Arterial complications after total knee arthroplasty (TKA) are rare; however, the sequelae can be disastrous. Infection and the need for amputation or vascular reconstructive surgery are not uncommon. A thorough preoperative assessment can identify at-risk patients, many, if not all, of whom have preexisting peripheral arterial disease. In the presence of peripheral arterial disease, the use of a tourniquet during TKA has been implicated in subsequent arterial complications. Following the guidelines that have been established regarding preoperative assessment, the role of the vascular surgeon, and the use of a tourniquet before and during TKA can assist the orthopaedic surgeon in assessing candidates for TKA and reducing the risk of arterial complications.

Arterial complications and total knee arthroplasty.

Background: Some surgeons release the tourniquet before closing the wound to secure hemostasis during knee arthroplasty. We examined whether early tourniquet release could reduce the perioperative blood loss and whether not releasing the tourniquet until after wound closure would increase the risk of early postoperative complications.

Methods: We searched electronic databases and reference lists of relevant articles, retrieved all of the published randomized controlled trials designed to address these issues, and performed a meta-analysis.

Results: Eleven studies involving a total of 872 patients and 893 primary knee arthroplasties were analyzed systematically. The studies showed considerable clinical and methodological diversity. Early release of the tourniquet increased the total measured blood loss (weighted mean difference = 228.7 mL; 95% confidence interval = 168.3 to 289.1; p < 0.00001). Early release also increased blood loss as calculated on the basis of the maximum decrease in hemoglobin concentration (weighted mean difference = 320.7 mL; 95% confidence interval = 204.3 to 437.1; p < 0.00001). The rate of reoperations due to postoperative complications was 3.1% (nine of 290) in the group with late tourniquet release compared with 0.3% (one of 290) in the group with early tourniquet release; the risk difference was 3% (95% confidence interval, 0.1% to 5%), which was significant (p = 0.04).

Conclusions: Early tourniquet release for hemostasis increases the blood loss associated with primary knee arthroplasty. However, tourniquet release after wound closure can increase the risk of early postoperative complications requiring another operation. Well-conducted large studies are needed to further explore the risk of early postoperative complications associated with late tourniquet release in knee arthroplasty.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Timing of tourniquet release in knee arthroplasty. Meta-analysis of randomized, controlled trials

Aims A number of biomarkers have been associated with abdominal aortic aneurysm (AAA), but there has been no assessment of how such markers along with clinical risk factors can be used to stratify the risk of AAA presence and its progression. The aims of this study were to assess the diagnostic, prognostic, and risk stratification potential of plasma D-dimer for AAA presence and growth.

Methods and results We included 1260 subjects (337 with AAA) recruited from a population screening study and 132 (41 with AAA) from a referral clinic. A total of 299 of the population group were followed by repeat ultrasound imaging for a median of 5.5 years to monitor AAA growth. The diagnostic and prognostic potential of plasma D-dimer was assessed by multivariate regression (adjusting for other AAA risk factors), receiver operator characteristic, and classification and regression tree (CART) analyses. In both groups, the dominant risk factor for AAA was D-dimer; thus in the population group, cut-off values of >400 and >900 ng/mL had adjusted odds ratios of 12.1 (95% CI 7.1–20.5) and 24.7 (95% CI 13.7–44.6), respectively. In both groups, CART analyses confirmed the dominating role of plasma D-dimer in defining extreme risk-groups with AAA prevalence as disparate as 3 and 82%. Average yearly AAA growth was positively and significantly associated with D-dimer which was able to predict growth as disparate as 0.4 and 2.5 mm/year.

Conclusion This study suggests that plasma D-dimer can play a role in the diagnosis and prognosis of AAA.

Evaluation of the diagnostic and prognostic value of plasma D-dimer for abdominal aortic aneurysm

Arterial injuries complicating total knee arthroplasty are rare but may result in significant morbidity. There are three reports of popliteal artery pseudoaneurysm resulting from arterial trauma during total knee replacement. We report a case of a popliteal pseudoaneurysm with rupture into the surrounding muscle, its evaluation, and successful repair 5 months after arthroplasty.

Popliteal pseudoaneurysm following total knee arthroplasty.

A systematic review and meta-analysis of the association between markers of hemostasis and abdominal aortic aneurysm presence and size

We reviewed 40 cases of arterial complications after total knee replacement from the literature and report 4 of our own cases. The incidence is low (0.03%-0.2%), but the prognosis is poor, with death or amputation in one fourth of the cases. Preexisting arterial insufficiency, absent pedal pulses, arterial calcification on plane radiographs, femoro- popliteal/distal grafts are all predisposing factors. Therefore, preoperative risk factor evaluation as well as rapid and adequate handling in case of bleeding and/or ischemic complications pre- and postoperatively are crucial. Cooperation with a vascular surgeon is also essential.

https://www.tandfonline.com/doi/pdf/10.3109/17453679608995616

Arterial complications after knee arthroplasty 4 cases and a review of the literature

Coagulation and fibrinolysis after open infrarenal abdominal aortic aneurysm repair in a long-term perspective.

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Arterial complications after knee arthroplasty 4 cases and a review of the literature

Coagulation and fibrinolysis after open infrarenal abdominal aortic aneurysm repair in a long-term perspective.