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  Complications of concern in total joint arthroplasty are related to technical errors and non-technical perioperative system issues

  
  
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  Proper attention to evidence-based techniques and appropriate surgical training can mitigate preventable complications in total joint arthroplasty

The volume of total joint arthroplasty cases in the United States continues to grow; this includes a considerable burden of surgical revisions. Despite scientific and technological advances in total joint arthroplasty, complication rates remain unreasonably high. The learning curve of surgical trainees and midcareer surgeons with newly described techniques contributes to complications in total joint arthroplasty.

The vast success of total hip and knee arthroplasty is apparent as observed in the number of procedures performed each year in the United States, now totaling nearly 1 million.¹ Despite the observed success, many challenges in total joint arthroplasty remain. Complications related to total joint arthroplasty may be divided into those that occur in direct relation to the surgical procedure, and those that occur as a result of limitations in implant survivability. Of present concern are complications that occur intraoperatively and perioperatively. Such events have a wide range of impact including extended hospitalization, hospital readmission, and in some cases, mortality.

There are several groups of recognized complications that occur following total joint arthroplasty, some temporary, and others, permanent. Neurologic injuries result in minor neuralgia, paresthesia, disabling pain or frank paralysis, and may be related to intraoperative events or underlying neurologic conditions aggravated by nerve tissue manipulation. Thromboembolic disease may result in small, nondetectible thromboses or significant deep venous thrombosis with risk of pulmonary embolic events, possibly fatal. Lack of satisfactory visualization, common with less invasive approaches, may allow bone fractures or tissue insult to occur and, in severe cases, result in a need for reoperation.

A distinction important to make is whether intraoperative complications are a result of errors in technique, lack of proper planning, or complications due to underlying patient disease. It is of considerable importance for surgeons to develop a technique or plan and stick with it to the best of their ability; this strategy will give surgeons the most control they may have to avoid adverse events. Medical decision making related to patient indication and selection is also of significant importance. It is opportune to explore a variety of common total joint arthroplasty scenarios that surgeons may consider relevant to patient selection.

TOTAL KNEE ARTHROPLASTY (TKA)

As the adage goes, “common things are common.” This notion certainly applies to complications related to total knee arthroplasty (TKA). Some of the most prominent complications identified continue to include patellofemoral difficulties such as patellofemoral instability, patellar fracture, soft-tissue conditions, and frank extensor mechanism disruption (see Figure 15.1a-d). In the absence of patellar resurfacing, preoperative pain may persist. With resurfacing of the patella, instability, fracture, loosening, crepitus, clunk, and tendon rupture have been noted. Predisposition to patellar instability or fracture may occur with asymmetrical resection; hence symmetrical resection is preferred (see Figure 15.2a,b). Intraoperative analysis of patellar tracking remains critical. Patellar trauma, over-resection, and devascularization may lead to fracture with accompanying extensor mechanism disruption. Development of excessive soft tissue superior to the patella may lead to nodule development and palpable clunk when ranging actively from knee flexion to extension. Lastly, rupture of the extensor mechanism from the patellar or quadriceps side remains a devastating complication following TKA.

Fractures are observed following TKA. Supracondylar femur fractures are the most common. Predisposing factors may include anterior femoral notching, noted osteopenia, limited range of motion with subsequent manipulation, or apparent bone deficiency. Condylar bone resection as observed in posterior stabilized (PS) TKA procedures together with aggressive range of motion is associated with fracture either intraoperatively or postoperatively during physical therapy (see Case Study 15.2). Tibial fractures, in contrast, are less common than femoral fractures. They may occur intraoperatively in the proximal tibia associated with an aggressive impaction technique.

Sentinel complications are very conspicuous around the knee. Vascular injuries are rare, but serious, and require close postoperative monitoring. In cases of known vascular pathology, tourniquet use can be avoided. Of the neurologic complications that occur, peroneal nerve palsy is the most commonly observed. This is most closely associated with valgus knees and flexion contracture; it occurs with an incidence of 1% to 10%.²

Wounds following TKA may be difficult to manage and can progress to sepsis without aggressive management. Using previous incisions, if present, to avoid necrotic flaps as well as aggressive wound management with persistent draining wounds are critically important. Diligent debridement and exploration are important for appropriate healing; however, unnecessary return to the operating room (OR) for irrigation and debridement may predispose the patient to postoperative infection (see Case Study 15.1).

TOTAL HIP ARTHROPLASTY (THA)

Total hip arthroplasty (THA) is accompanied by a different collection of unique injuries and complications in contrast to TKA (see Table 15.1). Some complications, however, are similar to TKA. As in TKA, a most concerning complication following THA is neurovascular injury. Vascular injuries may be related to retractor placement, cement or screw placement, or aggressive retraction techniques using a variety of anatomic approaches. Neurologic injuries, although rare, occur 0.4% to 3% of the time in primary THA and at a slightly higher rate, up to 8%, with revision surgery. Observed neurologic complications may be a result of compression, retraction, extensive dissection, extremity overlengthening, or a combination of these. It has been noted that lengthening of up to 6% of the sciatic nerve intraoperatively is tolerated, with lengths beyond that representing a higher risk for neurologic impairment.³ If present, few indications exist for reoperation following neurologic impairment following THA (see Case Study 15.4).

