Literature Review on Total Knee Arthroplasty Complications

Abstract

Background: Knee arthroplasty is one of the most common and successful surgeries for osteoarthritis patient. It vary depending on which compartment need to be replaced to total and partial knee arthroplasty.  The purpose of this review was to discuss some of the most common reported complications following TKA that lead to revisions,  to explore the causes behind these complications and to summarise some of the current recommendation for postoperative monitoring.

Method: Electronic databases (Web of science, Google scholar and PubMed) were searched to study the literature for articles related to the complications following total knee arthroplsaty.  The search within these databases were limited from 2000 to 2018.

Results: Infection, aseptic loosening, instability, polyethylene wear, malalignment and malposition, arthrofibrosis, extensor mechanism deficiency, pain, periprosthetic fracture and avascular necrosis in the patella were the most common reported complications the led to revision surgeries.

Conclusion: Different factors can contribute in developing  complications after TKA. These factors can be related to the surgery, patient or implant. A thorough Understanding of the causes of these complications, providing training with qualified and expert surgeons as well as improving implants manufacturing can contribute significantly in the success of TKA.

(Abstract words count 190)

Introduction

Knee arthroplasty or knee replacement is one of the most common and successful surgeries for end stage osteoarthritis. In 2010, the prevalence of knee replacement in the United States was 10.38% (4.7 million individuals with knee replacement) (Maradit Kremers et al., 2015).   There are two different types of knee implants: total knee arthroplasty (TKA) and partial knee arthroplasty (PKA).  These implants vary depending on the affected compartments that need to be replaced. While partial knee replacement aims to replace the damaged bone and tissues, total knee arthroplasty aims to maintain the normal alignment of the knee. Furthermore, the method of fixation vary from cemented to uncemented fixation. Along with the increase in TKA surgeries, some  complications may occur intra-operatively or post-operatively. The purpose of this review is to discuss some of the common reported complications following TKA that lead to revisions,  to explore the causes behind these complications and to summarise some of the current recommendation for postoperative monitoring.

Methods

Web of science, Google scholar and PubMed electronic databases were searched to study the literature for the articles that had the following terms in the title: knee arthroplasty OR replacement, Knee replacement complications, total knee replacement failure and TKA revision. Furthermore, the search method included filtering the articles to minimize the search results. Only articles from the latest publications (2000 to 2018) were preferred.

Results

A total of 19 reference paper were selected.  Further,  six articles were chosen to study the most common complication following TKA that lead to revisions. According to these studies, the most common reported complications that lead to revisions are: infection, aseptic loosening, instability, polyethylene wear, malalignment and malposition, arthrofibrosis, extensor mechanism deficiency, pain, periprosthetic fracture and avascular necrosis in the patella.

Discussion

Knee osteoarthritis

Knee osteoarthritis (OA) is the most common joint disease worldwide and one of the most common indications for total knee arthroplasty. The prevalence of osteoarthritis  is constantly increasing. According to a survey conducted by World Health Organization (WHO) in 2004, 43.4 million people are suffering from moderate to severe disability globally due to osteoarthritis (World Health Organisation, 2008). Knee osteoarthritis is considered to be the  11th cause of disability in the world as it leads to activity limitation, thereby affecting the quality of life (Palazzo et al., 2016). It affects around 250 million people globally as of 2010 (Cross et al., 2014) .This growth could be attributed to the increase in elderly population in both developed and developing countries. Along with this, risk factors like obesity and sedentary life style have reached an epidemic proportion. Other joint related factors such as abnormal loading, malalignment and injury can also attributes to osteoarthritis. Degeneration of the articular cartilage, subchondral bone loss, inflammation of the synovial membrane and meniscus degeneration are predominantly features seen in osteoarthritis (Favero et al., 2015). Based on the x-ray findings,  osteoarthritis is classified into mild, moderate, advanced, and far advanced stages. This classification is based on the structural changes happing at the joint which include: decrease in joint space, irregular joint line, sclerosis of the subchondral bone , spur and cystic formation, joint deformity and bone defect.

Total knee arthroplasty complications

Total knee arthroplasty, as any major surgery, can be accompanied by several complications. These complications vary from intraoperative to early and late complications. Some of these complications are systemic such as myocardial infarction, pulmonary embolism, renal failure, stroke, organ infection and DVT (Cho, 2014). Some complications might happen during the surgery such as direct injury to the extensor mechanism, patellar fracture or rupture of the quadriceps and patellar tendon.  In case of severe osteoporosis, fracture of femur or  tibia  might happen with a minimum amount of  trauma intra or post operatively. According to the reviewed studies, the most commonly reported post-operative complications that led to revisions are: infection, aseptic loosening, instability, polyethylene wear, malalignment and malposition, arthrofibrosis extensor mechanism deficiency, pain, periprosthetic fracture and avascular necrosis in the patella. However, this review focuses on the highest and the most commonly reported complications after TKA that led to revisions:

 Aseptic loosening

Aseptic loosening is one the most common late complications that lead to TKA failure. It can be defined as  loss of the bond between prosthesis and the bone in absence the of infection. It  can result from poor initial fixation during the surgery, loss of fixation due to the cumulative mechanical stress over time, polyethylene wear (especially in the insert with thin and low conformity) or the biological loss of fixation secondary to the osteolysis (Abu-Amer et al., 2007, Mulcahy and Chew, 2014). Schroer et al. (2013) and Sharkey et al. (2014) reported that aseptic loosening was the most common cause of revisions accounting for 31.2% and 39.9% of all revisions, respectively. Recently, Delanois et al. (2017) reported that aseptic loosening was the second most reported complication after infection following TKA accounting for 20.3% of all revisions.

It has been thought that the type of fixation is responsible for the poor initial fixation that occur during the surgery.  Sharkey et al. (2014) claimed that aseptic loosening is related to the methodology of prosthesis fixation. There is a debate about whether the ideal fixation can be achieved using cemented or uncemented component. It has been reported by surgeons that cemented fixation is less challenging in terms of technicality, moreover it offers more initial stability. On the other hand, uncemented fixation has some advantages in providing long term fixation and less fat embolization. Fehring et al. (2001) reported that 13% of early revisions were attributed to attributed to cementless fixation and  there would have been a decrease in early revisions if all TKAs would have been exclusively cemented.   Nakama et al. conducted a systematic review in 2012 and concluded that even though cemented fixation has smaller displacement of tibial component when compared with cementless fixation, it has higher risk in late aseptic loosening than cementless fixation. On the other hands, Gandhi et al. (2009) concluded a meta analysis stating that  survival and functional score were similar in both cemented and un-cemented prosthesis. 

Aseptic loosening can occur as a biological response to the particles around  the prosthesis leading to osteolysis. This  leads to inflammation, thereby evoking  the body response against foreign body. This response lead to the activation osteoclasts differentiation leading to osteolysis (Mulcahy and Chew, 2014, Abu-Amer et al., 2007).  Aseptic loosening can also occur as a result of surgical factors such as malalignment, malposition or  uncorrected instability during surgery.

Infection

Infection is a common complication following TKA and the primary cause of early revisions. Delanois  et al. (2017) reported  that infection is the most common cause of TKA revisions (20.4%). Early infections are likely to be due to perioperative causes,  whereas in case of late infections, it is most likely to happen as a result of haematogenous seeding (Cho, 2014).

Some people are at a higher risk in developing infections compared to others following TKA. Multiple factors are responsible in increasing their risk to infection including  immunodeficiency, Diabetes mellitus, Peripheral vascular disease,  intake of Immunosuppressant and Obesity. The risk of infections increases with postoperative wound complications such as  hematoma and delayed healing (Bliss and McBride, 1985).  In order to decrease the rate of infection, perioperative factors such as usage of  antibiotics, minimising the injury to soft tissues and decreasing the traffic in the operating rooms should be considered (Schroer et al., 2013).  It has been suggested by Vanhegan et al. that identification of the  causative organisms of infection can dramatically decrease the rate of failure following TKAs.  According to  Schroer et al. and Fehring et al., although infection can not be controlled completely, the surgeon can play an important role in avoiding it.

