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REVIEW ARTICLE Table of Contents  
Ahead of print publication
Staying safe from pitfalls in primary knee replacements


1 Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
2 Department of Orthopaedics, Sri Dhaatri Orthopaedic, Maternity and Gynaecology Center, Vijayawada, Andhra Pradesh, India
3 Department of Orthopaedics, JIPMER, Puducherry, India

Click here for correspondence address and email

Date of Submission15-Jan-2021
Date of Decision27-May-2021
Date of Acceptance31-May-2021
Date of Web Publication19-Jul-2021
 

  Abstract 


With increasing numbers of primary knee replacements and the growing concerns of revision knee replacements, research is now tending to look back and look forward for all that is possible to reduce the complications and improve patient satisfaction in this highly successful surgery. The clinician must make a comprehensive assessment of the patient, identify the real needs and optimize the risks of this major surgery, against real benefits. This article reviews relevant aspects of preoperative, intraoperative, and postoperative care that practically influence a successful outcome that every potential candidate for knee replacement rightfully deserves.

Keywords: Complications, knee arthroplasty, outcomes, risk factors, safety


How to cite this URL:
Gangadharan R, S. Kambhampati SB, Menon J. Staying safe from pitfalls in primary knee replacements. Apollo Med [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=321833





  Introduction Top


A perfect outcome in medicine, though aspirational is often difficult to achieve. The number of primary knee replacements has been steadily increasing over the years globally, perhaps matching predicted numbers from the United States.[1] Despite large numbers and remarkable success, a consistently perfect outcome in primary total knee replacements (TKRs) is yet to be realized. The standards of such highly specialized and skilled surgical procedures can be negatively influenced by compromises in any of the smaller, seemingly unassuming aspects of care. This paper attempts to highlight the relevant areas in the patient's journey receiving a primary TKR, that are likely to influence the outcome. Although the recommendations appear prescriptive, the authors' aim is to expand the readers' perspective in providing comprehensive care and identifying the avoidable pitfalls in the ever-evolving field of arthroplasty. We have also collated information that would allow surgeons to engage patients more in the decision-making process as well as permit a more objective path for assessing outcomes.

We have summarized the likely influencers of the outcome as modifiable and nonmodifiable patient and surgical factors. There are no absolute nonmodifiable surgical factors, although very few factors can be graded as relatively nonmodifiable. Surgeons and establishments should welcome change in their perspectives and embrace a culture of constant improvization and learning in these key areas. This article is based on pertinent high-quality publications, guidelines and registry data, retrieved by selective literature search and the authors' collective experience.

Factors influencing outcomes of primary TKR have been classified and discussed under headings as given in [Table 1].
Table 1: Classification of Factors that influence outcomes of primary knee replacement

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  Patient Selection and Optimization Top


Right patient and symptoms

It is very important to select the right patient for surgery. Very young patients, <45 years, who may be managed with alternative options should be considered less favorably for joint replacement and other alternative options should be aggressively explored. The results of TKR in this age group, although promising, show high loosening and revision rate of 8.8%.[3] It is also important to consider psychological aspects of the patient and their capacity to co-operate with postoperative rehabilitation as outcomes heavily depend on these factors,[4] including lower socioeconomic status. Although a systematic review has shown no longitudinal association between preoperative psychosocial factors,[5] and postoperative functional recovery in joint arthroplasty, the authors recommend exercising caution in considering surgery in patients with limited capacity or cognition. Referred pain from the hip and spine should be ruled out as the main source of pain in the knee, before proceeding to TKA.

Body mass index

Patients will gain weight following knee arthroplasty,[6] causing further implications in patients with high body mass index (BMI). Studies[7],[8] have confirmed several complications in morbid obesity, including erythema, gastrointestinal, respiratory and extra-surgical site infections (SSIs), following lower limb arthroplasty. Surgeons should also be aware of the implants in the market that are specifically contraindicated in obese patients,[9] to avoid litigation. Additional careful examination of the limbs is required preoperatively to assess the limb girth, skin condition and assess ease of tourniquet application. Other problems to be addressed include difficult regional anesthesia, additional positioning supports, specialized operative tables and large incisions for relatively small size components, long operative times, and potentially more blood loss.


  Pain and patient satisfaction Top


Pain from knee osteoarthritis arises from several factors. Studies have identified different patient characteristics based on their physical status, level of emotional problems and objective structural damage seen radiologically.[10] Patients can be categorized to one of the three classes (1-3) depending on the high or low prevalence of emotional problems and structural damage. Kittelson et al.[11] identified four different phenotypes, based on co-morbidities, knee joint sensitivity, levels of psychological distress and radiological joint disease.

