Popliteal aneurysm after total knee arthroplasty: Case reports and review of the literature

Vascular complications after total knee arthroplasty include arterial occlusion, arterial severance, arteriovenous fistula, and arterial aneurysm. Both a false aneurysm and a true aneurysm of the popliteal artery are described. The false popliteal aneurysm resulted from direct surgical trauma and required excision and repair. The true popliteal aneurysm was unsuccessfully treated with excision, transfemoral thrombectomy, and bypass surgery. Many of the vascular complications after total knee arthroplasty may be preventable and the following prudent guidelines are suggested. Careful preoperative evaluation is critical, including past medical history, palpation of pedal pulses, and review of radiographs to identify abnormal calcification in the vessels. Vascular consultation may be necessary. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative.     

Primary total knee arthroplasty for complex distal femur fractures in elderly patients

Fractures of the distal femur in the geriatric population are associated with a high incidence of postoperative complications and poor results. Nonunion, loss of fixation, and malunion of these fractures occur with all types of treatment. The postoperative treatment of these patients demands a lengthy period of limited weightbearing that can increase the rate of medical complications. Our experience with these challenging fractures caused us to consider the use of a primary distal femur replacement total knee arthroplasty with the goals of elimination of fracture healing issues, early mobilization, and immediate weightbearing. Twenty-four distal femoral replacement knee arthroplasties were done from July 1998 to January 1999. Reviewed with a mean followup of 11 months, 17 patients (71%) resumed their preoperative level of ambulation. Knee range of motion averaged 1 degree - 103 degrees. No major surgical or significant medical complications were experienced by these patients. Our experiences with this small number of patients have shown that an immediate arthroplasty offers many advantages over open reduction and internal fixation for geriatric patients with poor bone quality, preexisting degenerative joint disease, and medical problems.     

Late presentation of a mycotic popliteal artery pseudoaneurysm in the setting of a revised total knee arthroplasty complicated by both prior infection and periprosthetic fracture: a case report

Reports of adverse arterial events associated with total knee arthroplasty (TKA), such as ischemia, thrombosis, arterial injury, or pseudoaneurysm, are relatively rare in the orthopedic and vascular literature and are most commonly associated with direct trauma to the vessel. Additionally, arterial complications typically present within a short postoperative time frame. A delayed presentation of a mycotic arterial pseudoaneurysm in the setting of a revision arthroplasty complicated by infection and fracture has not, to the best knowledge of the authors, been described in the literature. We report the delayed presentation of a mycotic pseudoaneurysm in the setting of a revision TKA previously complicated by both infection and periprosthetic fracture. One year after fracture repair, the patient presented with acute thigh swelling and was diagnosed with a mycotic pseudoaneurysm of the right proximal popliteal artery. He was treated with surgical excision, reverse saphenous vein interpositional grafting, and a long-term course of broad-spectrum antibiotics. In the setting of a revision TKA and previous complications, the risk of future complications is increased and may not always involve direct vascular trauma. In patients with previously infected joints and new-onset vascular events, mycotic pseudoaneurysm must be included in the differential diagnosis.     

80岁以上高龄患者人工关节置换手术的疗效和并发症研究

目的研究80岁以上高龄患者人工关节置换手术治疗的疗效以及并发症的发生情况。方法对80岁以上高龄患者行人工关节置换手术,21例为全髋关节置换,18例为全膝关节置换。研究两组患者人工关节置换手术的疗效以及并发症的发生情况。结果全髋关节置换手术的生化指标TP、ALB降低;指标在治疗前后的差异均具有统计学意义(P<0.05)。全膝关节置换手术前后的TP、ALB差别不大,差异无统计学意义(P>0.05)。GLB增高、A/G减小,差异具有统计学意义(P<0.05)。BMD和CRP在术前和出院时变化不大(P>0.05)。疼痛、功能、下肢畸形于人工全髋关节置换术前,术后1、6个月评分逐渐增加,总差异具有统计学意义(P<0.05)。疼痛、关节功能、活动度、肌力状态、屈膝畸形、稳定性于人工全膝关节置换术前,术后1、6个月评分逐渐增加,总差异具有统计学意义(P<0.05)。并发症:全髋关节置换术切口皮肤坏死1例;全膝关节置换术深静脉栓塞1例;假体周围骨折2例;无死亡病例。结论 80岁以上人工关节置换手术在严格掌握适应证的情况下可以有效地避免术后并发症发生。     

