Risk Factors Of the many risk factors predispos-ing to arterial injury that have been identified, one of the most impor-tant is a history of arterial insuffi-ciency.1,4,12,14,15,20,21 An
Trang 1Arterial complications after total
knee arthroplasty (TKA) are quite
rare, and the scant literature
regard-ing this topic consists mainly of
case reports.1-13 Calligaro et al14
reviewed 4,097 TKAs performed at
their hospital and found that 7
patients (0.17%) had acute ischemia
after the procedure On analysis of
9,022 arthroplasties, Rand15found 3
cases of postoperative arterial
com-plications (incidence of 0.03%) A
tourniquet was used in almost all
reported cases In all of these
re-ported cases, the patients had acute
thrombosis rather than vessel
lacer-ation Because of these and other
associated complications, there
have been concerns about the use of
a tourniquet during TKA.16-18
Arterial ischemia following TKA
can lead to serious complications,
such as problems with wound
heal-ing, infection, and limb loss
Be-cause of the relatively poor
vascu-larity of the skin surrounding the
knee, arterial injury can compromise
wound healing in an already disad-vantaged limb and can lead to deep infection In already ischemic limbs, further arterial injury or deep infec-tion can necessitate amputainfec-tion.19 In one review of the data on 44 patients with arterial complications after TKA, 11 (25%) required an amputa-tion.1 In a study of 14 patients with arterial complications after TKA, Kumar et al20found that amputation was necessary for 6 patients (43%), and 1 patient died as a result of over-whelming sepsis Understanding the vascular risks associated with TKA, especially those associated with the use of tourniquets, can po-tentially decrease morbidity by encouraging appropriate preopera-tive workup and prompt postopera-tive recognition
Risk Factors
Of the many risk factors predispos-ing to arterial injury that have been
identified, one of the most impor-tant is a history of arterial insuffi-ciency.1,4,12,14,15,20,21 Any patient with a history of intermittent clau-dication, rest pain, and previous arterial ulcers should be considered
at risk for arterial complications during or after TKA.1,4,15,21 Previ-ous vascular surgery should alert the orthopaedist to refer the patient for a complete vascular assessment because of the risk of graft occlu-sion.1,4,15,20,21 Absent or asymmetri-cal pedal pulses are also risk factors that should be investigated.1,12,15,20-22
Calligaro et al14 reported that arterial injuries occurred only in patients with identifiable preexisting atherosclerotic disease DeLaurentis
et al21 demonstrated an increased prevalence of arterial complications
Dr Smith is Research Associate, Department
of Orthopaedics, University of British Columbia, Vancouver, Canada Dr McGraw
is Professor, Division of Reconstructive Orthopaedics, Department of Orthopaedics, University of British Columbia Dr Taylor is Associate Professor and Head, Division of Vascular Surgery, Department of Surgery, University of British Columbia Dr Masri is Associate Professor and Head, Division of Reconstructive Orthopaedics, Department of Orthopaedics, University of British Columbia Reprint requests: Dr Masri, Department of Orthopaedics, Third Floor, 910 West 10th Avenue, Vancouver, BC, Canada V5Z 4E1 Copyright 2001 by the American Academy of Orthopaedic Surgeons.
Abstract
Arterial complications after total knee arthroplasty (TKA) are rare; however, the
sequelae can be disastrous Infection and the need for amputation or vascular
reconstructive surgery are not uncommon A thorough preoperative
assess-ment can identify at-risk patients, many, if not all, of whom have preexisting
peripheral arterial disease In the presence of peripheral arterial disease, the use
of a tourniquet during TKA has been implicated in subsequent arterial
compli-cations Following the guidelines that have been established regarding
preoper-ative assessment, the role of the vascular surgeon, and the use of a tourniquet
before and during TKA can assist the orthopaedic surgeon in assessing
candi-dates for TKA and reducing the risk of arterial complications.
