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.
Arterial complications associated with total knee arthroplasty (TKA) are rare, having a reported incidence of 0.03% to 0.2%.1-13 The majority of these cases involve acute thrombosis of the superficial femoral or popliteal arteries.1,14 Sequelae of acute ischemia include wound complications, infection, loss of limb and, rarely, death.2,4,15,16 The incidence of amputation is reported to be as high as 64%.2,3,17,18 Even at high volume centers, approximately 50% of patients who sustain a vascular injury during TKAs are not identified on the day of surgery.2,4,5,15,16,19-22
A preoperative history and physical examination performed by the orthopedic surgeon may determine if the patient is at increased risk for vascular complication and whether the at-risk limb can withstand the stress of the operation. History of claudication, prior peripheral artery reconstruction, absent or asymmetric pulses, or atherosclerosis observed on knee radiographs are some factors that place a patient at risk and warrant further investigation, including possible preoperative vascular consultation.3,4,6,4,7,20,23
Although numerous publications offer recommendations for the preoperative evaluation of the dysvascular limb, to our knowledge, no cases underscoring the importance of an immediate preoperative vascular examination, performed at the time of surgical site marking, in an at-risk patient for TKA, have been reported.3-6,15 This article presents a case of a patient who developed thrombosis of an endovascular stent during a 2-week interval between his last preoperative clinical evaluation and the date of surgery, with no change in his symptomatology.
A 70-year-old man presented with a long history of bilateral knee pain, left worse than right. On physical examination, patellofemoral and tibiofemoral crepitance was noted as well as medial joint line tenderness that reproduced the majority of his symptoms. Range of motion was 15° to 95° bilaterally. Pedal pulses were palpated as 1+ bilaterally. Radiographs of the left knee demonstrated severe arthritis of the medial compartment with varus deformity. Femoral, popliteal, and tibial vessel calcifications were also noted on the lateral radiograph of the knee.
Ankle-brachial indexes were obtained24 and noted to be 0.50 on the right and 0.57 on the left. Given the patient’s diminished pulses, abnormal ankle-brachial indexes, and history of multiple coronary artery stents placed in 2003, a referral to vascular surgery was made for preoperative evaluation. Lower extremity angiography demonstrated bilateral superficial femoral artery occlusions. Flow was reconstituted in the left superficial femoral artery with angioplasty and stent placement resulting in 0% residual stenosis. The stent necessitated a 30-day uninterrupted course of clopidogrel and aspirin. Approximately 4 months later, the patient developed angina and a workup revealed thrombosis in one of the coronary artery stents. He subsequently underwent revision stenting followed by a 1-year uninterrupted course of clopidogrel.
The patient approximately 1 year following revision coronary artery stenting (16 months following superficial femoral artery stent placement) for reexamnination of his lower extremities. Eight days prior to the scheduled left TKA, his pedal pulses were noted to be 2+ in the left leg and 1+ in the right leg. The patient was instructed to stop taking clopidogrel 7 days preoperatively to reduce the risk of bleeding. On the day of surgery, at the time of the patient’s surgical site marking in the preoperative holding area, pedal pulses were examined and found to be 1+ on the right side and nonpalpable on the left side. Symptoms were unchanged. Capillary refill was brisk and his toes were warm. Femoral pulses were 2+ bilaterally and popliteal pulses were 1+ on the right and nonpalpable on the left. Given the high suspicion for superficial femoral artery stent thrombosis, the patient’s TKA was cancelled. The patient underwent angiography of the left leg, which confirmed superficial femoral artery stent thrombosis (Figure 1). The lesion was subsequently recanalized with numerous stents and the patient was discharged 2 days postendovascular stenting in good condition with palpable pedal pulses bilaterally.
|Figure 1: Angiogram of the left (operative) leg obtained on the scheduled day of surgery. Note the complete occlusion of the superficial femoral artery stent. Abbreviations: CFA, common femoral artery; PFA, profunda femoris artery; SFA, superficial femoral artery.