Axillary artery thrombosis after humeral resurfacing arthroplasty

Shoulder arthroplasty is a very successful procedure that places significant technical demands on the surgeon. Complications, such as neural injury and postoperative fracture, have been reported in the literature. In this article, I describe 2 cases of axillary artery thrombosis that occurred after humeral resurfacing arthroplasty. Case 1 involved a 59-year-old woman who underwent humeral resurfacing arthroplasty. In the immediate postoperative period, a vascular insult was diagnosed by decreased radial pulse and perfusion. Immediate retrograde angiography revealed occlusion of the axillary artery near the level of the prosthesis. Retrograde balloon thrombectomy removed an arterial thrombus and circulation was restored. Case 2 involved a 64-year-old woman with a latent decrease in radial pulse amplitude after humeral resurfacing. Unsuccessful balloon thrombectomy necessitated a reverse saphenous vein bypass graft. Axillary artery injury that occurs after anterior shoulder dislocation is well documented. Shoulder position during humeral resurfacing reproduces anterior glenohumeral dislocation and may tense the axillary artery against the edge of the pectoralis minor. Elderly patients are predisposed to vascular injury because of loss of arterial elasticity. Meticulous neurovascular examination is crucial throughout the postoperative period, as collateral circulation may conceal perfusion deficits. Prompt recognition of vascular injury may prevent circulatory compromise.     

Femoral artery and vein injury after cerclage wiring of the femur: a case report

Iatrogenic injuries to the vascular system are a rare but serious complication of primary and revision hip arthroplasty. These injuries usually occur during screw or retractor placement at the acetabulum or proximal femur. Although vascular injury during the passage of cerclage wires is a fear of all surgeons, its occurrence is yet to be described. This case report describes an unusual injury to the femoral artery and vein by a cerclage wire passed around the femoral midshaft during revision total-hip arthroplasty. It underscores the need for diligent comparison of preoperative and postoperative vascular examinations and emergent vascular surgery consultation when needed to avoid disastrous complications.     

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.     

Therapeutic embolisation for postoperative haemorrhage after total arthroplasty of the hip and knee

We describe three cases of postoperative haemorrhage, two after total hip and one after total knee replacement, treated by percutaneous embolisation. After diagnostic angiography, this is the preferred method for the treatment of postoperative haemorrhage due to the formation of a false aneurysm, after hip or knee arthroplasty. This procedure, carried out under local anaesthesia, has a low rate of complications and avoids the uncertainty of further surgical exploration.     

Subcapital stress fracture of the femoral neck after total knee arthroplasty

Summary Although total knee arthroplasty is a valuable surgical technique, complications and problems do occur. Associated stress fracture of the femoral neck is relatively rare and we have only found eleven relevant reports. In this paper we present a case of bilateral total knee arthroplasty where three months after the second replacement, and without significant injury, the patient suffered a femoral neck fracture in the limb which had received the first new knee joint.

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Résumé L'arthroplastie totale du genou est une intervention chirurgicale qui peut apporter à nos patients une importante amélioration. Un certain nombre de complications sont en rapport avec cette technique. La fracture de fatigue du col du fémur n'est pas considérée comme l'une d'entre elles. Nous n'avons trouvé que 11 publications sur ce problème particulier. Nous présentons ici un cas d'arthroplastie bilatérale du genou chez qui, trois mois après la dernière opération, sans aucun traumatisme, se produisit une fracture du col du fémur.