Fractures related to THA may occur more commonly with cementless rather than cemented implants.^3,4 Etiology of fracture may be slightly different depending on the exposure involved. Fractures involving the posterior hip approach may involve excessive impaction and may be visualized and fixed easily with cables. In a like fashion, femoral fractures may also occur with limited approaches and, in some cases, may be difficult to visualize. Less and minimally invasive approaches that obscure full visualization of the proximal femur do not allow satisfactory appraisal of the fracture and may be more prone to missed injury. Fractures around the acetabulum are much less common and generally confined to THA revision, protrusion, and severe osteopenia (see Figure 15.3a-d).

Instability after THA remains a challenging problem in primary THA. It is still the most common complication, at 3% to 5% incidence.⁵

Variables to consider when evaluating instability include the following:

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  Approach

  
  
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  Tissue tension

  
  
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  Implant design

  
  
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  Implant position, fixation

  
  
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  Presence of spinal arthrodesis

  
  
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  Neurologic conditions

  
  
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  Previous hip surgery

  
  
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  Heterotopic ossification

As tissue or bone impingement may predispose to postoperative instability, implant design plays a significant role in restoration of tissue tension. Implant orientation is also of critical importance and may change depending upon surgical approach (see Case Study 15.3).

Recognition of leg-length discrepancy, both preoperatively and postoperatively, requires an examination in the supine and seated position, standing, and may require the use of blocks. A variety of techniques may be used to assess leg length intraoperatively.

These challenges and others continue to provide the most significant limitation to the long-term survivorship of total joint arthroplasty. Refer to Tables 15.2a and 15.2b below for the frequency of complications based on recent U.S. joint arthroplasty registry data.⁶

While consideration of such a complete list of adverse events may seem overwhelming, emphasis on proper planning, appropriate indications, and meticulous perioperative care, will allow a majority of difficulties to be avoided. Complications related to technical aspects of total joint arthroplasty can be circumvented by modifying techniques to correct such errors.

The learning curve in total joint arthroplasty for surgeons at all stages of practice involves a lifelong collection of practical techniques that may allow the clinician to avoid errors that have been previously observed. The expectation is that specific adverse events, under direct control of the surgeon, may be avoidable with some of the following technique considerations.

TOTAL KNEE ARTHROPLASTY

Surgical Incision: Location and Size Matter

Multiple risk factors exist for patients with poor wound healing. Some may include prior incisions, previous anterior trauma, burns, extensive dissection, diabetes mellitus, immunosuppressive or antirheumatic medications, and steroid use. As necrosis is a concern, incision selection in TKA is of considerable importance. The skin most at risk is that surrounding a previous long lateral incision with parallel medial incisions. Parallel incisions are discouraged; if needed, the bridge should be at least 7 cm in width. Use of the most lateral incision is advocated if multiple tracks exist from previous operations, as lateral flaps have generally been noted to be more problematic than medial flaps.⁷ In extremely questionable cases, a sham incision procedure may be performed, where the proposed skin incision is made, flap elevated, and then closed. Subsequent nonhealing should be addressed with plastic surgery assistance.⁸ In the unfortunate event of a major necrotic event, it is advised that capsular healing occur first, followed by split-thickness skin graft if the capsule completely closes. Should the capsule fail to completely close, plastic surgery may provide a gastrocnemius flap with subsequent split-thickness skin grafting.⁸ Prevention is generally the best treatment for wound healing with meticulous interrupted closure involved around tenuous skin.

Wound Care: The “Big Deal”

Little tolerance exists for a draining incision site in the perioperative period. The most effective means to prevent wound complications is to avoid them. Hence, with incisional drainage noted in the postoperative setting, steps should be taken to eliminate stimulus for wound expression. It is recommended to decrease bleeding as much possible in the OR prior to closure, including the use of fibrin spray, cautery, tranexamic acid, or fibrin sealants. Watertight capsule closure is mandated; if drainage is observed in the postoperative care unit, knee flexion with a drain clamp (if present) may be necessary to avoid additional bleeding. Flexion exercises should be suspended until the wound has been observed to be dry for at least 24 hours; immobilization may also be employed. Persistent drainage with subsequent resumption of flexion exercises is an indication for reoperation with debridement and reclosure. In the presence of acute swelling postoperatively, persistent drainage despite cessation of motion indicates that a wound hematoma should be evacuated. This is particularly true if increases in pain, decreases in wound integrity, neurovascular changes, or compartment syndrome appear to develop. Even if modest swelling is present, continued drainage observed over a period of 4 days warrants irrigation and exploration. The possibility of bleeding disorders must be considered in the setting of wound drainage; in identified patients at particular risk for bleeding, it is recommended to consider drain use postoperatively. It also may be necessary to avoid the use of a continuous passive motion machine until postoperative day 1. Such measures of immobility and drain use may be a concession to early motion; however, the priority of wound healing is of great significance.