Complications in Total Knee Replacement

Presented by SC 徐國祐 , 李建霖2005/05/31

Case Presenting Case 1, 鍾 OO, 66y/o, M, Case 2 邱 OO, 72y/o, F, Case 3 柯李 OO, 64, F,

Case 1 鍾 OO 68 y/o, man. PH: 1.HTN, 2. DM, 3. PTCA in 93/2, 1-VD, 4.

Cervical stenosis s/p OP in 94/4, 5. Smoking (+) ASA class III Bilateral knee pain and soreness for 2 years simultaneous bilateral TKR on 5/20 severe wound pain with chest tightness and

dyspnea were noted after transferred to general ward, EKG: no new ST-T change

symptoms improved after O2 supplement and pain control

Case 2 邱 OO 72 y/o, woman PH: 1.Cardiomegaly, 2.Denied other

major systemic disease, 3.Smoking (-)

ASA class II Bilateral knee pain for 10 years simultaneous bilateral TKR on 5/18 uneventful post-op course

Case 3 柯李 OO 64 y/o, woman PH: 1. HTN(+) and DM (+) under medical

control, 2. Smoking (-) 3. Denied other major systemic disease and major OP

ASA class II bilateral knee pain and swelling for 10

year simultaneous bilateral TKR on 5/23 uneventful post-op course

Discussion Perioperative Complication of Total

Knee Arthroplasty Case Report Pulmonary Embolism Reperfusion Injury Intra-op monitor

Comparison of Staged TKR and Simultaneous Bilateral TKR

Simultaneous Bilateral, Staged Bilateral, and Unilateral Total Knee Arthroplasty.

A SURVIVAL ANALYSIS

J Bone Joint Surg 85A:1533–1537, 2003

Introduction to Simultaneous Bilateral TKR

Definition: Staged Total Knee Replacement.

knee joints are replaced with total knee prostheses one at a time, at two separate operations, often  several months apart.

Simultaneous Bilateral Total Knee Replacement.both knees replaced with total knee prostheses during one operation seance, under one anesthesia.

Exsanguination in TKR Exsanguination of limb for decreased

blood loss and a good operation field - Esmarch bandage distal to proximal for tissue and venous compression - Elevation of limb for 2~3mins - Tourniquet for total tissue and artery compression

Esmarch tourniquet Pneumatic tourniquet (350mmHg or 50~100 above BP)

Materials and Methods A total of 6200 total knee replacements,

performed in 3998 patients between 1983 and 2000, consisted of 2050 simultaneous bilateral, 1796 unilateral, and 152 staged bilateral total knee replacements.

A review of each group was conducted to compare the rates of morbidity and mortality, the survival of the prosthesis, and the clinical outcome.

Result The simultaneous bilateral group had a

significantly higher rate of thrombophlebitis than did the unilateral group (p = 0.0326)

No significant difference between the simultaneous bilateral and unilateral groups was found with respect to deaths within the first two weeks (p = 0.5159), within three months (p = 0.3299), or within one year (p = 0.8863).

The patients who died within one year after surgery were significantly older (average age, 75.5 years) at the time of surgery than the patients who survived longer than one year (average age, 70.2 years; p < 0.0001).

Case Report

Massive Pulmonary Embolism After Application of an Esmarch Bandage

Chen-Wei Lu, MD*, Yi-Sharng Chen, MD†, and Ming-Jiuh Wang, MD, PhD‡*Department of Anesthesia, Far Eastern Memorial Hospital, Taipei, Taiwan; and

Departments of †Surgery and ‡Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiw

an(Anesth Analg 2004;98:1187–9)

Case Report 71 y/o man, bil. TKR 8 year ago before this o

peration, experienced a left femoral periprosthetic supracondylar comminuted fracture.

Spinal anesthesia with 10 mg of 0.5% hyperbaric bupivacaine

An Esmarch bandage was used to exsanguinate the lower limb, and the tourniquet was applied over the upper thigh region.

Case Report 5 min after application of the Esmarch

bandage, the patient complained of chest tightness, shortness of breath, and palpitation, and then he lost consciousness.