J Am Acad Orthop Surg 2001;9:253-257
Donna E Smith, MD, Robert W McGraw, MD, David C Taylor, MD, and Bassam A Masri, MD
Trang 2in patients with chronic
lower-extremity ischemia Only 24 (2%) of
1,182 patients who underwent TKA
in their series had underlying
pe-ripheral vascular disease, but 6
(25%) of the 24 patients had vascular
injuries, compared with no vascular
injuries in the patients without
peripheral vascular disease
The rare presence of a popliteal
aneurysm puts patients at risk for
arterial complications with the use
of a tourniquet.4,21 Radiographic
evidence of calcification of the distal
superficial femoral artery (Fig 1) or
popliteal arteries may also be a
har-binger of increased risk.1,6,12,15,20,21
Preoperative Assessment
A thorough preoperative vascular
assessment is of paramount
impor-tance to determine whether a
pa-tient is at risk for arterial injury,
par-ticularly if there is concern about
the vascularity of a limb or the
abili-ty of the limb to withstand the stress
imposed by the tourniquet.4,22 The
minimum assessment can be done
quickly by the orthopaedic surgeon
at the first consultation A focused
history should seek symptoms of
intermittent claudication or
ische-mic rest pain Occasionally, because
of the immobility imposed on the
patient by the local knee condition,
such a history may be difficult to
obtain
Previous vascular operations
such as coronary artery bypass,
carotid endarterectomy, and
abdom-inal aortic aneurysm repair indicate
substantial risk of peripheral arterial
disease.1 Physical examination
should include inspection of the skin
of the lower extremities to identify
changes associated with chronic
ischemia Skin discoloration,
ab-sence of hair, and dystrophic nail
abnormalities other than fungal and
psoriatic changes may all be
sugges-tive of poor circulation.22 The
pop-liteal fossa should be palpated to
rule out popliteal artery aneurysm.1
Pedal pulses should be palpated and compared with those in the con-tralateral foot.12,22 Radiographs should be inspected for evidence of calcification below the level of the femoral artery (Fig 1).1,12
If there is any suspicion of
arteri-al insufficiency, the ankle-brachiarteri-al index (ABI) should be determined with the use of Doppler ultrasound
Any patient with an ABI less than 0.9 is at increased risk for arterial complications and should be as-sessed preoperatively by a vascular surgeon.21 In patients with severe ischemia and an ABI less than 0.5, a preoperative angiogram is required because immediate surgical revas-cularization may be necessary.14
The vascular surgeon may recom-mend that bypass surgery be per-formed before TKA If the ABI is greater than 0.5, the patient may also be at increased risk for arterial complications, but preoperative angiography is not necessary
A vascular surgeon should also
be consulted preoperatively if there has been previous peripheral vas-cular surgery or angioplasty in the affected limb A previous arterial bypass should be assessed for patency and function with duplex ultrasound before TKA The failure
of a femoropopliteal bypass graft
at the time of TKA can be limb-threatening John et al23reported a 64% rate of amputation due to graft failure in a group of 99 patients
Figure 1 Radiograph showing calcification of the femoral artery and the superficial femoral artery (arrows) in the distal third of the thigh.
