Section 3 Knee Replacement

*Knee Surgery - Reconstruction and Replacement*

Knee Surgery, Sports Traumatology, Arthroscopy. 2015;**23**(11):3151-3156

et al. Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later. Arthroscopy.

[50] Helito CP, Camargo DB, Sobrado MF, Bonadio MB, Giglio PN, Pécora JR, et al. Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2018;**26**(12):3652-3659

[51] Ferretti A. Extra-articular

Joints. 2014;**2**(1):41-47

reconstruction in the anterior cruciate ligament deficient knee: A commentary.

[52] Ramaniraka NA, Saunier P, Siegrist O, Pioletti DP. Biomechanical evaluation of intra-articular and extra-articular procedures in anterior cruciate ligament

analysis. Clinical Biomechanics (Bristol,

reconstruction: A finite element

[53] Rezende FC, de Moraes VY, Martimbianco AL, Luzo MV, da Silveira Franciozi CE, Belloti JC. Does combined intra- and extraarticular ACL reconstruction improve function and stability? A meta-analysis. Clinical Orthopaedics and Related Research.

Avon). 2007;**22**(3):336-343

2015;**473**(8):2609-2618

2016;**32**(10):2039-2047

AM. Percutaneous reconstruction of the anterolateral ligament of the knee with a polyester tape. Arthroscopy Techniques.

[43] Chahla J, Menge TJ, Mitchell JJ, Dean CS, LaPrade RF. Anterolateral ligament reconstruction technique: An anatomic-based approach. Arthroscopy Techniques. 2016;**5**(3):e453-e457

[44] Helito CP, Demange MK, Bonadio MB, Tirico LE, Gobbi RG, Pecora JR, et al. Radiographic landmarks for locating the femoral origin and tibial insertion of the knee anterolateral ligament. The American Journal of Sports Medicine. 2014;**42**(10):2356-2362

[45] Saithna A, Thaunat M, Delaloye JR, Ouanezar H, Fayard JM, Sonnery-Cottet B. Combined ACL and anterolateral ligament reconstruction. JBJS Essential Surgical Techniques. 2018;**8**(1):e2

[46] Lutz C, Sonnery-Cottet B, Imbert P, Barbosa NC, Tuteja S, Jaeger

stabilization of the knee with the iliotibial band. Arthroscopy Techniques.

[47] Sonnery-Cottet B, Barbosa NC, Tuteja S, Daggett M, Kajetanek C, Thaunat M. Minimally invasive

injury. Arthroscopy Techniques.

Techniques. 2019;**8**(1):e23-ee9

[49] Ferretti A, Monaco E, Ponzo A, Basiglini L, Iorio R, Caperna L,

[48] Delaloye JR, Murar J, Vieira TD, Saithna A, Barth J, Ouanezar H, et al. Combined anterior cruciate ligament repair and anterolateral ligament reconstruction. Arthroscopy

anterolateral ligament reconstruction in the setting of anterior cruciate ligament

2016;**5**(2):e251-e256

2016;**5**(1):e211-e215

JH. Combined anterior and anterolateral

[42] Wagih AM, Elguindy

2016;**5**(4):e691-e6e7

**40**

**43**

**Chapter 4**

*Gabriel Stan*

**Abstract**

preserved.

**1. Introduction**

and stair-climbing.

