Complications of total knee arthroplasty
- Gregory M Martin, MD
Gregory M Martin, MD
- Medical Director, Orthopedic Institute at JFK Medical Center
- Preferred Orthopedics of the Palm Beaches
- Section Editor
- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Clinical professor, University of Washington, Seattle
- Clinical professor, University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific Arthritis Associates
Total knee arthroplasty is widely considered a safe and effective procedure for patients with end-stage degenerative or inflammatory arthritis of the knee. Nevertheless, complications during and after total knee replacement may occur. These include anesthesia-related risks, exacerbation of comorbid medical issues, medication and allergic reactions, and complications related more specifically to total knee arthroplasty.
Complications related to total knee arthroplasty, although uncommon, range from minor problems to devastating, life-threatening events. The incidence of some of these complications may potentially be reduced if the procedure is performed by a higher volume surgeon and hospital . Efforts should be made to minimize the risk of complications with appropriate patient selection and optimization, meticulous surgical technique, and attentive postoperative management. This topic discusses complications of total knee arthroplasty. The indications for, alternatives to, and surgical technique for total knee arthroplasty are presented separately. (See "Total knee arthroplasty".)
Peroneal nerve palsy — The most common neurologic complication after total knee arthroplasty is peroneal nerve palsy. Clinical manifestations include paresthesia, numbness, and extensor weakness (drop foot). Patients with severe valgus alignment in combination with a flexion deformity are at greatest risk.
If noticed in the postoperative period, the surgical dressings are immediately loosened, and the knee is flexed to relieve pressure on the nerve. Nerve recovery is variable. As an example, one study found that 50 percent of episodes of peroneal palsy had a full recovery; patients with some residual nerve function recovered more often than those with complete palsies .
Tourniquet-related nerve injury — Tourniquet use, common in total knee arthroplasty, may be associated with nerve injury due to compression and/or ischemia. However, studies indicate nerve injury from tourniquet use is quite rare, especially when used at lower tourniquet pressures and for shorter time periods [3,4].
- Katz JN, Mahomed NN, Baron JA, et al. Association of hospital and surgeon procedure volume with patient-centered outcomes of total knee replacement in a population-based cohort of patients age 65 years and older. Arthritis Rheum 2007; 56:568.
- Asp JP, Rand JA. Peroneal nerve palsy after total knee arthroplasty. Clin Orthop Relat Res 1990; :233.
- Olivecrona C, Blomfeldt R, Ponzer S, et al. Tourniquet cuff pressure and nerve injury in knee arthroplasty in a bloodless field: a neurophysiological study. Acta Orthop 2013; 84:159.
- Olivecrona C, Lapidus LJ, Benson L, Blomfeldt R. Tourniquet time affects postoperative complications after knee arthroplasty. Int Orthop 2013; 37:827.
- 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; 13:211.
- Campbell's Operative Orthopaedics, 9th, Mosby, 1999.
- Januel JM, Chen G, Ruffieux C, et al. Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review. JAMA 2012; 307:294.
- Lu N, Misra D, Neogi T, et al. Total joint arthroplasty and the risk of myocardial infarction: a general population, propensity score-matched cohort study. Arthritis Rheumatol 2015; 67:2771.
- Lalmohamed A, Vestergaard P, Klop C, et al. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement: a nationwide cohort study. Arch Intern Med 2012; 172:1229.
- Sharkey PF, Lichstein PM, Shen C, et al. Why are total knee arthroplasties failing today--has anything changed after 10 years? J Arthroplasty 2014; 29:1774.
- Meehan JP, Danielsen B, Kim SH, et al. Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty. J Bone Joint Surg Am 2014; 96:529.
- Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am 1990; 72:878.
- Yang K, Yeo SJ, Lee BP, Lo NN. Total knee arthroplasty in diabetic patients: a study of 109 consecutive cases. J Arthroplasty 2001; 16:102.
- Archibeck MJ, Berger RA, Garvin KL, et al. Orthopaedic Knowledge Update 7, Koval KJ (Ed), AAOS, 2002. p.517.
- Brick GW, Scott RD. The patellofemoral component of total knee arthroplasty. Clin Orthop Relat Res 1988; :163.
- Mine T, Tanaka H, Taguchi T, et al. Patellar tendon rupture and marked joint instability after total knee arthroplasty. Arch Orthop Trauma Surg 2004; 124:267.
- Aaron RK, Scott R. Supracondylar fracture of the femur after total knee arthroplasty. Clin Orthop Relat Res 1987; :136.
- Parratte S, Pagnano MW. Instability after total knee arthroplasty. J Bone Joint Surg Am 2008; 90:184.
- Bourne RB, Chesworth BM, Davis AM, et al. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010; 468:57.
- Beswick AD, Wylde V, Gooberman-Hill R, et al. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2:e000435.
- Kettelkamp D. Gait characteristics of the knee: Normal, abnormal, and post-reconstruction. In: American Academy of Orthopaedic Surgeons Symposium on Reconstructive Surgery of the Knee, CV Mosby, St. Louis 1978. p.47.
- Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during activities of daily living. Phys Ther 1972; 52:34.
- Ritter MA, Stringer EA. Predictive range of motion after total knee replacement. Clin Orthop Relat Res 1979; :115.
- Mitchelson AJ, Wilson CJ, Mihalko WM, et al. Biomaterial hypersensitivity: is it real? Supportive evidence and approach considerations for metal allergic patients following total knee arthroplasty. Biomed Res Int 2015; 2015:137287.
- INTRAOPERATIVE COMPLICATIONS
- Neurologic injuries
- - Peroneal nerve palsy
- - Tourniquet-related nerve injury
- Arterial injuries
- POSTOPERATIVE COMPLICATIONS
- Myocardial infarction
- Aseptic loosening
- Patellofemoral disorders
- - Patellofemoral instability
- - Patellar component loosening
- - Patellar component failure
- - Patella fracture
- - Patella clunk
- - Extensor mechanism rupture
- Periprosthetic fractures
- - Femoral fractures
- - Tibial fractures
- Wound problems
- Polyethylene wear
- Persistent pain and dissatisfaction
- Metal sensitivity
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS