Schlüsselwörter
Kniearthroplastik insgesamt - akute arterielle Thrombose - Thrombolyse - Thrombetomie - Bericht des Falles
Keywords
total knee arthroplasty - acute arterial thrombosis - thrombolysis - thrombectomy - case report
Introduction
The increase in life expectancy and an aging population have led to a sharp increase in the number of patients with knee joint diseases. Total knee arthroplasty (TKA) has become the most
important and effective method for the treatment of some serious knee joint diseases [1]. Arterial complications associated with TKA are rare, with a reported incidence of only 0.03 to 0.17% [2]
[3]
[4]. Less than 100 cases have been reported, but these include arterial transection, aneurysm, arteriovenous fistula, and thrombus embolization. Acute arterial embolization is
an extremely rare complication but if it is not treated in time it may lead to severe consequences. It has been reported that the mortality rate of these complications is as high as 7%, and
the amputation rate as high as 42% [5]
[6]. At present, there is no consensus on the best treatment for arterial thrombosis following TKA [7]. There are two main types of clinical treatment: endovascular treatment and open surgery. Endovascular treatment includes balloon angioplasty, thrombus aspiration,
thrombin injection, stent implantation, and coil embolization. Open surgery includes end-to-end anastomosis, Fogarty catheter connection and one-stage repair, vascular graft placement, or
bypass surgery [8]
[9]. The two cases reported here were treated by two different approaches, and the prognosis of the patients was also different. The cases are reported below.
Case Reports
Case 1
A 62-year-old male patient had pain in his right knee for 10 years that had been aggravated for the previous year. He had no specific medical history or history of peripheral vascular
disease. Physical examination on admission revealed tenderness on the inside of the right knee joint, limited movement, with a range of motion 20° extension to 90° flexion, normal feeling of
the right lower limb, and normal muscle strength. An X-ray showed narrowing of the right knee joint space with obvious local hyperosteogeny ([Abb. 1]
a, b). The admission diagnosis was right knee osteoarthritis (Kellgren–Lawrence [KL] grade VI). Doppler ultrasound showed moderate arteriosclerosis in both
lower extremities. On the 4th day of admission, the patient underwent a right TKA. The surgery lasted 90 minutes, using a tourniquet for 60 minutes and pressure of 260 mmHg. Before the
prosthesis was installed, a periarticular cocktail was injected around the joint capsule. No popliteal artery (PA) hemorrhage was found during the operation, and the dorsalis pedis artery
pulsed well after operation. The patient received routine anticoagulant therapy (subcutaneous injection of low-molecular-weight heparin 3200 U, once per day) and appropriate
anti-inflammatory treatment. On the first day after operation (20 hours after operation), the patient still felt numb and dull in the lower part of the right leg, and had difficulty lifting
the straight leg out of bed. The pulsation of the right foot dorsal artery was good, but he was unable to move his foot. Considering that these symptoms may be caused by preoperative nerve
block anesthesia, no special treatment was given. Postoperative X-ray examination showed that the joint prosthesis was in a good position ([Abb. 1]
c, d). On the second day after operation, the skin temperature of the right foot was obviously decreased, and the patient reported worsening pain in the right
foot. Distal movement and sensation were lost, and the pulse of the dorsalis pedis artery was weak. Ultrasonography immediately indicated the formation of an atherosclerotic plaque in the
right lower limb and local embolization of the right PA. After the diagnosis was confirmed by arterial angiography ([Abb. 2]
a), arterial catheter thrombolytic therapy of the right lower limb was performed immediately. The right PA was basically unobstructed after thrombolytic therapy
([Abb. 2]
b, c). On the second day after thrombolysis, the skin temperature of the right foot had recovered and the right dorsalis pedis artery pulsed well. However,
sensation and movement of the right leg were not restored, and there was slight swelling. Arteriography was performed again and indicated the formation of an arterial fistula ([Abb. 2]
d). The blood vessels and nerves of the popliteal fossa were explored immediately. During the operation, it was found that the PAs and veins were unobstructed,
and there was no arteriovenous fistula, only one small artery (diameter 1 mm) with active bleeding, which had formed a hematoma with a volume of approximately 15 mL, oppressing the origin of
the tibial nerve. After clearance, no obvious injury was found of the tibial nerve or the common peroneal nerve. However, the tension of the lateral osteofascial compartment of the leg was
increased, and the muscle color was slightly pale, oppressing the common peroneal nerve. After incision and decompression, the color of the muscle recovered, the color of the medial muscle
group was good, and no further incision of the medial lateral osteofascial chamber was performed. One week later, there was no significant improvement in calf movement or sensation. When
preparing to suture the incision, it was found that there was a large area of ischemic necrosis in the patient’s right leg muscle, and only the lateral residual muscle survived. The patient
underwent several rounds of debridement and skin grafting operations over the following 4 months. One year after discharge, the patient had complete loss of sensation in his right foot, foot
drop deformity, and difficulty in walking ([Abb. 3]). Ultrasound showed that the blood vessels of the right lower extremities were unobstructed, and the PA thrombus had disappeared.
