TKA Complications

Topic updated on 08/16/15 6:11pm
  •  Complications following TKA include
    • this topic (below)
      • patellar maltracking
      • instability (tibio-femoral)
      • stiffness
      • extensor mechanism rupture
      • neurologic injury (peroneal nerve)
      • vascular injury
      • wound complications
      • metal hypersensitivity
      • heterotopic ossification
      • blood loss and anemia
    • other topics
      • periprosthetic infection 
      • periprosthetic fracture 
      • patellar clunk  
Patellar Maltracking
  • Introduction
    • epidemiology
      • most common reason for secondary surgery following total knee arthroplasty
    • causes
      • may be related to
        • prosthetic design
        • extensor mechanism imbalance
        • asymmetric patellar resection
        • malrotation 
        • patellar malpositioning
  • Presentation
    • complaints may include
      • feelings of subluxation
      • frank dislocation
      • peri-patellar pain
      • limited flexion
  • Imaging
    • radiographs
      • merchant view
        • may show a laterally subluxed patella
    • CT
      • best to assess for rotational malalignment
  • Treatment
    • must appropriately address etiology
Patellar Component Loosening
  • Introduction 
    • epidemiology
      • 0.6-5% of cases
        • more common with metal-backed patellae
    • etiology
      • subclinical infection
      • maltracking or overstuffing, leading to high shear
    • risks
      • obesity
      • lateral release
      • joint-line elevation
      • postoperative flexion >100°
      • poor bone stock
      • asymmetric patellar resection
      • inadequate implant fixation (small pegs)
      • secondary osteonecrosis and osteolysis
  • Imaging
    • radiographs
      • lateral view
        • show patellar component adjacent/superficial to patella
        • show loss of radiolucent space in patellofemoral joint and contact between patella bone and femoral component
  • Treatment
    • revision of patellar component
      • if revision fails, resection of patellar component
  • Introduction
    • incidence
      • common cause of early failure following total knee arthroplasty
      • accounts for 10-20% of revisions
    • types
      • coronal plane (varus-valgus)
      • anteroposterior (flexion)
      • global
  • Coronal instability
    • definition
      • varus/valgus instability
    • causes
      • incompetent collateral ligaments
        • midsubstance 
          • MCL transection by oscillating saw during posterior femoral condyle cut or tibial cut
        • tibial avulsion 
          • from medially placed retractors or during medial subperiosteal elevation
      • incomplete correction of preoperative deformity
      • incorrect bone cuts with malalignment
    • treatment
      • intraoperatively
        • balance ligaments accordingly
        • MCL transection/deficiency 
          • suture repair or suture anchor reattachment, use of either CR or PS implant, hinged knee brace for 6 weeks postoperatively
          • use of unlinked constrained prosthesis
        • both MCL and LCL
          • revision to an hinged knee (linked constrained prosthesis)
  • Anteroposterior (flexion) instability 
    • definition
      • mismatch between flexion and extension gaps
    • causes/treatment
      • over resection of posterior femoral condyles  
        • treat with posterior augments
      • undersizing femoral component
        • upsize femoral component
      • excessive tibial slope
        • decrease slope and consider posterior-stabilized prosthesis
      • excessive distal femoral cut
        • augment distal femur
      • posterior cruciate ligament insufficiency following a cruciate-retaining arthroplasty 
        • convert to posterior-stabilized prosthesis
  • Global
    • definition
      • laxity of both flexion and extension gaps, as well as varus/valgus instability
    • treatment
      • may require revision to a hinged prosthesis
  • Introduction
    • definition
      • flexion contracture 10-15 degrees
      • flexion < 90 degrees
    • incidence
      • 1.3%-12%
    • risk factors
      • poor preoperative ROM 
        • most important factor
      • patella baja 
      • increased medical comorbidities
      • low pain tolerance
      • delayed rehabilitation
      • technical factors
        • overstuffing patellofemoral joint
        • malrotation
        • tight flexion and/or extension gaps
        • joint line elevation
        • excessive tightening of extensor mechanism during closure
          • closure in flexion (as opposed to extension) may limit this complication
        • tight PCL in cruciate-retaining prosthesis