It is not uncommon to see patients with severe radiological changes, for example, a high Kellgren-Lawrence Score,[12] reporting relatively less pain. In such cases, any other validated lower limb functional score would help to assess the need for offering a knee replacement in advanced disease, with instability or deformity, as a major symptom. Knee stiffness per se, without pain or instability, causes a higher prevalence of postoperative stiffness.[13],[14],[15] The most important risk factor for developing postoperative knee stiffness is compromised preoperative range of movements. Only 71.4% of the patients with < 90° of range of motion ROM preoperatively achieved a range over 90° postoperatively.[16]

Not all patients are satisfied with primary knee replacements, ranging from 76% in 2006[17] 82%–89% in 2010.[18] It is very important to have realistic expectations preoperatively to have a “satisfied” patient.

Role of infection in knee arthroplasty

A multi-faceted strategy is required to combat infection in arthroplasty.[19] Several risk factors have been identified,[20],[21] that are associated with prosthetic joint infection (PJI) [Table 2]. Any history of previous septic arthritis is a relative contraindication and should be treated with extreme caution and well-planned staged procedures.[22],[23] Any illness or surgical procedures that produce bacteremia peri-operatively increases the chances of PJI. There is a firm belief among the majority of orthopaedic surgeons[24] that invasive dental procedures predispose to PJI. It would be safe to recommend that any such invasive procedure be postponed, whenever possible, for at least 8–12 weeks following TKR.
Table 2: Risk factors for prosthetic joint infection

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Elderly patients often harbor urinary infection due to stasis and incontinence. There is no advantage in treating asymptomatic bacteriuria with antibiotics before joint replacement surgery.[25] Simple screening questions (dysuria, frequency, temperature) will identify symptomatic patients. If symptomatic, appropriate empirical antibiotics should be then given, until they are asymptomatic. If symptoms persist, despite two courses of uroseptic treatment, patients should be referred on for urological management and their knee replacement surgery should be postponed until the full clearance is obtained.

Uncontrolled, long-standing diabetes mellitus is a risk factor for mortality and infection. The risk of infection requiring re-operation rises with increasing glycated hemoglobin (HbA1c) levels.[26] A recent multicentric study[27] recommends that screening of all patients undergoing TKR using Fructosamine Binding Globulin levels.

Specialized theatre environment for orthopedic procedures, were developed to reduce the number of bacterial load per cubic micron. However, the concept of laminar flow theatres has been challenged more recently, with evolving evidence that refutes actual clinical benefit in reducing the infection rates, inviting further research.


  Preoperative Factors Top


Common risks of any of the anesthetic modality should also be included in the consenting process. It is important that the patient, and family in select cases, understand the procedure, its complications and outcomes specifically in relation to that patient during consenting. Optimization of comorbidities is mandatory for successful outcomes. Reverse transcriptase-polymerized chain reaction has become mandatory in the preoperative evaluation for the foreseeable future of the post-COVID era. The presence of these viral markers including blood-borne viruses necessitates the use of protective gear for the personnel.

Patients with severe anemia must be evaluated for etiology. Mild anemia is optimized with hematinics. Having an algorithm led Hb-screening and management program has shown to reduce transfusion, readmission, length of stay in hospital and costs.[28]

Patients with a higher risk of thrombosis or bleeding should receive the correct dose of thromboprophylactic medications, in consultation with medical or hematological experts, carefully titrated to counteract bleeding and/or reduce the risk of thrombosis.

Postoperative oxygen targets in chronic obstructive pulmonary disease should be modified. Patients with a history of previous malignancies, previous chemo/radiotherapy could have compromised their cardio-pulmonary or hepato-renal reserves and have a slightly higher risk of venous thromboembolism.

Anticoagulants, antiplatelet agents or biologics should be withheld before surgery with appropriate alternative options and restarted once the wound is healed, approximately at about 14 days postoperatively. Patients on long-term steroids should be individually assessed based on their equivalent prednisolone dosage, for potential increased requirements in the immediate postoperative period. The guidelines from a collaborative study by the American College of Rheumatology and the American Association of Hip and Knee Surgeons[29] provide seven such recommendations, admitting low or moderate-quality evidence. Clear, well-communicated protocols for these patients in high volume centers will help prescription or nursing errors, enhancing the patient experience.

