TKA complications.pptx

Complications of TKA

1. Complications in Total Knee Arthroplasty Dr. Vishal PG Resident Department of Orthopaedics (ABVIMS & Dr. RML Hospital)

2. TKA has been quite a successful treatment option in end stage arthritis of knee joint. However, as the number of TKA has increased so have the complications. According to a study conducted in 2013 by knee community, 22 complications have been identified to be associated with TKA. Can be grouped into three major categories : Intraoperative Early post-operative Late post operative

3. Intraoperative Early Post-operative Late Post-operative Vascular injury Bleeding Instability Neurological complications Superficial skin problems Joint stiffness Extensor mechanism injury patellar tendon injury Quadriceps tendon injury Patellar fracture Deep skin problems Periprosthetic joint infection Deep vein thrombosis Periprosthetic fractures Pulmonary embolism Aseptic loosening osteolysis Patellofemoral joint problems MCL injury

4. Intraoperative complications Vascular Injury

5. Vascular injury Rare but serious and fatal complication during TKA Forms: Thromboembolism D irect vascular laceration Pseudoaneurysm A rteriovenous fistula Causes: Direct damage T hermal effect of cement polymerization J oint manipulations D islocations E xcessive manipulation

6. Preventive measures: Preoperatively Identify high risk group by proper History and physical examination Co-morbidities like DM, Htn , Smoking, Vascular claudication Proper attention to look for- Coldness of the extremities to be operated skin atrophy and thinning prominent vascular structures ulcerative wound distal arterial pulse weakness ankle-brachial index below 0.9

7. Intra-operatively Tourniquet causes intimal damage. Avoid in high risk pt. Proper placement of retractors (posterior retractors to be placed away from 1 cm lateral to midline) Careful release of PCL and posterior capsule during distal femoral cut Management Suspected vascular injury Deflate the tourniquet Perform bleeding control/ revascularisation (Vascular surgeon consultation) Close the incision Acute ischemia cases with delayed diagnosis of 4–6 hours cause irreversible damage. Prophylactic fasciotomy is performed after revascularization .

8. Pseudoaneurysm P ulsatile swelling in the popliteal fossa. Cause: due to d irect damage to the popliteal artery during surgery. Diagnosis: USG T reatment E xcision of the lesion and repair with vascular graft is applied after embolization.

9. Arteriovenous fistula L ess common. Cause: I njury to the medial and lateral geniculate arteries and its branches. Present s as Pulsatile swelling in the popliteal region that gives “trill.” Hemarthrosis or pseudoaneurysm may develop.

10. Diagnosis : Ultrasound and Angiography Treatment S hould be evaluated together with cardiovascular team Embolization L esion excision G raft repair

11. Intraoperative complications NERVE INJURY

12. NEUROLOGICAL COMPLICATION R are during TKA. Peroneal nerve injury (most common) Sacral plexopathy and S ciatica N europathy Risk factors: Flexion deformity Advanced valgus deformity Presence of an intra-articular hematoma T ourniquet applications exceeding 2 hours

13. D ifficult to detect intraoperatively. Post operative neurological assessment must be done in each patient. Management Immediate p hysical therapy should be started. EMG examination is to be done after 3 months. If no improvement is observed, nerve exploration may be planned in the future.

14. Intraoperative complications Extensor Mechanism Injury

15. E xtensor mechanism consists of quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar tendon, and Tibial tuberosity. Injury post-op> intra-op Includes: Patellar tendon rupture Quadriceps tendon rupture Patellar fracture

16. Patellar tendon rupture -U sually occurs at the site of insertion to the tibial tuberosity. - I ntra-tendinous and infrapatellar tendon rupture may also occur.) R isk: less than 1%. R isk i ncreases when patellar tendon mobility decreases.   -Patella B aja - Previous surgery -Severe limitation of movement in the knee  

17. Intra-operative causes: Forced manipulation in stiff knee. T ibial bone cutting. Post-operatively : falling onto the knee while knee is flexed (m/c) Patellar tendon injury without trauma is seen by weakening the tendon after Non-traumatic: r epeated contact of the polyethylene insert  weak ens patellar tendon

18. Presentation: S welling L oss of extension Palpable defect at the infrapatellar side. Treatment: Age, functional status, tendon rupture localization, and soft tissue status are to be considered.  

19. Treatment: Low functional expectation/ unsuitable for surgery: Splinting and bracing A cute patellar tendon rupture intraoperative primarily requires repair using staple and suture anchors. P oor soft tissue quality : r econstruction using biological materials (hamstring tendon autograft, achilles , peroneal tendon autograft, and extensor mechanism allograft) or synthetic materials.

20. Quadriceps tendon rupture It is very rare. R upture from the insertion side to the patella. Risk factor: Excessive patella cutting P revious quadriceps snip V-Y tipping C linical finding is similar to patellar tendon rupture.  

21. Treatment Partial tears: Plaster cast Complete tear : extensor loss greater than 20°. Requires surgical repair U nsatisfactory results due to high complication rates and tendency to re-rupture depending on tendon quality and soft tissue condition.  

22. Patella fractures - most common injury among the extensor mechanism injuries. Causes Excessive bone cutting while preparing for patellar component. Vascular compromise secondary to lateral release Patellar maltracking due to component malposition Excessive joint line elevation Knee flexion more than 115 degrees Thermal necrosis from PMMA D irect trauma to the anterior knee. A vulsion due to the pull of the quadriceps muscle.  

23. Classification: Based on integrity of extensor mechanism and stability of implant. Type 1 : St able implant and intact extensor mechanism Type 2 : stable implant but a discontinuous extensor mechanism T ype 3 : u nstable implant and discontinuous extensor mechanism. Patellar bone stock is classified as 3A if good and 3B if poor.

24. Management: Type I : knee immobiliser/ cylindrical cast for 6 weeks Type II : Transverse middle-third: Tension band wiring and retinacular repair. Proximal and distal pole fracture.Partial patellectomy Type III 3A: Fracture fixation 3B: Patellectomy and extensor mechanism repair

25. Medial collateral ligament injury M edial collateral ligament (MCL) is important for soft tissue stabilization and coronal plan stability. I ncidence of iatrogenic MCL injury is 2.2–2.7%. Factors that increase the risk of MCL injury: Using a larger saw blade than femoral condyle Delayed excision of medial side osteophytes Performing challenging manipulations of varus-valgus Patients with flexion contractures Patient-related risk factors include obesity and severe deformities

26. Unrecognized MCL injuries cause early instability and implant wear and thus the need for early revision. Intra-op Sudden instability in the valgus stress test during knee stabilization indicates MCL injury T/t options: i) Repair varies according to injury level. Fr om fe moral insertion site: Fixation with screw. T hrough tendon: repairing with insoluble suture technique is recommended. F rom tibial insertion site:insoluble suture anchor technique and staple fixation ii) C onstrained prosthesis use iii) Revision at the same session

27. Early post-op complications

28. THROMBOEMBOLISM Prevalence of DVT: 1-84% after TKA (without prophylaxis) DVT ——> PE Thrombi in Popliteal vein is more likely to cause PE than that in calf veins. Various risk factors have been associated with development of DVT and TE Prophylaxis measures have significantly reduced the incidence.

29. Age: >40yrs Oesterogen use H/oStroke Nephrotic syndrome Cancer Prolonged immobility Previous Thromboembolism CHF IBD Obesity Varicose vein Smoking Hypertension DM H/O MI Risk Factors

30. Virchow triad

31. CAPRINI SCORING FOR RISK CATEGORY

32. https://orthotoolkit.com/caprini/

33. PROPHYLAXIS In 2017,Dua et. Al. Reported significant decrease in DVT and VTE cases due to increase in prophylactic measures.