Medial Epicondyle Osteotomy for

Varus malalignment is the most common deformity leading to total knee arthroplasty (TKA) for knee arthritis. For correcting this deformity, a stepwise approach is used by surgeons during TKA. When a severe varus malalignment is present, there are some concerns regarding balancing procedure, meaning that aggressive release of medial structures could lead to instability and need for a more constrained implant. In this chapter, the results of an unconventional method for balancing severe varus malalignment are shown. This method is medial epicondyle osteotomy (MEO). For this reason, a total of 135 knees with severe varus deformity were studied. In 65 cases, the MEO technique was used for balancing during TKA. The other 70 cases were balanced using additional resection of medial tibial plateau. Clinical and radiological outcomes were measured before and after surgery for both groups. Also the results were compared to a control group consisting of 50 patients with TKA for varus deformity less than 15 degrees. The amount of resected tibial bone was noted for study groups. Range of motion, the Knee Society Score (KSS), frontal laxity, and correction of femoro-tibial angle were studied. Frontal laxity decreased from 12.81° ± 3.9° to 0.37° ± 1.2° (P < 0.001). The results showed no statistically significant differences between groups regarding the KSS, range of motion, femoro-tibial angle, and frontal laxity. The amount of resected tibial bone and the mean thickness of the polyethylene insert were statistically significantly smaller in the MEO group. MEO technique could be useful when treating severe varus arthritis knee during TKA by avoiding aggressive medial release and malalignment. Also the bone stock is

Balancing Severe Varus Knee

**Keywords:** medial epicondyle osteotomy , knee varus deformity, total knee arthroplasty, prosthetic outcomes, survivorship

Total knee arthroplasty is a common surgical procedure for the end stage of knee arthritis, providing long-term pain relief and patient satisfaction. Although many studies have measured the success of knee arthroplasty in terms of survival, another important aspect of TKA is its functional outcome; that is, postoperatively, patients should be free of pain and able to perform daily activities such as standing, walking,

The varus knee is the most common deformity that requires total knee arthroplasty. Malalignment affects articular hyaline cartilage, menisci, subchondral bone, and ligaments, and contributes to progression of osteoarthritis (OA). When varus

#### **Chapter 4**

## Medial Epicondyle Osteotomy for Balancing Severe Varus Knee

*Gabriel Stan*

#### **Abstract**

Varus malalignment is the most common deformity leading to total knee arthroplasty (TKA) for knee arthritis. For correcting this deformity, a stepwise approach is used by surgeons during TKA. When a severe varus malalignment is present, there are some concerns regarding balancing procedure, meaning that aggressive release of medial structures could lead to instability and need for a more constrained implant. In this chapter, the results of an unconventional method for balancing severe varus malalignment are shown. This method is medial epicondyle osteotomy (MEO). For this reason, a total of 135 knees with severe varus deformity were studied. In 65 cases, the MEO technique was used for balancing during TKA. The other 70 cases were balanced using additional resection of medial tibial plateau. Clinical and radiological outcomes were measured before and after surgery for both groups. Also the results were compared to a control group consisting of 50 patients with TKA for varus deformity less than 15 degrees. The amount of resected tibial bone was noted for study groups. Range of motion, the Knee Society Score (KSS), frontal laxity, and correction of femoro-tibial angle were studied. Frontal laxity decreased from 12.81° ± 3.9° to 0.37° ± 1.2° (P < 0.001). The results showed no statistically significant differences between groups regarding the KSS, range of motion, femoro-tibial angle, and frontal laxity. The amount of resected tibial bone and the mean thickness of the polyethylene insert were statistically significantly smaller in the MEO group. MEO technique could be useful when treating severe varus arthritis knee during TKA by avoiding aggressive medial release and malalignment. Also the bone stock is preserved.

**Keywords:** medial epicondyle osteotomy , knee varus deformity, total knee arthroplasty, prosthetic outcomes, survivorship

#### **1. Introduction**

Total knee arthroplasty is a common surgical procedure for the end stage of knee arthritis, providing long-term pain relief and patient satisfaction. Although many studies have measured the success of knee arthroplasty in terms of survival, another important aspect of TKA is its functional outcome; that is, postoperatively, patients should be free of pain and able to perform daily activities such as standing, walking, and stair-climbing.

The varus knee is the most common deformity that requires total knee arthroplasty. Malalignment affects articular hyaline cartilage, menisci, subchondral bone, and ligaments, and contributes to progression of osteoarthritis (OA). When varus

alignment is present, the forces passing the knee are unequally distributed between condyles with an increased load passing through medial condyle due to an increase of the adduction moment during gait [1].

