Total Knee Arthroplasty: Complications and Results

Authors

Complications

Complication rate

Smith et al. [6]

Infection (24%), aseptic loosening (7%), periprosthetic fracture (5%)

63%

Baier et al. [7]

Infection (4%), aseptic loosening (6%), arthrofibrosis (7%), patellar complication (3%)

28%

Shen et al. [8]

Infection (12%), aseptic loosening (11%), patellar complication (2%)

22%

Farid et al. [9]

Infection (15%), aseptic loosening (16%), periprosthetic fracture (7%), quad/patellar tendon rupture (4%)

27–56%

Cottino et al. [10]

Infection (11%), aseptic loosening (2.5%), stiffness (2.5%)

12%

In addition to surgical complications, we must also focus on medical complications. Comorbidities such as obesity and diabetes have been identified as independent risk factors for the appearance of possible postoperative complications.

The possibility that patients with class III obesity [body mass index (BMI) > 40 kg/m²] have to be operated on TKA is 32 times higher than in normal weight individuals, so is the possibility of suffering postoperative complications in the context of a revision surgery. Carter et al. found a 2.6× increased rate of early complications compared to patients with a normal weight and a higher rate of wound complications (prolonged drainage) in the morbidly obese such as infection or cellulitis [13]. Roth et al. revealed a stronger association between BMI and perioperative complications in RTKA as opposed to revision total hip arthroplasty (RTHA), showing that complication rates after revision total joint arthroplasty increased with BMI but only after a certain threshold [14]. Watts, in his study on aseptic revisions, found that morbid obesity was clearly associated with reoperation, periprosthetic joint infection, and re-revisions compared with the control group [15].

The impact of diabetes is well-known and has been linked to an increased risk of mortality, surgical wound infection, and periprosthetic joint infection. It is even considered an independent risk factor for revision due to both septic and aseptic failures [16]. Regarding the type of diabetes, Gu et al. found a complication rate of 31% in patients with insulin dependence, compared with 21.7% for patients not dependent on insulin and 19.7% in patients without diabetes. Insulin-dependent diabetes mellitus was associated with an increased number of serious complications following RTKA, such as septic shock and postoperative blood transfusions [17]. This association necessarily implies the need for strict control of perioperative glycemia, recommending a glycosylated hemoglobin (HbA1c) at levels lower than 8.5 g/dL to prevent potential postsurgical complications [18]. In another study by Gu et al., they found that the male sex was shown to be an independent risk factor for an extended length of stay, infection, failure to wean from drugs postoperatively, and sepsis. The female sex was a risk factor for urinary tract infections. The complication rate was reported to be 13.5% for men and 10.3% for women [19].

Prevention of these complications might be fundamental to the success of the postoperative development after revision surgery.

The main surgical complications include deep or superficial infection, aseptic loosening, disruption of the extensor mechanism and patellar complications, stiffness or arthrofibrosis, and periprosthetic joint fractures.

Regarding the resolution of this type of complication in cases of primary infection, two-stage replacement continues to be the “gold standard.” Periprosthetic joint infection occurs in 8–10% of revisions. Vadiee et al. showed a general failure rate of 26% after a second two-stage arthroplasty and suggested that selected patients with acceptable general health and a culture-sensitive microorganism typically result in a satisfactory outcome [20]. On the other hand, patients with S. aureus methicillin-resistant (SAMR) or polymicrobial infections should be evaluated considering options such as amputation or fusion (Fig. 3.1).

../images/479782_1_En_3_Chapter/479782_1_En_3_Fig1_HTML.jpg — Fig. 3.1

Patient with recalcitrant total knee arthroplasty (TKA) infection not cured after a two-stage revision total knee arthroplasty (RTKA) and requiring a knee arthrodesis. Phases from the failure of the primary prosthesis to the final fusion: (a) anteroposterior (AP) view of the infected primary TKA; (b) AP radiograph of the rotating hinge implanted (two-stage revision arthroplasty); (c) lateral view of the rotating hinge; (d) the rotating hinge was removed because of the persistence of infection, and antibiotic-loaded cement and spacer were implanted; (e) definitive fusion with an intramedullary device

However, in recent years, multiple studies have advocated the strategy of one-stage revision with the following contraindications: significant soft tissue compromise, significant bone loss, or generalized sepsis [21]. In the case of acute infections of primary arthroplasties, various success rates have been reported with debridement, antibiotics, and implant retention (DAIR). Ottesen et al. noted in a recent study an overall success rate of 84% with a minimum follow-up of 2 years [22].

Aseptic loosening or instability may be resolved using implants with a higher degree of constriction with the help of augments, cone, or sleeves (Fig. 3.2).

../images/479782_1_En_3_Chapter/479782_1_En_3_Fig2_HTML.jpg — Fig. 3.2

Polyethylene wear and instability resolved with a rotating-hinge prosthesis: (a) preoperative AP view; (b) postoperative AP view of the rotating hinge implanted; (c) postoperative lateral radiograph of the rotating hinge

Stiffness and arthrofibrosis are usually treated with rehabilitation programs, manipulation under anesthesia, open or arthroscopic debridement [23], and finally revision arthroplasty.

Extensor mechanism disruption is a devastating complication. In a recent review [24], reconstruction of patellar tendon rupture has a much lower complication rate than repair. However, these techniques can lead to up to a 25% reinfection rate, rupture, and 44% extension lag. Newer techniques such a synthetic mesh augmentation (Fig. 3.3) and gastrocnemius rotational flap should be considered [25].

../images/479782_1_En_3_Chapter/479782_1_En_3_Fig3_HTML.jpg — Fig. 3.3

Mesh augmentation of disruption of patellar tendon: (a) polypropylene mesh size; (b) definitive reconstruction

Periprosthetic fractures associated with knee arthroplasty can be managed conservatively or operatively with osteosynthesis (locking plates or intramedullary nail) or a knee revision system if the fracture compromises the stability of the implant. In the current literature, locking plates (Fig. 3.4) have shown better results than more traditional plates, even though in a recent meta-analysis, no differences were found in terms of delayed union, operating times, and rates of complications between clinical results of locking plates and retrograde intramedullary nails [26].

../images/479782_1_En_3_Chapter/479782_1_En_3_Fig4_HTML.jpg — Fig. 3.4

Periprosthetic fracture in rotating-hinge prosthesis managed with a locking plate: (a) lateral view of the fracture, (b) AP view after fixing the fracture

3.3 Results

Despite the development of new implants, better strategies for the management of antibiotics, and perioperative optimization of patients, the results of RTKA are slightly poorer compared to primary cases. Survival rates of revision surgery are reported to be approximately 80% at 10 years. Among them, survival of late revision arthroplasties is significantly better than early revision (within 2 years), with revision failure rates of 17% and 2%, respectively, according to Hardeman et al. [27].

Similarly, revisions carried out in the context of a septic case usually report poorer results. It is difficult to determine the success of this procedure given the heterogeneity of the studies in terms of the causes of primary failure (partial or full components revision) and the implants used (posterior stabilized, hinged or inked implants, cemented or cementless). Rajgopal et al. [28] suggest that revision knee arthroplasty for flexion instability secondary to an undersized femoral component or over-resection of bone from the posterior femoral condyles has poorer outcomes compared with those undergoing revision surgery for infection or aseptic loosening.

Implant failure and the subsequent need for revision continue to place a major economic burden on healthcare [29]. In Table 3.2 we summarize the results of recent and classic studies available in the literature [3, 6, 7, 9, 10, 30, 31].

Table 3.2

Results and survival rates in revision total knee arthroplasty (RTKA)

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