34. Low risk : Clexane 0.6 mg s.c OD for 3 days f/b oral rivaroxaban 10 mg od for 10 day AND/OR IPCD (if drugs C/I); To start 6 hr. after removal of drain/epidural catheter. High risk : Clexane 0.6mg s.c OD for 5 days f/b oral Rivaroxaban 10 mg od for 10 days AND IPCD during hospital stay. Dose to be adjusted if creat clearance less than 30 ml/min USG doppler on 4 th day post op in high risk.

35. C/I to drug therapy Intracranial hemorrhage within last yr Craniotomy within 2 week Intraocular surgery within 2 weeks Gastrointestinal OR genitourinar y H aemorrhage within last month Active intracranial lesions/neoplasms Hypertensive emergencyEnd stage liver disease (INR > 1.5) B leeding disorder/ coagulopathy

36. Management of DVT Clinical examination: Unreliable Radiography: Venography: Gold std., has R/o Anaphylaxis and DVT also. Duplex USG: Reliable method to diagnose DVT after TKA

37. Treatment options Therapeutic dose of anticoagulant Fibrinolytic drugs ( Alteplase , STK) IVC filters Surgery

38. INFECTION

39. INFECTION Approx. 1.5% of patients develop peri-prosthetic infection in first 2 yrs after TKA. Risk factors: Rheumatoid arthritis ( esp seropositve men) Skin ulceration Previous knee surgery Use of hinged prosthesis Obesit UTI Steroid use Renal failure DM Poor nutrition Malignancy Psoriasis

40. Prevention Proper preoperative part preparation Strict adherence to aseptic technique in OT room Filtered vertical laminar flow with limited ingress and egress of OT personelle Prophylactic antibiotics

41. Management Diagnosis History and Physical examination. Consistent painful TKA/ Acute onset pain in a previously pain free TKA O/E Active Pus discharge Swelling Tenderness Erythema Painful ROM

42. Low risk case: Supacef 1.5 gm 60 min prior to incision/tourniquet application, 2 nd dose(of supacef ) 60 min after incision. High risk case: Supacef 1.5 gm and teicoplanin 400 mg 60 min prior to incision/tourniquet application, second dose(of supacef ) 60 min after incision post op supacef 1.5 gm bd for 3 days teicoplanin 400 bd for 3 days ceftum 500 bd for 7 days

43. DIAGNOSIS Clinical evaluation RADIOGRAPH X-ray: Bone resorption at bone cement interface. Cyst formation Periosteal new bone formation. ASPIRATION Standard for diagnosis Repeated aspiration at gap of two weeks.

44. Treatment options Suppression with antibiotics Joint debridement with poly exchange Resection arthroplasty Knee arthrodesis Exchange arthroplasty

45. Suppression with Antibiotics Rarely indicated Indication: prosthesis removal is not feasible Low virulence organism Risks: Development of resistant strains Progressive loosening Extensive infection Septicaemia

46. Joint debridement with prosthesis retention: Indications: Early (<4 weeks) post op infection Acute infection in a well fixed prosthesis (>4 weeks after SX with acute symptom onset) C/I Chronic infection Infection with S.aureus

47. Several points have been recommended that could lead to higher success rates for debridement: Infectious disease consultation and antibiotic monitoring Diagnosis and treatment of hematogenous sources of Infection Newer antibiotics Six-week duration of postoperative intravenous antibiotics R epeat cultures within 2 weeks of the initial debridement and repeat debridement if these cultures were positive Polyethylene exchange at the time of debridement; exchange of gown, gloves, and instruments; and redraping at the time of wound closure

48. Resection Arthroplasty Resection of infected prosthesis and cement and debridement of synovium Appose bone ends with heavy sutures or pins Cast application for 6weeks

49. Knee Arthrodesis Provides stable, painless limb with some expected shortening. Indications: High functional demand Single joint involvement Young age Deficient extensor mechanism Poor soft tissue coverage Immunocompromised pt High virulent organism

50. Knee arthrodesis Can be performed using: External fixator IM nail

51. External fixator : Advantage: Minimal soft tissue stripping Adequate wound access Compression at arthrodesis site Disadvantages: Pin tract infection Possible NV damage Limited stability Stress riser at pin removal site

52. Remove all the prosthesis Cement, hypertrophic synovium and as much scar tissue as possible Use EM total knee guides to make bone cuts Knee in 10 degree flexion and 5 degree of valgus Apply biplanes fixator and cross pins.