      • infection
      • HO
      • hamstring spasms
        • usually resolves within 6 months
  • Evaluation
    • check preoperative ROM from records
    • ESR/CRP
      • must rule-out infection
    • radiographs/CT scan
      • r/o technical factors
  • Treatment
    • manipulation under anesthesia 
      • indications
        •  flexion <90 degrees within first 12 weeks of operation (timing is controversial)   
          • over aggressive manipulation
            • fracture
            • extensor mechanism disruption
      • contraindications
        • stiffness >3 months postoperatively 
          • manipulation associated with greater risk and lower benefit
    • arthroscopic lysis of adhesions with manipulation under anesthesia
      • indications
        • persistent late stiffness
    • revision total knee arthroplasty
      • indications
        • identifiable technical cause for stiffness
Extensor Mechanism Rupture
  • Introduction
    • incidence
      • 0.17% to 2.5%
    • causes
      • intraoperative
        • avulsion from tibial tubercle
      • postoperative
        • manipulation
        • impingement
        • trauma
  • Treatment
    • knee immobilizer x6 weeks
      • indications
        • partial quadriceps tendon rupture  
    • direct repair with suture
      • indications
        • patellar tendon avulsion < 30%
        • complete quadriceps tendon rupture with adequate soft tissues
    • primary repair and augmentation with graft 
      • indications
        • complete laceration of patellar tendon with adequate patellar bone stock
    • extensor mechanism allograft
      • indications
        • complete laceration of patellar tendon without adequate patellar bone stock and deficient soft tissues
Neurologic Injury (peroneal nerve)
  • Introduction
    • incidence
      • .3%-2%
    • risk factors 
      • preoperative valgus and/or flexion deformity 
      • tourniquet time > 120 min
      • postoperative use of epidural analgesia
      • aberrant retractor placement
      • preoperative diagnosis of neuropathy (centrally or peripherally)
    • prognosis
      • 50% or more improve in time with no additional treatment
  • Evaluation
    • EMG
      • obtain after 3 months if no improvement
  • Treatment
    • remove dressing and place knee in flexed position 
      • indications
        • initial postoperative management in all cases noted in the immediate postoperative period
    • ankle-foot orthosis
      • indications
        • complete foot drop
    • late nerve decompression or muscle transfer 
      • indications
        • no recovery after 3 months
Vascular Injury
  • Introduction
    • incidence
      • .017%-.2%
    • risk factors 
      • sharp dissection in posterior compartment of knee
      • posterior retractor placement
        • stay medial with retractor
      • pre-existing vascular disease
    • causes
      • direct laceration
      • thrombosis
  • Anatomy
    • lateral structure as it crosses knee
    • 1 cm off tibial plateau in extension
    • 2 cm off tibial plateau in flexion
  • Treatment
    • immediate vascular surgery consultation
Wound Complications
  • Introduction
    • risk factors 
      • systemic factors
        • DM II
        • vascular disease
        • rheumatoid arthritis
        • certain medications
        • tobacco
        • poor nutritional status
        • albumin <3.5g/dL
        • total lymphocyte count <1,500/uL
        • perioperative anemia
        • obesity
      • local factors
        • previous incisions
          • skin bridges should be >5-6cm
          • avoid crossing previous skin incisions at an angle <60 degrees
        • knee deformity
        • skin adhesions
        • poor local blood supply
      • technique
        • large subcutaneous skin flaps
        • not preserving subcutaneous fat layer
      • postoperative
        • hematoma
        • infection
  • Evaluation
    • must rule-out infection
  • Treatment
    • debridement and coverage with rotational flap 
      • indications
        • full-thickness necrosis
Metal Hypersensitivity
  • Introduction
    • incidence
      • rare
    • cause
      • nickel found in cobalt-chromium alloys
  • Evaluation
    • patch testing
    • lymphocyte transformation test (LST)
  • Treatment
    • revise to nonallergenic metal prosthesis
Heterotopic Ossification
  • Introduction
    • incidence
      • less frequent than after THA 
    • risk factors 
      • periosteal stripping off anterior femur
      • male gender
      • obesity
      • post traumatic deformity
Blood Loss & Anemia
  • Risk factors
    • closed suction drainage
      • associated with increased incidence of transfusion 