Arterial complications following TKA are infrequent but may have catastrophic consequences. Only 7 out of 11 patients had full restoration of limb function in 1 study.1 The spectrum of sequelae ranges from wound complications to infection, limb loss, and death. Legal suits have been reported in as many as 50% of cases.1 Many algorithms for initial vascular evaluation have been published and all emphasize the importance of various aspects of both the history and physical examination in identifying an at-risk patient.3,4,6,14,17,20,23
A history of intermittent claudication, ischemic rest pain, and vascular arterial ulcers, although not frequently encountered in the sedentary arthritic patient population, should raise concern for the possible need for vascular consultation. A history of previous vascular procedure should be interpreted as a potential marker for peripheral vascular disease.17,25 In fact, a history of previous peripheral artery reconstruction significantly increases the risk of acute thrombosis as well as the need for bypass grafting after TKA.4-6,14,20,26,27 Avoiding or minimizing tourniquet use does not eliminate the risk involved.14,26-28 Physical examination may reveal skin discoloration, hair absence, dystrophic nail abnormalities, or healed vascular ulcers signifying poor circulation. Pedal pulses should be palpated bilaterally for symmetry and strength.15,17 The popliteal fossae should be palpated to rule out a popliteal artery aneurysm.6,17,20
Many theories have been proposed about vascular injury mechanism and the role of the tourniquet. Tourniquet mechanical pressure has been implicated in causing fracture and dislodgement of atheromatous plaques resulting in partial or complete occlusion of distal vessels, thus creating an environment favorable for thrombus formation.21,27 Another proposed mechanism is fixation of the proximal superficial femoral artery with stretching of the distal artery during manipulation, leading to injury in already diseased and vulnerable vessels.22 Given these findings, recommendations have been made to reduce the tourniquet pressure and duration of tourniquet inflation to help prevent the problem from occurring in patients with long-standing peripheral vascular disease.27
A recent survey among orthopedic surgeons revealed that >70% of surgeons have turned down a patient for TKA because of worries about circulation.5 Sixty percent to 70% will not use a tourniquet if there is cause for concern about circulation, and nearly 70% will not if there has been previous vascular surgery.5 With respect to TKA after ipsilateral peripheral artery bypass graft, it is difficult to implicate the tourniquet as the cause of acute graft thrombosis. In 1 study, 6 of 7 knees underwent TKA with a tourniquet and had no vascular complications, whereas 1 of 3 knees underwent TKA without a tourniquet and developed acute thrombosis.28 Given the small numbers available, it is difficult to establish a relationship between use of tourniquets and graft thrombosis.
The primary advantage of tourniquet use is the bloodless field, which should facilitate cement application; however, the clinical relevance of this theory has yet to be confirmed. Two small prospective randomized studies have been conducted investigating the outcome after TKA with and without the use of a tourniquet.29,30 One study reported difficulty with cementing due to bleeding in 16 (33%) of 40 patients with no difference in blood loss, wound healing, or range of motion after 6 weeks.29 The second study found no difference in blood loss or technical difficulty when a tourniquet was not used.30
Despite the limited evidence, the consensus remains that patients who are at risk for arterial complications should be considered for TKA without the use of a tourniquet given the potential limb and life-threatening risks.17 If radiographic evidence of distal superficial femoral artery or popliteal artery calcification exists, it has been recommended that TKA should be performed without a tourniqet.6 A similar recommendation has been made for the patient with no palpable pedal pulses or with known peripheral vascular disease.17
In patients with a preexisting femoropopliteal bypass graft, 2 options have been proposed. First, there is evidence that TKA can be performed safely without a tourniquet.17 Second, if a tourniquet is deemed necessary, a 5000 unit intravenous heparin bolus can be administered prior to tourniquet inflation and reversed with protamine sulfate at the end of the procedure.17 We routinely perform TKA without the use of a tourniquet in any patient with radiographic evidence of femoropopliteal calcifications or prior vascular procedures on the ipsilateral extremity.
Consideration should be given to obtaining ankle-brachial indexes in the at-risk patient, noting that arterial calcification may falsely elevate this number. If ankle-brachial indexes are <0.9, the patient is considered at risk for arterial complications and should be referred to a vascular surgeon (Figure 2). Ankle-brachial indexes <0.5 denote severe ischemia and an indication for preoperative angiography. A vascular surgery consultation may also be used to evaluate prior bypass grafts for patency and function.2,6,17,31
|Figure 2: Algorithm for preoperative work up of the at-risk patient for TKA. Abbreviations: ABI, ankle-brachial index; TBI, toe-brachial index; XR, x-ray; TKA, total knee arthroplasty.
When endovascular stenting is carried out to reconstitute flow, guidelines for subsequent perioperative management of antiplatelet therapy are based on percutaneous coronary intervention trials because of the relative paucity of data for peripheral stents. If percutaneous coronary intervention is carried out, current guidelines recommend dual therapy with clopidogrel and low dose aspirin for a minimum uninterrupted course of 1 month after implantation of a bare-metal stent, and for 12 months after implantation of a sirolimus-eluting stent or paclitaxel-eluting stent.