ABP decreased from 136/80 to 60/30 mm Hg

SPO2 decreased from 98% to 79% HR decreased from 90 to 50 bpm ETCO2 partial pressure decreased to 18 mm

Hg within 1 min.

Case Report Endotracheal intubation Inotropic agents were given through CVP Emergent TEE revealed severely

distended RA and RV, with a large embolus in the RA (Fig. 1).

A large embolus was trapped in the foramen ovale, which seemed to be opened because of the greatly increased CVP (35 mm Hg)

Case Report

Case Report

Case Report Cardiac surgeons performed

embolectomy under CPB. CPB was converted to ECMO after

operation. The patient was discharged 45

days after the operation and was generally well 6 mo after the operation.

Case Report -- Summary Preoperative anticoagulation and diagnostic

workup should be performed to prevent the development of and exclude the possibility of venous thrombosis in patients with trauma of the lower extremities and delayed surgery.

We recommend that TEE be used immediately during unexpected intraoperative cardiovascular collapse and suggest that ECMO is helpful in the treatment of massive pulmonary embolism and acute RV failure.

Case Report

Risk assessment Preoperative diagnosis:

Compression ultrasonography Venography Latex D-dimer assay

Thromboembolism in TKR Incidence： < 1% Deep vein thrombosis(DVT) Pulmonary embolism(PE)--symptomatic

Pulmonary Emboli in TKR

Previous conception： PE happened following tourniquet deflation, and could not occur during inflation phase.

Sudden decreased SaO2, PaO2 and BP during tourniquet inflation was detected in some patient. Why?

Influence of tourniquet on PE?

Tourniquet vs. Control Anesthesia - ETGA - Propofol, Fentanyl, Vecuronium

- N2O, O2, Sevoflurane Exsanguinated by Esmarch bandage and

elevation Femur reaming by 20cm intramedullary rod Implant 20mm pegs with cement Tourniquet： 350mmHg

Anesthesiology 2002;97:1123-8

Arterial line, CVP (blood sampling) Monitor MAP, HR, PaO2, EtCO2 at stable

point (2.5mins, 5mins, 10mins) TEE

- grade 0： no emboli - grade 1： a few fine emboli - grade 2： cascade of emboli or embolic mass<5mm - grade 3： large embolic mass>5mm

Anesthesiology 2002;97:1123-8

Grade 0 Grade 1 (fine emboli)

Grade 2 (<5mm) Grade 3 (>5mm)

Anesthesiology 2002;97:1123-8

1.Emboli exists during inflation phase (even grade3) 2.Emboli ： Deflation>Inflation 3.Significant Emboli ： Tourniquet>Control

Anesthesiology 2002;97:1123-8

1. No difference in cardiopulmonary impairment compared with baseline except for tourniquet deflation. 2. Significant hemodynamic change after deflation and recovery in 5 minutes.

(2.5mins)

Anesthesiology 2002;97:1123-8

Tourniquet inflation phase Tourniquet compress femoral arteries and veins venous stasis, acidosis, endothelial injury, increased thromboplastin (hypercoaguable state) Virchow triad of thrombus formation

Anesthesiology 2002;97:1123-8

Tourniquet inflation phase Possible pathways of emboli enters IVC

Through medullary cavity of femur drainage v. IVC

Congestion side thromboembolism Insufficient compression of tourniquet

Anesthesiology 2002;97:1123-8

Tourniquet deflation phase

1.emboli exists before deflation2.emboli peak within 1 mins after deflation3.emboli area returns to pre-deflation level at 2~3mis after deflationAcute PE may happen within 2 mins after deflation.

Large thrombus in ischemic area enters circulation after deflation.

Anesthesia & Analgesia 2001, 776-80Deflation

Echogenic embolic materials (1)

Fat/Bone marrow Bone cement Thrombus Air Cold blood of ischemic limb Intra-op infusion fluid (from SVC)

FromIVC

Anesthesiology 2002;97:1123-8

Echogenic embolic materials (2)

Blood sample of emboli from PAC and femoral vein. shows no fat or bone marrow component.