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Qbank (18 Questions)

(OBQ12.207) A 56-year-old male undergoes an uncomplicated revision total knee arthroplasty. Post-operatively, he is noted to have a foot drop that has persisted despite conservative management including bracing and physical therapy. At two months, the patient undergoes external neurolysis with no improvement in function. At 18 months follow-up, he demonstrates passive ankle dorsiflexion 10 degrees past neutral, complete absence of active dorsiflexion, and 5/5 inversion strength. Which of the following is the most appropriate treatment at this time? Topic Review Topic

1. Continue Ankle-foot orthosis (AFO) and physical therapy
2. Repeat neurolysis with possible nerve repair
3. Peroneus tertius transfer
4. Peroneus tertius transfer with achilles tendon lengthening
5. Posterior tibial tendon transfer to dorsum of foot

(OBQ11.126) A patient undergoes the procedure depicted in Figures A and B with standard components (non-gender specific). Which of the following outcomes most appropriately describes the difference in females compared to males for this procedure? Topic Review Topic
FIGURES: A   B        

1. Greater implant survivorship
2. Decreased WOMAC scores
3. Increased rate of extensor mechanism rupture
4. Increased postoperative pain
5. Increased component osteoloysis

(OBQ11.250) A 64-year-old male underwent the procedure shown in Figures A and B 7 weeks ago. He complains of difficulty with going down stairs. He reports no pain and denies constitutional symptoms. On examination the incision is well healed and no effusion is present. He is able to perform a straight leg raise with 5/5 strength. He lacks 2 degrees of terminal extension and has 80 degrees of active flexion. The knee is stable to varus and valgus stress testing at extension and mid flexion. His C-reactive protein and erythrocyte sedimentation rate are normal. What is the next most appropriate step in management? Topic Review Topic
FIGURES: A   B        

1. Manipulation under anesthesia
2. Cortisone injection followed by physical therapy for quadriceps strengthening
3. Aspiration to evaluate for septic arthritis
4. Revise femoral component by downsizing A-P diameter
5. Revise tibial component and add 5 degrees of posterior tibial slope

(OBQ10.62) A 65-year-old male undergoes a primary total knee arthroplasty. His preoperative radiographs are seen in figures A and B. Postoperative examination reveals an inability to dorsiflex his ankle or extend his toes. Sensation is decreased along the dorsum of his foot as well as between the 1st and 2nd toes. All of the following are risk factors for this complication following total knee arthroplasty EXCEPT? Topic Review Topic
FIGURES: A   B        

1. Aberrant retractor placement
2. Postoperative epidural analgesia
3. Correction of a 20 degree preoperative valgus deformity
4. Excessive medial release
5. Preoperative diagnosis of neuropathy

(OBQ10.270) A 55-year-old patient is scheduled for total knee arthroplasty. A radiograph is provided in Figure A. Each of the following are risk factors for heterotopic ossification EXCEPT? Topic Review Topic
FIGURES: A          

1. Incorrect sizing of femoral and/or tibial components
2. Male gender
3. Obesity
4. History of trauma
5. Presence of preoperative osteophytes (hypertrophic arthrosis)

(OBQ09.230) A 66-year-old female presents with knee instability going down stairs 18 months after a posterior cruciate retaining total knee arthroplasty. She reports having recurrent effusions. Radiographs are shown in Figure A. What is the most likely cause for her instability? Topic Review Topic
FIGURES: A          

1. Intraoperative rupture of the patellar tendon
2. Alteration of the joint line
3. Posterior cruciate insuffiency
4. Anterior cruciate insufficiency
5. Catastrophic component loosening

(OBQ07.222) A 65-year-old female has severe knee arthritis with a significant flexion contracture and valgus deformity. In the recovery room following her total knee replacement, she is unable to dorsiflex her ankle. Management should include? Topic Review Topic

1. Application of an AFO to prevent an equinus contracture
2. Unwrap any compressive dressings and flex the knee
3. Immediate EMG
4. Open exploration of the peroneal nerve
5. Reassurance

(OBQ06.198) A 54-year-old woman is at physical therapy 3 months after a total knee arthroplasty when she feels a pop and develops increased pain in her knee. She continues therapy for another 3 months but reports weakness and frequent buckling. On exam, she has full passive extension but a 60 degree extensor lag. A lateral radiograph is shown in Figure A. What is the treatment of choice? Topic Review Topic
FIGURES: A          

1. Reconstruction with a bone-tendon allograft
2. Repair augmented with hamstring autograft
3. Continued therapy and strengthening
4. Arthrodesis
5. Treatment with orthotics for support

(OBQ05.142) A 65-year old healthy male has just undergone primary total knee arthroplasty. Which of the following is associated with use of a closed suction drain in this procedure? Topic Review Topic

1. Increased incidence of wound dehiscence
2. Increased incidence of transfusion
3. Decreased incidence of infection
4. Decreased incidence of hematoma formation requiring return to OR
5. Decreased pain scores on post-op days 1 and 2

(OBQ04.82) What preoperative knee deformity puts a patient at most risk for a postoperative peroneal nerve palsy after total knee arthroplasty? Topic Review Topic

1. Valgus deformity only
2. Valgus and flexion contracture
3. Varus and flexion contracture
4. Varus deformity only
5. Flexion contracture only

(OBQ04.103) A 62-year-old female underwent a primary total knee arthroplasty of the left knee 10 days ago. She presents to clinic with skin necrosis of the midline incision. There is no deep infection present upon aspiration of the knee joint. She undergoes superficial irrigation and debridement and is left with exposed patellar tendon as shown in Figure A. What is the most appropriate next step in management? Topic Review Topic
FIGURES: A          

1. Split thickness skin grafting
2. Twice daily wet-to-dry dressing changes with Dakin's solution until healing by secondary intention
3. Latissimus dorsi free flap transfer
4. Vacuum-assisted closure device until healing by secondary intention
5. Medial gastrocnemius muscle flap transfer and skin grafting

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