Ideally, all patients who are postpercutaneous coronary intervention, who are not at high risk of bleeding, should be treated with clopidogrel and aspirin for a minimum uninterrupted course of 12 months and all elective surgeries during this 12-month period should be postponed to a later date. Patients who require surgery within the initial 12-month period should have antiplatelet therapy continued in the perioperative period.32 If, however, antiplatelet therapy is interrupted in this period, recommendations are against the routine use of unfractionated heparin, low-molecular-weight heparin, direct thrombin inhibitors, or glycoprotein IIb/IIIa inhibitors.33 The optimal duration of clopidogrel therapy after 12 months has not been established and depends on the judgment of the risk:benefit ratio for the individual patient.32
After the initial 12-month uninterrupted course of antiplatelet therapy, if a patient is to undergo an elective surgery, recommendations for the perioperative management of aspirin and/or clopidogrel-containing drugs include stopping treatment 7 to 10 days prior to the procedure and restarting treatment approximately 24 hours postoperatively.33 Occasionally, patients who are at high risk for late stent thrombosis may have to undergo elective procedures while continuing antiplatelet therapy in the perioperative period. Predictors of late stent thrombosis include long stents, overlapping stents, small or multiple vessel stents, low ejection fraction, advanced age, diabetes mellitus, renal failure, and acute coronary syndrome.32 In these circumstances, the perioperative management of antiplatelet therapy is individualized to the patient and considerations include the risk of bleeding from the elective procedure, the anticipated gain in quality of life from the elective procedure, and the risk of an adverse event from interrupting antiplatelet therapy. These difficult cases require a multidisciplinary approach individualized to each patient. In our patient, clopidogrel was discontinued 10 days prior to the planned surgery after discussion with the patient’s cardiologist and vascular surgeon. The patient was outside of the 12-month period for both the peripheral stent and the revised cardiac stent.
To our knowledge, the use of an immediate preoperative vascular examination at the time of surgical site marking has not yet been advocated in the literature as an essential part of the preoperative evaluation of an at-risk patient undergoing TKA. Acute arterial ischemia in the postoperative period may compromise wound healing and result in a higher risk of surgical site infection, possibly resulting in amputation or death. When revascularization is undertaken in the postoperative setting, additional complications may be encountered including postischemic reperfusion injury necessitating prophylactic fasciotomies.34 The end result is a prolonged postoperative course leading to worse functional outcome.
We advocate the routine use of an immediate preoperative pulse examination, performed at the time of surgical site marking, to circumvent the potentially catastrophic complications associated with an ischemic TKA. This straightforward examination prevented the near certain and unacceptable complications that our patient would have suffered had he undergone TKA with a completely occluded superficial femoral artery stent.
- Parvizi J, Pulido L, Slenker N, Macgibeny M, Purtill JJ, Rothman RH. Vascular injuries after total joint arthroplasty. J Arthroplasty. 2008; 23(8):1115-1121.
- Calligaro KD, DeLaurentis DA, Booth RE, Rothman RH, Savarese RP, Dougherty MJ. Acute arterial thrombosis associated with total knee arthroplasty. J Vasc Surg. 1994; 20(6):927-930.
- Calligaro KD, Dougherty MJ, Ryan S, Booth RE. Acute arterial complications associated with total hip and knee arthroplasty. J Vasc Surg. 2003; 38(6):1170-1177.
- Rand JA. Vascular complications of total knee arthroplasty. Report of three cases. J Arthroplasty. 1987; 2(2):89-93.
- Kumar SN, Chapman JA, Rawlins I. Vascular injuries in total knee arthroplasty. A review of the problem with special reference to the possible effects of the tourniquet. J Arthroplasty. 1998; 13(2):211-216.
- DeLaurentis DA, Levitsky KA, Booth RE, et al. Arterial and ischemic aspects of total knee arthroplasty. Am J Surg. 1992; 164(3):237-240.
- Dennis DA, Neumann RD, Toma P, Rosenberg G, Mallory TH. Arteriovenous fistula with false aneurysm of the inferior medial geniculate artery. A complication of total knee arthroplasty. Clin Orthop Relat Res. 1987; (222):255-260.
- Hagan PF, Kaufman EE. Vascular complication of knee arthroplasty under tourniquet. A case report. Clin Orthop Relat Res. 1990; (257):159-161.