Abb. 1 X-ray of the right knee joint of the first patient. a, b Preoperative radiographs showed stenosis of the right knee joint and osteophyte hyperplasia. The letter R stands for the
right knee joint. c, d Postoperative radiographs showed that each implant was installed in the proper position. The letter R stands for the right knee joint.
Abb. 2 Arterial angiography of the first patient. a Local segmental embolization of the right PA. The letter R stands for the right knee joint. b Thrombolysis of the ductus
arteriosus was performed. The letter R stands for the right knee joint. c The right PA was basically unobstructed. The letter R stands for the right knee joint. d
Arteriovenous fistula was formed. The letter R stands for the right knee joint.
Abb. 3 Pictures 1 year after operation of the first patient. a–d The skin of the right leg healed well, but sensation and movement of the lower leg were completely lost, the right foot
was drooping and inverted, and the toe contracture was deformed. The letter R stands for the right calf.
Case 2
An 84-year-old woman had suffered from right knee pain with movement restriction for 20 years due to osteoarthritis. She had a history of previous left knee arthroplasty, hypertension,
hyperlipidemia, diabetes, coronary heart disease, two percutaneous coronary interventions (PCIs), right lower limb acute lymphangitis, and long-term smoking. The admission physical
examination revealed tenderness on the inside of the right knee joint, limited movement, range of motion from 40° extension to 70° flexion, normal feeling in the right lower limb, and normal
muscle strength. X-ray showed narrowing of the space of the right knee joint and obvious local hyperosteogeny ([Abb. 4]
a, b). The admission diagnosis was right knee osteoarthritis (KL grade VI). Doppler ultrasound showed atherosclerotic plaque formation in both lower
extremities. On the 9th day of admission, the patient underwent a right TKA, which lasted 120 minutes, using a tourniquet for 80 minutes and pressure of 260 mmHg. Before the prosthesis was
installed, we injected a periarticular cocktail around the joint capsule. No PA hemorrhage was found during the operation. The dorsalis pedis artery pulsed well after operation, and the skin
temperature of the right ankle was slightly reduced. The patient received routine anticoagulant therapy (subcutaneous injection of low-molecular-weight heparin 3200 U, once per day) and
appropriate anti-inflammatory treatment. On the 1st day after operation (16 hours after operation), the skin temperature of the right foot was still lower than that of the left, but normal
sensory activity of the right foot and pulsation of the dorsalis pedis artery were observed. X-ray examination showed that the joint prosthesis was in a good position ([Abb. 4]
c, d). On the 2nd day after operation, the pain in the right leg was aggravated and the right foot was pale and cold. The right ankle and toe could not be
extended, sensation below the ankle was lost, and the pulsation of the dorsalis pedis artery had disappeared. The patient was immediately examined by vascular ultrasound and arterial
angiography of both lower extremities, and the cause was confirmed as PA embolization ([Abb. 5]). Emergency PA incision and thrombectomy were performed. During the operation, it was found that the P3 segment of the PA was locally embolized for a distance of
approximately 3 cm. The arterial wall was stripped, and the lesion was opened with a Fogarty catheter. Needle puncture marks on the wall of the PA were found during the operation, but there
was no formation of blood scabs. Vascular repair and reconstruction and preventive incision and decompression of the osteofascial compartment of the leg showed that muscle vitality was good.
After the operation, the patient was given routine symptomatic support treatment comprising anticoagulation, tube dilatation, and anti-infection. An ultrasound showed that the blood vessels
of the right lower extremities were unobstructed. At discharge (45 days after operation), the patient’s right leg was slightly swollen, but the incision had healed well and the dorsalis
pedis artery pulsed well. The patient was able to walk with the assistance of a walker, but local skin on the right foot was numb and sensation was significantly reduced. The right ankle and
right toe could not be stretched backwards, and the right foot was prolapsed. One year after using an ankle orthosis to correct the right ankle, the motor function of the right ankle and toe
had recovered, and the patient was able to walk normally ([Abb. 6]) but there was still some residual numbness and sensory abnormalities in the dorsum of the foot.