Instability

Instability is another complications following TKA. It is defined as abnormal displacement of the of the prosthesis articular component which ultimately cause clinical failure. It can result from a surgical error  or from a poor implant selection. The instability following TKA can be classified to extension (symmetric and asymmetric), flexion and global instabilities. Symmetric extension instability results from the inadequate space filled by the thickness  of the component due to the excessive bone removal of the distal part of the femur. This can be solved during the surgery by augmenting the femur distally. Both flexion an extension instability can arise when excessive bone is removed from the proximal part of the. In this case, the surgeon can choose a  thicker tibial insert to stabilise the joint. An angular deformity of  the knee prior to the surgery can result in asymmetric extension instability.  Flexion instability is cause by a surgical technical error which decreases the size of the femoral component or create more tibial slop. This creates a  flexion gap which is larger than the extension gap. This can be seen in the patients with axially aligned and fixed prosthesis (Mulcahy and Chew, 2014).  Fehring et al. (2001) suggested discouraging the concept of leaving flexion gap looser than extension gap to decrease the incidence of flexion instability. Global instability  is a combination of flexion and extension instability as well as medio-lateral instability. It can be a result of multiple factors such as laxity of soft tissues around the joint due to polyethylene wear, micro motion of the implant, disruption extensor mechanism and motor dysfunction. Fehring et al. (2001) reported that 27% of early revisions  were attributed to instability.  Likewise, Sharkey et al. (2002) reported that instability accounts for 21.2% of early revisions. In contrast, Sharkey et al. (2014) reported that the overall incidence of revisions due to instability has decreased significantly to  7.5%. Moreover, This decrease is attributed to progression in surgical techniques as well as prosthesis designs.

Polyethylene wear

Polyethylene wear is usually a late complications after TKA.  It is commonly seen in the patients who have metal prosthesis and incongruent articular surface. There are multiple factors that contribute to  polyethylene  wear such patient weight and level of activity, polyethylene geometry and alignment with the femoral condylar component of the prosthesis, and polyethylene molecular weight and thickness (Mulcahy and Chew, 2014). The surface wear of polyethylene can occur as a result of mechanical scraping of femoral component against it.  Delamination wear appears as chunks under the microscope and it occurs  when some parts of the liner peel off. This lead to release polyethylene particles which cause body response leading to  osteolysis.  Sharkey et al. (2002) reported that the most common complication that need revision surgery is polyethylene wear, accounting for 44.4%. They conducted another study 10 years later using a larger sample. They found that polyethylene wear (3.5%) is not the primary cause of TKA failures any more. The percentage dropped significantly when compared with the results 10 years ago. Schroer et al. 2013 reported that polyethylene wear accounts for less than 1% of all early revisions but accounts for 48.3% in late revisions (more than 15 years). This drop reveals the advancement in implants designs and polyethylene manufacturing which have led to decreased polyethylene wear.

 Current recommendation for post-operative monitoring

Post-operative monitoring of total knee arthroplasty for possible complications is an integral part of the post-surgical management. It helps to a great extent in reducing the incidence of prosthesis failure and subsequent revision surgery.

One of the primary complication of total knee arthroplasty is surgical site infection. Surgical site infection is defined as an infection that occurs after surgery at the body part where the surgery was performed Within 90 days after surgery. The visible signs of surgical site infection may include purulent drainage from the incision, positive fluid or tissue cultures, wound dehiscence or wound reopened by the surgeon in presence of fever, pain or tenderness, localized swelling and redness (Ashraf et al., 2018). Developing a surveillance protocol for surgical site infections can reduce its incidence to a very high extent. These surveillance data could include factors like age, diabetes, number of comorbidities, preoperative urinary tract infections, ASA levels, duration of surgery, preoperative haemoglobin and Hospital stay. Post-operative hematoma as well as continuous drainage need to be monitored after TKA as they are strong predictors of surgical site infection (Anderson et al., 2014).

Screening for a pre-existing cardiopulmonary condition, pulmonary oedema and Pulmonary embolism is very important in initiating the management as it is the key in controlling those life threatening conditions. Patient should be monitored for disorientation, loss of consciousness or paralysis which could be a sign of an emboli. Pain and swelling on the lower limbs should be monitored especially during the initial post-operative days to identify the occurrence off deep vein thrombosis. Postoperative surveillance with duplex ultrasonography of the lower extremity has been found to be effective in locating deep vein thrombosis in even asymptomatic patients. Patient has to be seen 6 weeks after the surgery, then three months, six months, one year and once every year thereafter (Cho, 2014).

Conclusion

Although total knee arthroplasty TKA is a successful surgery, it can be associated with several complications which may lead to revision surgeries. The complications vary from intra to post-operative early and late complications. This review has focused on some of  the complications following TKA. It has explained some of the links between these complications and other factors including patient, implant or surgery. A thorough Understanding of these complications, providing training with qualified and expert surgeons as well as improving implants manufacturing can contribute significantly in the success of TKA.

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