- Mureebe L, Gahtan V, Kahn MB, Kerstein MD, Roberts AB. Popliteal artery injury after total knee arthroplasty. Am Surg. 1996; 62(5):366-368.
- O’Connor JV, Stocks G, Crabtree JD Jr, Galasso P, Wallsh E. Popliteal pseudoaneurysm following total knee arthroplasty. J Arthroplasty. 1998; 13(7):830-832.
- Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008; 23(6 Suppl 1):139-145.
- Robson LJ, Walls CE, Swanson AB. Popliteal artery obstruction following Shiers total knee replacement. A case report. Clin Orthop Relat Res. 1975; (109):130-133.
- Wagner HJ, Starck EE. Acute embolic occlusions of the infrainguinal arteries: percutaneous aspiration embolectomy in 102 patients. Radiology. 1992; 182(2):403-407.
- Hozack WJ, Cole PA, Gardner R, Corces A. Popliteal aneurysm after total knee arthroplasty. Case reports and review of the literature. J Arthroplasty. 1990; 5(4):301-305.
- Rush JH, Vidovich JD, Johnson MA. Arterial complications of total knee replacement. The Australian experience. J Bone Joint Surg Br. 1987; 69(3):400-402.
- Bellemans J, Stockx L, Peerlinck K, Vermylen J, Lacroix H, Suy R. Arterial occlusion and thrombus aspiration after total knee arthroplasty. Clin Orthop Relat Res. 1999; (366):164-168.
- Smith DE, McGraw RW, Taylor DC, et al. Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg. 2001;9(4):253-257.
- Sierra RJ, Trousdale RT, Pagnano MW. Above-the-knee amputation after a total knee replacement: prevalence, etiology, and functional outcome. J Bone Joint Surg Am. 2003; 85-A(6):1000-1004.
- Abularrage CJ, Weiswasser JM, Dezee KJ, Slidell MB, Henderson WG, Sidawy AN. Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. J Vasc Surg. 2008; 47(4):803-807.
- Holmberg A, Milbrink J, Bergqvist D. Arterial complications after knee arthroplasty: 4 cases and a review of the literature. Acta Orthop Scand. 1996; 67(1):75-78.
- Zahrani HA, Cuschieri RJ. Vascular complications after total knee replacement. J Cardiovasc Surg (Torino). 1989; 30(6):951-952.
- McAuley CE, Steed DL, Webster MW. Arterial complications of total knee replacement. Arch Surg. 1984; 119(8):960-962.
- Barrack RL. Neurovascular injury: avoiding catastrophe. J Arthroplasty. 2004; 19(4 Suppl 1):104-107.
- Bernstein J, Esterhai JL, Staska M, Reinhardt S, Mitchell ME. The prevalence of occult peripheral arterial disease among patients referred for orthopedic evaluation of leg pain. Vasc Med. 2008; 13(3):235-238.
- Ninomiya JT, Dean JC, Goldberg VM. Injury to the popliteal artery and its anatomic location in total knee arthroplasty. J Arthroplasty. 1999; 14(7):803-809.
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- Parfenchuck TA, Young TR. Intraoperative arterial occlusion in total joint arthroplasty. J Arthroplasty. 1994; 9(2):217-220.
- Turner NS, 3rd, Pagnano MW, Sim FH. Total knee arthroplasty after ipsilateral peripheral arterial bypass graft: acute arterial occlusion is a risk with or without tourniquet use. J Arthroplasty. 2001; 16(3):317-321.
- Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br. 1999; 81(1):30-33.
- Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br. 1995;77(2):250-253.
- Stewart AH, Baird RN. The prevention and early recognition of arterial complications in total knee replacement: a vascular surgical perspective. Knee. 2001; 8(4):265-267.
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- Berger C, Anzbock W, Lange A, et al. Arterial occlusion after total knee arthroplasty: successful management of an uncommon complication by percutaneous thrombus aspiration. J Arthroplasty. 2002; 17(2):227-229.
Drs Garabekyan and Oliashirazi and Ms Winters are from the Department of Orthopedics, Marshall University, Huntington, West Virginia.
Drs Garabekyan and Oliashirazi and Ms Winters have no relevant financial relationships to disclose.
Correspondence should be addressed to: Tigran Garabekyan, MD, Department of Orthopedic Surgery, Marshall University, 1600 Medical Center Dr, Ste G-500, Huntington, WV 25701 (email@example.com)