Lifestyle habits such as smoking, drinking, and intravenous drug abuse have important intraoperative and postoperative implications and hence should be sought for and curtailed appropriately. Smokers have higher rates of medical complications and mortality than nonsmokers or ex-smokers and hence smoking cessation should be encouraged before offering knee replacement.[30]

Orthopedic assessment

Any preoperative deformity-fixed and correctable, laxity-coronal, sagittal or axial planes should be sought for. Proximal and distal joints should be examined, at least clinically. This would influence the decision to operate, anticipate technical difficulties and ensure ordering of appropriate implants and instrumentation. Quadriceps strengthening exercises should be initiated at the earliest opportunity. The neurovascular status of the limb should be evaluated and documented. If in doubt, angiograms should be done to detect vascular issues and addressed before surgery. Excessive vascular calcification should alert the surgeon to avoid tourniquet.

Pre-existing spinal deformities in the elderly, that compromise strength, position and rotation of the limb, should be actively looked for-example, lumbar lordosis that restricts knee extension, referred to as “Knee-spine syndrome”[31] or severe kyphoscoliosis. Such patients may require a more-constrained implant (in the severe kyphoscoliotic patient) or a realistic guarded expectation (in the lordotic patient).

The risk of foot drop following knee replacement is higher on correction of fixed flexion and/or fixed valgus deformities. Preoperative valgus deformity ≥10°, total tourniquet time >120 min, diagnosis of a preexisting neuropathy and rheumatoid arthritis, younger age and higher BMI[32],[33] have been identified as risk factors for common peroneal nerve palsy.

Younger patients often have a secondary cause for arthritis such as previous fractures, malunions and the corresponding deformities should be evaluated thoroughly. Elderly patients and patients with inflammatory arthritis may have arthritis of multiple joints and should have an appropriate plan to mobilize after surgery and listed only after exhausting all available medical control of the systemic disease.

Any extra-articular tibia vara should be measured using any of the four methods, as explained by Saibaba et al.[34] Any excessive measurements need to be treated with caution as conventional resection methods may not restore the desired mechanical axis of the limb in all cases.

Surgical planning

A plan for the type of implant and sizes may be made using templating software. Planning and equipment required should be checked before surgery to avoid intraoperative hiccups. The presence of previous metalwork in either femur or tibia may preclude the use of routine intramedullary alignment systems.

Bilateral simultaneous TKR is shown to have a higher incidence of complications compared to staggered same admission or sequential bilateral TKR. The severity of medical comorbidities or the impact of major complications should trump orthopedic heroism. Patients should be informed of the possible complications during consenting and the average longevity and survival of the implant used.

Risks and complications

The common complications are listed in the nonexhaustive [Table 3].
Table 3: Complications following total knee replacement

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Local complications

In the English Registry,[36] of those implants that were revised, the most common causes of revision are as follows: Loosening/lysis (40%), infection, pain, instability, malalignment, stiffness, wear, progression of the disease. American data[37] reported complications in about 5.6% of patients within 30 days from primary TKR.

The Australian data[38] suggest that at 6 months following primary TKR, the most common minor complications were joint stiffness (18.5%), swelling (15.6%) and paraesthesia (15.6%), and the most common major complications were arthroplasty-related readmission (6.0%) and reoperation (2.5%). SSI accounted for 2.1% of re-admissions followed by manipulation under anesthesia (1.9%) and deep vein thrombosis (DVT) (0.4%). The most common reasons for reoperation following TKA were joint stiffness (1.5%) and SSI requiring surgery (0.5%). The 6-month mortality rate was found to be 0.2% as compared to 90-day mortality of 0.4%.[39]

Rarer pitfalls

Although extremely rare,[40] the risk factors for vascular injury are revision surgery, peripheral vascular disease, weight loss, renal failure, coagulopathy, and metastatic cancer.[41] Other reported complications include periprosthetic fracture (PPF),[42] dislocation/dissociation of components and implant fracture.


  Intraoperative Factors Top


These include anesthesia, theater environment equipment, personnel, implants and surgeon factors. Types of anesthesia affect outcomes variably. Epidural combined with spinal has lower chances of DVT compared to GA. However, epidural analgesia reduces mobility. Selective nerve blocks improve early mobility but need expert anesthetists adept at administering ultrasound-guided blocks.

Well-equipped kit and well-trained theatre personnel guarantee efficiency. The rate of complications is lower in high volume centers compared to low volume centers.[43] Similarly, surgeons who operate on higher volumes have a lower complication rate compared to those doing less.

