hg (group II), and SBP + 150 mm Hg (group III). The quality of the bloodless field, total blood loss, and limb swelling were determined perioperatively. Clinical outcomes were evaluated by visual analog scale for pain at thigh and surgical site, serum creatinine phosphokinase levels, wound complications, range of motion, and Knee Society Score.ResultsVisual analog scale for pain at thigh and surgical site were lowest in group I (P < .01) and highest in group III (P < .01). However, the quality of bloodless field at the tibial cutting surface was significantly better in group III compared to group I/II but not at the femoral cutting surface. The total blood loss and limb swelling showed no difference among 3 groups. Postoperative serum creatinine phosphokinase levels at 24 and 48 hours and wound complications in group III were significantly higher than group I (P < .01) and group II (P < .01). Nevertheless, postoperative knee range of motion and Knee Society Score were not significantly different among 3 groups.ConclusionPost TKA, the lowest tourniquet pressure was associated with significantly less postoperative tourniquet and surgical site pain, muscle damage, and wound complications.     

Total Knee Arthroplasty in Patients With Prior Anterior Cruciate Ligament Reconstruction

Background

Few studies have analyzed the outcomes of total knee arthroplasty (TKA) in patients with prior anterior cruciate ligament (ACL) reconstruction, and the reported outcomes are controversial. The purpose of this study is to assess if prior ACL reconstruction had any impact on the outcome of subsequent TKA.

A Meta-Analysis of Patellar Replacement in Total Knee Arthroplasty for Patients With Knee Osteoarthritis

Background

This meta-analysis (MA) aims at comparing the clinical outcomes of resurfacing and nonresurfacing the patella in patients undergoing total knee arthroplasty in the treatment of knee osteoarthritis.

Comparison of Mechanical and Nonmechanical Failure Rates Associated With Rotating Hinged Total Knee Arthroplasty in Nontumor Patients

Rotating hinge total knee arthroplasty (TKA) has had acceptable to poor results in terms of clinical outcomes and survivorship, leading to skepticism with regard to its use. A total of 271 hinged TKAs performed between 1998 and 2008 were studied to determine survivorship and factors affecting survivorship. A median survivorship of 6.9 years was found for the best-case cohort (n = 111), and 4.1 years, for the worst-case group (n = 174). Of the 111 patients, 51 (45.9%) experienced a failure that required reoperation, with more than half of these (29/51, or 56.9%) due to nonmechanical modes of failure. Comparison of the kinematic hinge implants with the distal femoral replacements showed that the Kaplan-Meier survivorship was slightly higher for the patients with distal femoral replacements, although this was not significant (P = .962). Our study suggests that the hinge TKA is well designed and provides acceptable survivorship in healthy patients who do not have nonmechanical complications.     

Kneeling Is Safe for Patients Implanted With Medial-Pivot Total Knee Arthroplasty Designs

Nine ADVANCE (Wright Medical Technology, Arlington, TN)) Medial-Pivot (MP) and 9 ADVANCE Double-High total knee arthroplasties were analyzed under radiographic surveillance at standing, mid kneeling, and full kneeling. In vivo tibiofemoral contact positions were obtained using the 3- to 2-dimensional image registration technique. The contact in Double-High knee was always more posterior than that in the MP knee presumably because of the presence of the posterior cruciate ligament. The contact positions in both the designs moved anterior from standing to mid kneeling, moved posterior from mid kneeling to full kneeling, and remained within the intended articulation range of the implants. This study indicates that kneeling is safe in MP total knee arthroplasty even in the absence of a cam-post or posterior cruciate ligament.