53. Partial wt bearing is encouraged Remove fixator if clinical signs of union present (usually at 3months) Use cylindrical cast, long leg cast/ knee brace until radiological signs of union present Weight bearing as tolerated

54. Arthrodesis with IM nail Advantage: Immediate partial wt bearing allowed Greater fusion rate Two stage techniques is recommended Complete debridement and component removal 4-6 weeks of IV antibiotics Repeat joint aspiration after two weeks of IV antibiotic completed IM arthrodesis

55. Reopen the old knee incision and make an incision in the buttock for the proximal entry portal. Remove scar tissue from the knee joint to allow apposition of the bone surfaces. Ream the tibia antegrade from the knee joint to 1 mm larger than the diameter of the nail Ream the femur retrograde or antegrade 1 to 1.5 mm l arger than the diameter of the nail

56. Drive the nail from the piriformis fossa across the knee to t he level of the distal tibial metaphysis . Make final corrections in the distal femoral and proximal t ibial surfaces before final driving of the nail and impaction of the arthrodesis site. Compression at the fusion site can be done with a femoral distractor in the compression mode before distal interlocking. Do not notch the surface of the nail with any power instruments. Lock the nail proximally and distally and apply bone graft in areas of suboptimal apposition

57. Exchange arthroplasty Great chance of functional recovery after infected TKA Two stage arthroplasty is recommended Prosthesis removal Debridement Antibiotic spacer placement IV antibiotic for 6 weeks Reimplantation

58. Use of antibiotic impregnated PMMA Advantage: Maintains soft tissue tension High level local antibiotic delivery Improved exposure at time of reimplantation Ability to wt bearing at interval

59. Above knee amputation Indication: Life threatening infection Persistent local infection with massive bone loss

60. Late post operative complications Instability Joint stiffness Peri-prosthetic fractures Aseptic loosening Patello-femoral joint problems

61. Instability Third most common cause of revision (17%) after aseptic loosening and infection. Presentation: Pain and swelling with loss of movement. A bnormal friction and rattling noise in some range of motion. D uring walking, varus or valgus orientation and recurvatum can be seen over knee Anterior knee pain during sitting up is typical in flexion instabilities.

62. Risk factors: Asymmetric gap: most common causes of instability. R ectangular gap in both flexion and extension after bone ex cisions and soft tissue release is required for stability of TKA. Excess tibial cut: loose extension and flexion. Excess d istal femoral cut: loose extension. Excess posterior femur cut: loose in flexion. if the distal femoral incision is excessive, the use of distal femoral augment should be preferred instead of the use of a thick insert

63. Joint stiffness A mount of knee ROM after TKA greatly affect patient satisfaction after TKA. Flexion range of at least 90° is required. A flexion range of less than 90° for 6 weeks after TKA surgery is defined as a rigid knee. Sixty-five degrees of flexion is required during walking; 106° of flexion is required when sitting on a chair and tying shoes.