Surgical technique

Primary knee replacement is mainly a soft tissue surgery which incorporates a few steps of bony resection and implantation. Surgeons offering knee replacement should be fully aware, adaptable and adequately trained in different techniques and have a stepwise approach in precisely delivering the intended stability, movement and independent ambulation. Some of the determining and controversial factors are summarized in [Table 4] and the Do's and Don'ts in [Table 5].
Table 4: Summary of controversies in primary total knee arthroplasty with a gist of sentinel papers - the favorable arms are highlighted in bold

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Table 5: Common do's and don'ts to avoid pitfalls in primary total knee replacement

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Ligament balancing

The spectrum of the complexity of knee replacements is reflected by various levels of constraint in design. Most knee replacements in several registries are either a posterior cruciate-retaining or sacrificing design. Further restraint becomes necessary if there is residual laxity of the lateral collateral ligament in full extension, or when there is mid-flexion instability, i.e., a nonhinged semi-constrained device. Augments are selectively used to restore the joint line to the optimal level. Best results are obtained when the joint line is restored to within 5 mm of the preoperative level.

An incompetent medial collateral ligament equates to a fully constrained implant. Surgical decisions are usually made preoperatively. Any untoward intraoperative event should not be ignored, allowing some steering away from the planned procedure, to avoid another mishap in the outcome.

Optimal angles for cuts

Distal femoral resection should be carefully performed as casual errors in the first step, can be compounded in subsequent resections.[59],[60] The arbitrary 5° distal femoral resection should be adjusted as per the patient's varus/valgus deformity and femoral length (patient's height), to avoid the undesirable excessive resection of condyles. When facilities are available, long leg views and preoperative measurements of the femoral-mechanical-anatomical axis will help guide the distal femoral resection angle.[61] Avoid anterior distal femoral notching, which per se is not a predictor of PPF; this should weigh against overstuffing the anterior compartment with a larger femoral component.

Measured resection versus balanced resection

While the surgeons could use either of the resection principles, care must be exercised to deliver a well-balanced knee in extension and flexion, before definitive implantation. The gap balancing technique may be superior in achieving restoration of alignment and higher functional scores, with a compromise of a slightly elevated joint line.[62] Although there are technical differences in the levels of resected bones, more recent comparative studies have shown that there are no differences in functional scores.[63],[64]

Patellofemoral resurfacing versus unresurfacing

Debate flourishes on the suitability of resurfacing the patella. It is widely accepted that if there is no or minimal wear in the retropatellar surface, or if the patella is extremely thinned out, it could be left unresurfaced, as resurfacing is not completely free of complications, most commonly overstuffed anterior compartment. Patellar fractures constitute the second-most common site of PPFs, more common after resurfacing from 0.2% to 21% of cases compared to an unresurfaced patella (0.05%).[65]

Component rotation

Subtle rotational malalignment is a common obscured cause of unsatisfactory outcome caused by patellar maltracking. This can either be at the femoral or tibial component or both. Rotating platform designs promise an increasing range of movements, negating the need for precise positioning of the tibial component. There are in vitro studies that show their ability to decouple the complex kinematics to pure rotation, i.e., decreased wear of the dual-surface articulation, thereby decreasing the chances of aseptic loosening.[66] However, there is a risk of the inserts spinning out.


  Postoperative Factors Top


It is incumbent upon surgeons to provide proactive individualized care to aid complete rehabilitation. Effective pain management with comprehensive care all around can make a successful day-case TKR possible. At discharge, all medications should be clarified to patient on stop or re-start times.

An expected timeline of recovery and guidance should be provided to support and encourage functional activities. More importantly, precautionary guidance to red flags of infection or DVT should also be communicated.

Clear confirmed follow-up appointments for wound inspection, suture removal and patient feedback and possible participation in recording outcome measures should be encouraged. Patients may be followed up at year 1, 5, and 10, unless concerns. Helpline or a clear point of contact should be offered to report any problems or doubts, in the interim, or provide any constructive feedback.


  Conclusion Top


Elaborate observational studies throughout the world have identified specific factors that predispose to poor outcomes in knee arthroplasty. High volume surgical centers with well-established and constantly improvised care pathways should aim to excel giving comparable, if not better, standard of results. Meticulous patient selection, a thorough preoperative assessment aiming for optimization of medical conditions, careful preoperative planning, with efficient conduct and precise delivery of surgery in conjunction with standardized and individualized postoperative care and rehabilitation are the known pearls proven to avoid pitfalls in total knee arthroplasty.

With increasing demands and dissemination of services rolled out to many centers of the country, it becomes imperative to carefully regulate the care provided. We hope that enrolment and active participation in the Indian Joint Registry would throw light on long term data from the sub-continent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Rajkumar Gangadharan,
Department of Trauma and Orthopaedics, Aintree University Hospitals, Lower Lane, Liverpool, L9 7AL
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_5_21




 
 
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Abstract
Introduction
Patient Selectio...
Pain and patient...
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Conclusion
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