J.Bone Joint Surg. 80A 389~396, 1998

Large emboli thrombus

Small emboli cold blood and air emboli Anesthesiology 2002;97:1123-8

PE and hemodynamic change Reduced at least 40% cross-section area of

pulmonary arterial bed to produce hemodynamic changes.

Mechanical obstruction (pulmonary emboli)

Pulmonary vasoconstriction

(by neuroendocrine substance, eg, serotonin)

TEE is not good enough?

Anesthesiology V99, No.2 , Aug, 2003

Ischemic reperfusion(I/R) injury Definition： Secondary tissue damage inflicted when

blood flow is restored after an ischemic period.

Cardiovascular surgery pp.620-31, 2002

Pathophysiology of I/R injury in limb (1) Critical tissue ischemic time Tissue

Time

Muscle 4 hrs

Nerve 8 hrs

Fat 13hrs

Skin 24 hrs

Bone 4 days

most vulnerable to ischemia

Cardiovascular surgery pp.620-31, 2002

Pathophysiology of I/R injury in limb (2) During ischemic phase….. - Muscle cells damage O2 & ATP↓muscle damage (injury or death)

- Microcirculation change Endothelium injury (protrusion or swelling)

disjunction of endothelium RBC compaction, WBC plugging, platelet aggregation along vessel wall

increased leakage of plasma

Cardiovascular surgery pp.620-31, 2002

Pathophysiology of I/R injury in limb (3) increased extravascular pressure compression of vessel

- Increased thromboembolism venous stasis, acidosis, endothelial injury, increased thromboplastin (hypercoaguable state) Virchow triad of thrombus formation

- No reflow phenomenon

Cardiovascular surgery pp.620-31, 2002

Pathophysiology of I/R injury in limb (4) Reperfusion is followed by an inflammat

ory response to ischemic area. Cell level ： - reoxygenationoxygen free radical↑

- mitochondria unable to use ATP

- cytokine and mediators response

remove damaged tissue and healingre-damage

Robbins Pathologic basis of disease, pp11-13

Pathophysiology of I/R injury in limb (5) Local inflammatory response

Tissue damage (mostly, muscle cells)

breakdown products(pro-coagulant) induce intrinsic

clotting system cytokine and inflammatory mediators release inflammation response re-damage muscle cells

and endothelium

Cardiovascular surgery pp.620-31, 2002

Pathophysiology of I/R injury in limb (6) Systemic inflammatory response Breakdown products flow into circulation

inflammation response…., esp. in lung damage of endothelium cells of vessels generally increased vascular permeability BP↓shock….

Pulmonary vasoconstriction

Cardiovascular surgery pp.620-31, 2002

I/R injury of tourniquet Tourniquet used < 2hrs No obvious muscle damage Small I/R injury and little systemic

inflammatory response in normal population Elders, autoimmune disease, neuromuscular

disease…….

Cardiovascular surgery pp.620-31, 2002

Propofol vs. Midazolam in TKR

Midazolam 5mg

Propofol0.2mg/kg and 2mg/kg*hr continuous infusion

Tourniquet deflation

Anesthesia & Analgesia, 2002, pp.1617~1620

I/R injury

Reactiv

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Propofol 2, 6-diisopropylphenol Similar to phenol-based free radical

scavengers. Small dose propofol still shows anti-

oxidant effect on I/R injury of tourniquet.

Anesthesia & Analgesia, 2002, pp.1617~1620

Intra-op monitor for PE in TKR BP, HR, SaO2 , EtCO2

TEE Pulmonary vascular resistance PVR/SVR ratio (drug effect) - embolic event： PVR↑, SVR may↓or no change PVRSVR ratio ↑

- drug effect： PVR and SVR change in same way

PVR/SVR ratio changes little Pulmonary artery catheter(Swan-Ganz)

Clinical Orthopedics and related research 2002, 396, 142-51

Take home message PE still occurs during tourniquet inflation

phase. For intra-op PE - pre-op:compression ultrasonography, venography and latex D-dimer assay - Intra-op:TEE, PAC(PVR, PVR/SVR) Small dose propofol has anti-oxidant effect on

ischemic reperfusion injury.

Thanks for your attention!!