Anatomical changes are present in varus knee as a result of deforming forces. According to Puthumanapully, some reference axes and surface features are significantly different to normal knees [2]. For the femur, he found less femoral anteversion in varus knees. In the tibia, the tubercle (and tibial tubercle axis) was externally rotated and there was a medial tilt of the tibial plateau in the coronal plane. The coronal slope was found to be significantly more (P = 0.001) in varus knees (3.5°) when compared to normal knees (0°), indicating that the slope contributes to the varus deformity. Normal femoral version has been reported to be varied between 10° and 20° [3]. Retroversion or decreasing femoral anteversion is associated with external rotation of the knee and varus deformity contributing to the development of OA in adults [4]. Authors like Bretin and Papaioannou showed that loads shift from center to medial compartment when external femoral malrotation is present [5, 6].

OA also affects the anatomy of superficial medial collateral ligament (MCL), which is the main structure providing medial stability. These changes are secondary to fibrosis of the posteromedial complex, to impingement of marginal osteophytes, and to extrusion of the medial meniscus. According to Haidar, there is no shortening of the MCL in knee OA. There are deforming structures such as the oblique ligament with adhesion and thickening of posteromedial corner structures. Those changes are supposed to cause a posterior bowing to the superficial MCL without an actual shortening of the ligament. The scarring tissue in the posteromedial corner and the adhesion act as a soft phyte tensioning and deform the ligament and the posterior capsule [7].

Ignorance, fear of surgery, access to alternative and traditional medicine, and the high costs of treatment are among main reasons that contribute to late presentation for treatment. Factors like age of the patients, level of activity or disease progression have been discussed when deciding to choose methods of treatment in knee osteoarthritis (OA). Financial aid is a leading factor in decision-making of treating OA. Conservative treatment in knee osteoarthritis is also expensive because it fails to correct the malalignment and abnormal joint loading. The disease will progress and the TKA will be the optimal solution for treatment. Severe preoperative deformities have long been a challenge for surgeons performing total knee arthroplasty.

Limb alignment and proper soft tissue balance are the main factors that influence long-term results of TKA in terms of survivorship. What kind of alignment should be obtained, anatomical, mechanical, or kinematic, is still a matter of debate, but everyone agrees that a balanced prosthetic knee will provide better results. Most of the authors state that the mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpendicular to the mechanical axis of the tibia [8].

Technical flows are challenging for surgeons no matter the surgical strategy. A part of this issue is represented by the instruments' errors. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal respect the anatomic axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Alignment is critical to load transfer, both at the articular surface and at the implant-host interface, and hence essential for the success of total knee replacement (TKA). Most of the early failures

**45**

(Zimmer Nexgen).

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

of TKAs are related to technical flaws. Valgus or varus malpositioning of the tibial component of a total knee implant may cause increased propensity for loosening or implant wear and they may eventually lead to revision surgery [9]. Experimental and clinical data indicate that, in order to achieve optimal mid-term and long-term results of a TKR, good alignment in the frontal plane of the lower limb is mandatory. Releasing the superficial MCL can sometimes lead to a major instability of the knee and other surgical methods should be assessed for balancing the prosthetic knee in cases of severe varus deformity when aggressive MCL release is expected. A severe varus deformity (more than 15 degrees) is a challenge in terms of the type and extent of release required. More constrained types of implants may be needed

A balanced knee must be the goal of every TKA because this will increase the chances for a better survivorship [10–13]. When malalignment is present, some parts of the soft tissue around the knee are contracted and must be released, thus

When severe varus deformity is present, medial structures become fibrous. Among the methods used to correct severe varus deformity, the most common are subperiosteal release of the superficial medial collateral ligament and joint line release of the medial collateral ligament. Some other methods like medial epicondyle osteotomy (MEO) and tibial reduction osteotomy are less used due to concerns

For this study, we used the medial epicondyle osteotomy technique because we believe that this method will allow early recovery, bone stock preservation, and a good overall alignment of the limb as we will show later in this chapter. Some authors also used the MEO technique in the past, but their method involves subsequently reattaching the medial epicondyle with screws, sutures, or anchors in an optimal position for balancing the prosthetic knee, which will not allow early rehabilitation after surgery. We did not reattach this fragment and early rehabilitation program was started. The goal of our study was to underline the results of TKA after using MEO as a balancing method for severe varus deformity. The results were compared with those of TKA after using additional resection of the tibial medial plateau to correct this deformity and to those of TKA for varus deformity less than