     

类风湿关节炎行关节置换术围手术期管理的研究进展

类风湿关节炎是最常见的炎性关节病,尽管目前类风湿关节炎缓解药物不断改进,药效却只能延缓关节功能障碍的进展。人工膝或髋关节置换术现已成为晚期类风湿关节炎患者的惟一选择,经手术治疗后患者的关节功能及畸形问题可得到不同程度改善。但类风湿关节炎的病程持续进展直接影响术后的远期效果,如何完善围手术期管理,将关节置换术与药物治疗有效结合逐渐成为临床工作者关注的重点。本文拟通过对行关节置换术类风湿关节炎患者的术前药物使用、术中手术技巧、假体选择、术后治疗、康复锻炼及并发症等国内外管理现状加以概括总结,为提高此类患者远期疗效及生活质量提供有益帮助。     

Total knee arthroplasty after an artificial femoral-popliteal arterial bypass graft

We experienced one case of left knee total knee arthroplasty (TKA) after artificial vascular bypass surgery for both femoral arteries from the right inguinal region. Patients requiring TKA after arterial bypass surgery to report a thrombosis are very rare, but the incidence of thrombosis in the cases of TKA after arterial bypass surgery was reported to be higher when compared to the incidence of acute arterial occlusion after common TKA. When TKA is performed in such a patient, a strict anticoagulation therapy is necessary to perform assessment of vascular status carefully pre- and postoperatively. Further, it is important to perform surgery with consideration of intraoperative procedures such as no use of tourniquets during surgery. In addition, if a postoperative ischemia is suspected, it is necessary to perform emergent vascular reconstructive surgery immediately.     

Complications of femoral nerve blockade in total knee arthroplasty and strategies to reduce patient risk

Femoral nerve catheters are widely used for analgesia in total knee arthroplasty. Although evidence suggests that catheters improve pain control and may facilitate short-term rehabilitation, few reports exist regarding their complications. This case series explores the experience of femoral nerve catheter use at high-volume orthopedic specialty hospitals. Serious complications including compartment syndrome, periprosthetic fracture, and vascular injury are reported. The authors support femoral nerve catheter use with appropriate precautions taken to reduce risk of patient falls, vascular injury, and wrong-site surgery.     

Diagnosis and Treatment of Arterial Occlusion after Knee Arthroplasty: The Sooner,the Better

Knee arthroplasty, including total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA), is an effective procedure for patients with severe knee joint diseases. Arterial occlusion after knee arthroplasty is a rare but severe complication. However, there are few comprehensive reviews or analyses focusing on it. In this study, we presented a case of successful treatment of acute arterial occlusion of the popliteal artery after TKA by emergent balloon angioplasty, and conducted a review and analysis of published cases with this complication. After search and screening, 36 studies with 47 cases of arterial occlusion after knee arthroplasty in the past 35 years (1984–2018) were included. Among the 47 patients, there were 22 men and 25 women. The mean age was 68 years old. A total of 43 patients had primary TKA while 2 had revision surgery for TKA and 2 for UKA. For arterial occlusions, 66% presented symptoms in less than 1 day after knee surgery and 95% of the occlusion sites were around the popliteal artery. For treatment, 89% chose surgical treatment. Compared with conservative treatment, surgical treatment was more effective (P < 0.01). The patients who underwent surgical treatment less than 1 day after diagnosis had less sequelae (P < 0.05). For arterial occlusion after knee arthroplasty, we should pay attention to the perioperative risk factors and presentations, and diagnose and treat surgically at an early stage.     