Trang 3A pulsatile fullness or mass in
the popliteal fossa may be an
aneu-rysm Baker’s cysts are also
com-mon in this patient group Both
popliteal aneurysms and Baker’s
cysts can be distinguished with
ultrasonography if the clinical
as-sessment is equivocal Most
periph-eral atherosclerotic aneurysms are
popliteal aneurysms (Fig 2), which
are often bilateral.24 The most
com-mon sequelae of these aneurysms
are thrombosis and embolization;
either or both occurred in 33 (61%)
of 54 patients in one study.24 The
reported rates of amputation
neces-sitated by thrombosis of a popliteal
aneurysm vary from 20% to 50%.4
The consequences of thrombosis
and embolization are devastating;
therefore, repair is always indicated
before TKA
Mechanisms of Injury
Most arterial complications follow-ing TKA are associated with tourni-quet use and are related to indirect vessel injury and thrombosis, espe-cially in the previously diseased artery.4,7,15,20,25 The documented mechanisms of injury can be classi-fied into four general categories:
arterial occlusion, arterial sever-ance, arteriovenous fistula tion, and arterial aneurysm forma-tion.4 Arterial occlusion—probably the most common mechanism of arterial injury—can result from thrombosis of the popliteal artery due to manipulation and low flow because of tourniquet use.1,4,21
Manipulation can also cause intimal tears that lead to thrombosis.4,9,21
Because an atheromatous popliteal vessel has decreased elasticity, injury may result due to the distor-tion, tracdistor-tion, and fracture of the atherosclerotic plaque that may oc-cur when the knee is manipulated during TKA.12,26 Essential collateral vessels may also be disrupted at the time of TKA.13
Another mechanism of injury is trauma at the level of the superficial femoral artery due to tourniquet use Mechanical pressure can trau-matize atherosclerotic plaques, lead-ing to distal embolization of plaque fragments (Fig 3).1,4,9,10,12,13,21 The tourniquet can also cause thrombo-sis of the superficial femoral artery, resulting in ischemia of the knee and leg.9,12,13,21 With correction of exten-sive flexion contractures, compres-sion of the artery between musculo-tendinous and osseous structures may also occur.1,9,13,21 Preexisting popliteal aneurysms may develop thrombosis due to the low flow state caused by tourniquet inflation.1 In-jury to the popliteal artery or one of the collateral arteries can result in false aneurysms, thrombosis, and arteriovenous fistulas.1,4,21 Throm-bosis and occlusion of a preexisting bypass graft can also occur.4 Release
of the tourniquet before wound clo-sure allows the surgeon to rule out direct laceration to the vessels.22
Furthermore, release of the tourni-quet just prior to the insertion of the polyethylene insert allows visualiza-tion of the posterior aspect of the wound and easier control of any obvious arterial complications
Postoperative Assessment
At the end of the procedure, while the patient is still anesthetized, the vascularity of the affected limb should be assessed.1,12 Ischemia is present if previously palpable pulses are absent Once the patient is awake, other signs of arterial insuffi-ciency, such as pallor with poor or absent capillary refill, pain, pares-thesias, and paralysis, can be demon-strated.1,12 The neurologic status of the affected limb may be difficult to assess because of the residual effects
of a spinal anesthetic Measurement
of the ABI will define the degree and presence of ischemia
A vascular surgeon should be consulted immediately if there are any concerns.1,12 Emergency arteri-ography of an ischemic limb is war-ranted, and revascularization should
be undertaken as soon as possible.14
If a distal bypass is required, con-tralateral saphenous vein grafts are preferred The prognosis is poor if diagnosis or management is de-layed.9
Recommendations Regarding Tourniquet Use
The use of a tourniquet during TKA
is controversial There are many potential risks, including arterial compromise, pulmonary edema,27
cardiac arrest,28neurologic injury,29,30
pulmonary emboli,31and muscle injury.29,30 These are rare but poten-tially limb- and life-threatening risks The primary advantage of the
Figure 2 A 79-year-old man who
under-went TKA had diminished pulses
postop-eratively An urgent angiogram revealed
an aneurysm in the popliteal artery (white
arrow) and occlusion of the popliteal artery
(black arrow) distal to the aneurysm.
Urgent vascular surgery resulted in
suc-cessful limb salvage The aneurysm is not
visible on the angiogram.