64. Risk factors: Surgical technique: Inadequate posterior femoral incision Inadequate medial collateral ligament release S evere varus deformity Other factors: Hip osteoarthritis H eterotropic ossification R eflex symptomatic dystrophy Arthrofibrosis : most treatment-resistant cause of joint stiffness. It develops due to excessive increase of fibrous tissue in the joint

65. Treatment Physiotherapy Prophylactic role, limited role in joint stiffness after TKA. U se of continuous passive motion device (CPM) in the early postoperative period reduces bleeding and is beneficial in preventing joint stiffness by reducing the formation of fibrosis M anipulation under anaesthesia : S hould be performed in cases where knee flexion is below 90° between 2 weeks and 3 months. A n average gain of 30–47° was reported Revision rates are lower in patients with early manipulation

66. S urgical procedures A rthroscopic release/open release limited revision knee arthroplasty/total revision knee arthroplasty

67. PERI-PROSTHETIC FRACTURES Supracondylar femur fracture Tibial fracture

68. Periprosthetic fractures: Fractures that occur during or after surgery within 15 cm of the knee joint or within 5 cm of the intramedullary part of the prosthesis, if any Can occur during or after surgery. It includes: Supracondylar femur fracture Tibia fracture

69. Supracondylar femur fracture Risk factors: Anterior femoral notching (m/c, if notched use a stemmed femoral component) Osteoporosis Female gender Revision arthroplasty Neurological disorder

70. Classification : ( Rorabeck , Angliss and Lewis) Type I: Undisplaced fracture with stable prosthesis Type II: Displaced fracture with stable prosthesis Type III: Unstable prosthesis with/without fracture displacement

71. Tibial Fracture: Very rare Classification ( felix ) Type I: Tibial plateau fracture Type II: adjacent to stem Type III: Shaft fracture distal to stem Type IV: Tibial tubercle fracture

72. Type I R evision is recommended because tibial component will be in varus alignment. The medial defect should be closed with bone graft or metal support Type II N onsurgical treatment if the component is stable and there is minimal displacement I nternal fixatio n: di splaced type 2 fractures U nstable component: Revision using a long tibial stem to cross the fracture line Type III/IV Internal fixation should be performed

73. Management: Small lesion and the prosthesis is stable: Observation+/- Bisphosphonates and calcium supplementation If the prosthesis is u nstable D ebridement, polyethylene replacement, and curettage, followed by impaction of the defect with bone graft. Revision

74. Aseptic loosening The deterioration of the relationship between prosthesis and bone. Causes Patient related Overuse Osteopenia Implant design C ementless prosthesis C onstrained prosthesis Surgery related: Malalignment .

75. In the early period, a radiolucent line is seen between the component and bone on radiography, and a collapse occurs as the loosening progresses. Loosening is more common around the tibial component . In the presence of loosening around the whole component, septic loosening should be considered Revision surgery for pain with instability

76. Osteolysis Osteolysis usually occurs due to inflammatory reactions caused by worn polyethylene particles or in the presence of infection. Metal particles can also cause osteolysis. Titanium causes more osteolysis than cobalt and chromium. Giant cells that develop against abrasive particles act by forming a membrane. Particle size is important for this mechanism. S izes range from 1 to 100 micrometers cause osteolysis. Incidence of osteolysis increases when pres-fit prosthesis is applied; screw fixation without cement is used or cement breaks. (Contact with cancellous bone)

77. Presentation: P ain, joint effusion, and synovitis due to joint instability. Radiograph: Focal bone destruction. It can be seen that there is non-continuity of trabeculae and bone cortex in cancellous bone. CT and MRI can be used for osteolysis that cannot be detected on direct radiography.

78. Patellofemoral joint problems Pt presents with anterior knee pain. In a study, Patella and malrotation were among the eight most common causes of failed TKA Causes: Advanced valgus alignment Previous high tibial osteotomy Tibial tuberosity osteotomy

79. S urgical technique to prevent patellofemoral joint problems. Component placement : If the femoral component is placed medially, anteriorly, or flexed, or if there is internal rotation and if the component is excessive in size, patellofemoral problems may occur finally. Likewise, the medialization and internal rotation of the tibial component increases the risk. Surgical approach type : Midvastus and subvastus interventions that protect the extensor mechanism more can reduce PF joint problems. Lateral release : The need for lateral retinacular release increases PF joint problems. Patella resection amount : When patellar component is used, resection of the patella with anterior–posterior reduction of 12 mm increases the risk of PF joint problems

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