The value of immediate preoperative vascular examination in an at-risk patient for total knee arthroplasty

Arterial complications associated with total knee arthroplasty (TKA), although infrequent, may be associated with the following sequelae: infection, limb loss, and rarely, death. When revascularization is undertaken in the postoperative setting, additional complications may be encountered including postischemic reperfusion injury necessitating prophylactic fasciotomies. The end result is a prolonged postoperative course leading to worse functional outcome. A preoperative history and physical examination performed by the orthopedic surgeon can determine if the patient is at increased risk for vascular complications and whether the at-risk limb can withstand the stress of the operation. Consideration should be given to obtaining ankle-brachial indexes in this patient population, noting that arterial calcification may elevate the value. This article presents a case of an immediate preoperative vascular examination, performed at the time of surgical site marking, in an at-risk patient prior to TKA. We detail the clinical course of a patient with peripheral vascular disease and indwelling superficial femoral artery stent, who developed stent thrombosis in the 2-week period between his last clinic visit and date of surgery, with no change in symptoms. This restenosis was detected on routine preoperative physical examination and resulted in cancellation of the TKA in the preoperative area, allowing the patient to undergo emergent revascularization. We emphasize the importance of an immediate preoperative vascular examination in the setting of TKA and provide a comprehensive review of the literature with guidelines on the perioperative management of antiplatelet agents and appropriate use of the tourniquet.     

Vascular injuries in total hip replacement arthroplasty: a review of the problem

Considering the proximity of the major endopelvic and exopelvic vascular structures to the hip joint, we find that reported vascular complications of total hip replacement are relatively rare. We encountered 1 case of vascular injury after primary, and 2 cases after revision, total hip arthroplasty. This stimulated us to send a postal survey to the members of the British Hip Society inquiring about such vascular complications, with a view to evaluating their incidence, management, and final outcome. We received 42 valid replies of 82 questionnaires sent. A conservative estimate from this study is 1 vascular injury in 14 consultant life years of practice. A total of 26 vascular injuries were studied in detail, which included 3 of our index cases. There were 14 cases encountered in revision hip replacement, while the rest occurred in primary hip replacement surgery. Three patterns of presentation of vascular injuries were recognized--immediate, early, and late, all of which require prompt recognition and appropriate treatment. The potential of vascular injury seems to be underestimated in primary total hip replacements, leading to late recognition and poor outcome.     

False aneurysm of the lateral superior genicular artery. A complication after the implantation of a knee prosthesis

Arterial complications after total knee arthroplasty are rare. If the formation of a false aneurysm does occur, it usually affects the popliteal artery. We report the case of an 77 year old female with a false aneurysm of the lateral superior genicular artery. The patient was suffering from gonarthrosis and received a duocondylar knee replacement without resurfacing of the patella. Postoperatively, she reported anterior knee pain and a revision of the joint with lateral release was carried out. In the third postoperative week, a painful swelling in the lateral and superior aspect of the knee occurred. A scintigraphic investigation with enrichment in the early period was misinterpreted as infection. Ultrasonographic and angiographic investigations gave the right diagnosis of a false aneurysm. In the same angiographic investigation, the aneurysm could be cured by coil embolisation. The interval between the operation leading to the problem and the formation of the aneurysm, as well as the low incidence of this complication, made it hard to diagnose. Ultrasonographic and angiographic examinations allow for proper diagnosis in cases of unclear painful swellings. When dealing with an arterial complication following total knee arthroplasty, a specialized radiologist or vascular surgeon should be consulted immediately.     

Distal femoral replacement in periprosthetic fracture around total knee arthroplasty

Introduction

Total knee arthroplasty is a common orthopaedic procedure in the UK; consequently, revision surgery and periprosthetic fractures are increasing in incidence. Strategies for management of these cases include non-operative strategies, internal plate fixation and revision of the distal femoral component. One under-reported practice is to perform distal femoral replacement in cases with poor distal femoral bone stock.

Materials and methods

The department's electronic database was searched for all patients undergoing revision of total knee arthroplasty. From these, all patients having distal femoral replacement for periprosthetic fracture around the distal femoral component using the Stryker Global Modular Replacement System (GMRS) implant were filtered. A retrospective analysis of the patient notes was performed to examine the patient demographics, surgical factors and postoperative complications. Postoperative scores were performed for these patients.