Trang 4tourniquet is the bloodless field,22
which should facilitate cementing;
however, the clinical relevance of
this has not been established
Two small prospective,
random-ized studies have been
conduct-ed,16,18both of which had similar
numbers of patients (77 and 80,
respectively) and study design
Wakankar et al18 demonstrated no
difference in blood loss, wound
healing, or range of motion after 6
weeks, but reported difficulty with
cementing due to bleeding in 13
(33%) of 40 patients Abdel-Salam
and Eyres16 found no difference in
blood loss or technical difficulty
when a tourniquet was not used
The group that underwent TKA
without a tourniquet were able to
do a straight leg raise at 2.4 days,
compared with 4.6 days for the
tourniquet group, which was a
sta-tistically significant difference
(P<0.05) However, there was no
significant difference between the two groups in regaining range of motion and in the Hospital for Special Surgery knee score at 1 year Operating time and overall blood loss were similar in both groups Presumably, there was less postoperative pain when a tourni-quet was not used, because those patients required significantly fewer analgesic injections in the first 2
days after the procedure (P<0.05).
The incidence of wound infection when a tourniquet was used was higher, but the difference was not statistically significant Wound infections developed in 5 patients
in the tourniquet group, but in none
of the patients in the no-tourniquet group Four of the wound infec-tions were superficial No patients
in either study had any tourniquet-related complications
Overall, these two studies sug-gest that it is safe to perform TKA without a tourniquet However, larger studies are needed to evalu-ate possible differences in wound healing, range of motion, and com-plication rates after TKA performed with and without a tourniquet Because of the potential limb-and life-threatening risks, consider-ation should be given to not using a tourniquet in those patients with factors that increase their risk of arterial complications Several rec-ommendations have been made for patients who require TKA but have identified vascular risk factors There are two options for patients with a preexisting femoropopliteal bypass graft There is evidence that TKA can be performed safely with-out a tourniquet.4,21 If a tourniquet
is deemed necessary, a 5,000-U intravenous bolus of heparin can be administered prior to tourniquet inflation and reversed with prot-amine sulfate at the end of the proce-dure Before making any decisions about the use of a tourniquet, the patient should be assessed by a vas-cular surgeon, and graft function should be evaluated with duplex ultrasound Arteriography is also warranted if there is any concern about graft function Graft prob-lems should be corrected before TKA Prosthetic arterial bypasses may be especially at risk for throm-bosis if a tourniquet is used
In the patient with chronic arter-ial insufficiency, the ABI is a useful tool for preoperative assessment If the ABI is greater than 0.5, the patient can safely undergo TKA without the need for further inves-tigation The patient should, how-ever, be informed of the risk of postoperative ischemia and should
be advised that revascularization may be required If the ABI is less than 0.5, arterial bypass should be performed either before or
immedi-Figure 3 An 82-year-old woman had painful blue toes after TKA with tourniquet control.
Pedal pulses were not palpable An urgent angiogram revealed atherosclerotic lesions in
the superficial femoral artery (arrows) and popliteal artery Fragmentation of these
athero-sclerotic plaques with distal embolization had occurred, resulting in “blue toes syndrome.”
Trang 5ately after TKA Alternatively,
TKA can be performed without a
tourniquet.21
If there is radiographic evidence
of calcification of the distal
superfi-cial femoral artery or popliteal
ar-tery, it has been recommended that
TKA should be performed without
a tourniquet.21 A similar
recom-mendation has been made for the
patient with no palpable pedal
pulses or with known peripheral
atherosclerotic disease.4,9,12,21
Summary
The incidence of arterial complica-tions after TKA is low, but the se-quelae can be devastating Most patients at risk have identifiable peripheral arterial disease, which must be sought preoperatively The risk factors include (1) a history of arterial insufficiency, (2) absence of pedal pulses, (3) a suspected popli-teal aneurysm, and (4) radiographic evidence of calcification of the
super-ficial femoral artery or popliteal artery If any of these factors is pres-ent at the preoperative assessmpres-ent, a vascular surgeon should examine the patient, and the TKA may have to be performed without a tourniquet Recent studies have shown that TKA can be performed safely without use
of a tourniquet With detailed preop-erative assessment, patients at risk for arterial complications can be iden-tified, and precautions can be taken
to avoid complications
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