Abb. 4 X-ray of the right knee joint of the second patient. a, b Preoperative X-ray showed stenosis of the medial space of the right knee joint and osteophyte hyperplasia. The letter R
stands for the right knee joint. c, d Postoperative radiographs showed that the position of the joint prosthesis was good. The letter R stands for the right knee joint.
Abb. 5 Arterial angiography of the second patient. a, b Arterial angiography showed segmental local embolization at the distal end of the right PA. The letter R stands for the right
knee joint.
Abb. 6 Pictures 1 year after operation of the second patient. a The patient was able to walk normally. The letter R stands for the right knee joint. b The back of the right foot
stretched forcefully and there was no foot prolapse deformity. The letter R stands for the right knee joint.
Discussion
There are relatively few reports of arterial complications following TKA, most of which occur in patients with a history of peripheral vascular disease [10]. High-risk patients are those with intermittent claudication, pain at rest, previous ischemic ulcers, previous vascular surgery, pedal pulse loss, or asymmetry [11]. Therefore, patients with peripheral arterial disease need to be evaluated in detail before operation. Among them, history collection and physical examination are not
only the most important part of the preoperative evaluation, but also the basis of diagnosis and treatment. The surgeon should carefully inquire about the patient’s past medical history and
previous course of treatment, pay attention to the patient’s skin damage, check the muscle strength of both lower limbs, perform a sensory evaluation, check the patient’s peripheral vascular
status, measure the ankle-brachial index (ABI), and check the arterial pulsation (anterior tibial artery, posterior tibial artery, and dorsalis pedis artery). Supplementary evaluation of
medical history and physical examination are carried out through an appropriate diagnostic auxiliary examination. For patients with blood supply problems, noninvasive vascular examination
(Doppler ultrasound) should be performed. If the result of the examination is abnormal, a vascular surgeon should be consulted to assess the risk of operation. In the two patients reported
this time, preoperative lower limb vascular ultrasound suggested the formation of atherosclerotic plaques in both lower limbs, which may rupture due to mechanical pressure, leading to arterial
embolism and dysfunction. The second patient reported above had hypertension, diabetes, coronary heart disease, two PCI histories, and a long-term smoking history. These are risk factors for
arterial embolization.
For patients with peripheral artery disease, the TKA operation should be performed gently to avoid vascular injury, paying particular attention to the use of a tourniquet [12]. The use of a tourniquet during TKA can effectively reduce the amount of blood loss and reveal the surgical visual field more clearly [13]. However, long-term low perfusion may cause local damage to the distal skin, nerves, and blood vessels, which is conducive to thrombosis. Most patients suffering from
osteoarthritis are elderly and have associated atherosclerosis. Their blood vessels have become calcified and inelastic, and the mechanical pressure of the tourniquet may lead to intimal tear
and plaque fragmentation, resulting in embolization [14]. Matziolis et al. [15] reported a case of arterial embolization caused by the use of a tourniquet for only approximately 10 minutes during TKA. This demonstrates that a calcified plaque is
fragile and even short-term use of a tourniquet can cause plaque rupture. Some studies have shown that TKA without a tourniquet is safe and beneficial for early rehabilitation in patients with
vascular diseases of the lower extremities [13]. The two patients described in this report showed atherosclerosis by color Doppler ultrasound before surgery, but a tourniquet was still used during the operation. This
may have caused arterial intima tearing and plaque damage, leading to arterial thrombosis. Therefore, for patients with peripheral artery disease, attention should be paid to shortening the
duration of use of a tourniquet or not using a tourniquet at all. If intraoperative vascular injury is suspected (such as excessive bleeding, swelling of the popliteal fossa, or disappearance
of peripheral arterial pulsation), the tourniquet should be deflated before implanting the prosthesis in order to fully evaluate the vascular condition. Before the incision is closed, the
tourniquet should be loosened to ensure adequate hemostasis. If the tourniquet is relaxed after suturing the skin, any arterial injury may be covered up.