Results

From 2005 onwards, 11 patients (mean age 81 years, range 61–90 years) had their implants revised with a distal femoral replacement for periprosthetic fracture with associated poor bone stock. Follow up was for a mean of 33 months (range 4–72 months). One of these patients died of causes unrelated to their operation. Of the rest, all implants survived without the need of re-operation. The mean postoperative Oxford Knee Score for these patients was 22.5 (range 5–34).

Conclusions

Distal femoral replacement for patients with fracture around a total knee arthroplasty has been performed in our department with few complications and acceptable functional outcomes. It is a technically challenging operation and it should be a salvage procedure reserved for patients with poor bone stock and low demands where other methods of fixation are not suitable.

Level of evidence

IV.     

Joint line restoration after revision total knee arthroplasty.

In 99 patients, 107 knee replacements were revised in two centers by two surgeons using a single revision total knee arthroplasty system. A retrospective radiographic review of joint line position before and after revision total knee arthroplasty was made, and compared with the joint line position before primary knee arthroplasty. Prospectively collected Knee Society Clinical Rating Scores were correlated with radiographic findings. The joint line position in unreplaced knee replacements averaged 16 mm, and the joint line position in knee replacements before revision surgery averaged 17 mm. The joint line was elevated by the revision total knee arthroplasty in 85 of 107 knees (79%). After the revision total knee replacement, the joint line elevation averaged 24 mm. The Knee Society Clinical Rating Score after revision surgery averaged 131 points. If the joint line position was elevated more than 8 mm, the Knee Society Clinical Rating Score averaged 125 points, if the joint line was elevated less than 8 mm, the score averaged 141 points. Joint line elevation after revision total knee replacement is a problem. Excessive elevation may result in worse clinical outcomes. Distal femoral augments should be used more often and with greater thicknesses. Standard implants used for revision surgery should have increased distal dimensions.     

Vascular injuries in joint replacement surgery

Iatrogenic injuries to blood vessels in joint replacement surgery are rare events that occur as few per thousand. However, their sequelae are serious. The patient may either bleed to death, because vascular injury is not obvious and therefore difficult to diagnose, or lose the limb due to ischaemia. The highest risk of vascular injury is associated with repeat surgery and loosening of the acetabular component. We distinguish sharp and blunt force injuries. The former are caused by implants, sharp instruments, bone fragments or bone cement debris. The latter arise from stretching over a part of implanted material. Bleeding can be inapparent or apparent. Inapparent bleeding is difficult to diagnose and is recognized from the dynamics of blood losses. Haemodynamic instability or, in a worse case, even hypovolaemic shock may be the only signs of bleeding. Occlusion of an artery is manifested by limb ischaemia. The seriousness and progression of ischaemia depends on the rate of arterial occlusion, potential pathways for collateral circulation and the degree of atherosclerotic vascular disease. The patient with conduction anaesthesia does not feel pain and therefore the diagnosis must primarily be based on arterial pulsation in the limb and its skin colour. A pseudoaneurysm can develop due to a partially weakened vascular wall and its rupture is a life-threatening complication. Its presence is recognized as a pulsating mass in the groin. An arterio- venous fistula which arises from traumatic communication between the two vessels may lead to cardiac failure. The diagnosis is based on examination by sonography and digital subtraction angiography. The results of CT angiography and MR angiography are difficult to evaluate because of the presence of metal implants. In apparent bleeding it is sometimes difficult to locate the source. It is recommended to perform digital compression and gain access to the vessels from the extraperitoneal approach. When an expanding haematoma or ischaemia is present, the artery can be treated by surgical exploration or percutaneous transluminal angioplasty. A possibility of vascular injury should be taken into account particularly in revision arthroplasty. To check blood flow in the limb before surgery is advisable. If the procedure entails a significant risk of post-operative complications, a vascular surgeon should be available. In the case of acute intra-operative bleeding, the source should be localised as soon as possible, the site compressed and an expert assistance called in. When the source is not obvious, it should not be attempted to apply vascular clamps or clips at random; this may do even more damage to the vessel.