The curative effect of treatment for arterial embolization following TKA is not good, and a high amputation rate and high mortality have been described in previous reports [16]. The key to a good prognosis is early diagnosis and effective treatment [17]. In the study by Calligaro et al. [18], 44% of arterial injuries in joint replacement surgery were not diagnosed on the day of surgery. Typical ischemic symptoms (such as pain and kinesthesia) are often masked
under anesthesia. Artifacts caused by joint prostheses can interfere with computed tomography (CT) and magnetic resonance angiography (MRA) results. The possibility of false negatives is also
a problem with Doppler ultrasound. These facts have brought great challenges to the diagnosis and treatment of arterial embolization by surgeons [19]. No PA hemorrhage was found during the operation in these two patients, and the dorsalis pedis artery pulsed well after operation. However, it could not be completely
ruled out that the thrombosis occurred at the time of surgery. If patients had undergone ankle/brachial index (ABI) measurements in the recovery room, problems might have been detected
earlier. The two cases reported here both developed pain and sensory disturbances on the 1st day after surgery, which were believed to be caused by surgical wound pain and preoperative nerve
block. This situation therefore did not attract attention until the 2nd day after surgery. Therefore, we believe that for all postoperative patients in the recovery room, particularly those
who have received regional anesthesia and are unconscious for several hours after operation, their circulation should be carefully evaluated in order to take more urgent intervention measures.
In addition, for patients with peripheral artery disease, it is necessary to check the patient’s arterial pulsation of the lower extremities and measure ABI before and immediately after
operation. Once the operation is completed, the pulse of the affected limb and ABI measurement should be checked and checked again in the anesthesia recovery room, and the vascular status
should be reported for at least 3 consecutive days after operation. The findings should be compared with the preoperative vascular examination and, if any differences are found, Doppler
ultrasound should be used to identify them immediately, and then arterial angiography should be performed to determine the precise location of the lesion. If the distal pulse cannot be found,
a vascular surgeon should evaluate the patient immediately. When patients experience pain after surgery, doctors should fully understand the nature of the pain. Due to arterial spasm at the
embolization site and the sudden increase in proximal arterial pressure, pain often starts at the obstructed plane and extends to the distal end. Surgeons should pay attention to distinguish
such pain from the wound pain, and not to blindly provide pain relief, which can cover up the condition.
Due to the rarity of this complication, its treatment plan should depend on the specific situation [20]. Two commonly used clinical treatment methods are interventional thrombolysis and surgical thrombectomy [21]
[22]. The latest research shows that for the early treatment of acute limb ischemia, there is no overall difference in amputation rate and mortality between interventional
thrombolysis and surgical thrombectomy [8]. No matter which kind of treatment is chosen, immediate revascularization and reducing the time of limb ischemia is the key to successful treatment [7]
[23]. It is generally believed that more than 4–6 hours of ischemia will cause irreversible muscle and nerve damage [24]. Therefore, some scholars advocate that all patients with suspected limb ischemia for more than 6 hours or muscle swelling during exploration should undergo fasciotomy
[25]. Of the two patients we reported, the first patient chose thrombolytic therapy, and the arterial blood supply was restored after the operation, but the osteofascial
compartment was not prevented from opening, thus allowing large areas of muscle infection and necrosis, which led to catastrophic consequences. This caused the patient a huge financial burden
as well as psychological pressure. The second patient developed similar symptoms. After learning the lesson of the first patient, we performed a timely operation to remove the embolus and
create an adequate osteofascial compartment to prevent incision and decompression in the second patient. The prognosis of the second patient was significantly better than that of the first
patient. Based on comprehensive considerations, we believe that when acute arterial embolization occurs following TKA, if the ischemia time exceeds 6 hours, preventive incision and tension
reduction are very important for functional recovery of the limbs after operation.
Conclusion
Acute arterial embolization following TKA is a rare but very serious complication. When high-risk patients undergo TKA, their medical history should be taken and a physical examination should
be carefully performed before the operation, the intraoperative procedures should be precise and gentle, the use of tourniquets should be avoided as much as possible, and the limb sensation
and blood supply should be carefully observed after the operation. Physical signs such as limb ischemia and disappearance of pulse must be recognized as soon as possible, and necessary
examinations (Doppler ultrasound and arterial angiography) should be performed immediately. Once the diagnosis is confirmed, we recommend working closely with vascular surgeons to carry out
revascularization immediately. If the diagnosis is delayed for more than 6 hours, prophylactic fasciotomy may be required as a treatment to avoid adverse consequences.