Between April 2006 and April 2017, we performed 135 TKAs on patients with

patients with TKA for preoperative varus less than 15°. In 65 cases (40 female and 25 men), the MEO technique was used, and in 70 cases (45 female and 25 men), additional resection of the tibial medial plateau. The mean age at the time of the TKA in MEO group was 68.6; mean height, 1.72 m; and mean weight, 76 kg. In the resection group, the mean age was 65.4 years; mean height, 1.77 m; and mean weight, 76.9 kg. In the control group, there were 30 female and 20 male patients; mean age was 62.5;

Patients with preoperative valgus and secondary OA to trauma or inflammatory diseases were not included in the study. All surgeries were performed by the same main surgeon, using the medial-parapatellar and subvastus approaches. The same type of cemented postero-stabilized knee prosthesis was implanted in all cases

No full weight bearing X Ray films were available for this study, so the distal femoral cut was performed at 5° of valgus relative to the anatomical axis of the

severe preoperative varus (of more than 15°). The control group included 50

15 degrees when standard measures were used for balancing.

mean height was 1.71 m; and mean weight was 76 kg.

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

if the MCL cannot be trusted.

regarding survivorship [16].

**2. Materials and methods**

leading to correction of the deformity [14, 15].

#### *Medial Epicondyle Osteotomy for Balancing Severe Varus Knee DOI: http://dx.doi.org/10.5772/intechopen.89740*

*Knee Surgery - Reconstruction and Replacement*

of the adduction moment during gait [1].

alignment is present, the forces passing the knee are unequally distributed between condyles with an increased load passing through medial condyle due to an increase

Anatomical changes are present in varus knee as a result of deforming forces. According to Puthumanapully, some reference axes and surface features are significantly different to normal knees [2]. For the femur, he found less femoral anteversion in varus knees. In the tibia, the tubercle (and tibial tubercle axis) was externally rotated and there was a medial tilt of the tibial plateau in the coronal plane. The coronal slope was found to be significantly more (P = 0.001) in varus knees (3.5°) when compared to normal knees (0°), indicating that the slope contributes to the varus deformity. Normal femoral version has been reported to be varied between 10° and 20° [3]. Retroversion or decreasing femoral anteversion is associated with external rotation of the knee and varus deformity contributing to the development of OA in adults [4]. Authors like Bretin and Papaioannou showed that loads shift from center

to medial compartment when external femoral malrotation is present [5, 6]. OA also affects the anatomy of superficial medial collateral ligament (MCL), which is the main structure providing medial stability. These changes are secondary to fibrosis of the posteromedial complex, to impingement of marginal osteophytes, and to extrusion of the medial meniscus. According to Haidar, there is no shortening of the MCL in knee OA. There are deforming structures such as the oblique ligament with adhesion and thickening of posteromedial corner structures. Those changes are supposed to cause a posterior bowing to the superficial MCL without an actual shortening of the ligament. The scarring tissue in the posteromedial corner and the adhesion act as

a soft phyte tensioning and deform the ligament and the posterior capsule [7].

Ignorance, fear of surgery, access to alternative and traditional medicine, and the high costs of treatment are among main reasons that contribute to late presentation for treatment. Factors like age of the patients, level of activity or disease progression have been discussed when deciding to choose methods of treatment in knee osteoarthritis (OA). Financial aid is a leading factor in decision-making of treating OA. Conservative treatment in knee osteoarthritis is also expensive because it fails to correct the malalignment and abnormal joint loading. The disease will progress and the TKA will be the optimal solution for treatment. Severe preoperative deformities have long been a challenge for surgeons performing total knee

Limb alignment and proper soft tissue balance are the main factors that influence long-term results of TKA in terms of survivorship. What kind of alignment should be obtained, anatomical, mechanical, or kinematic, is still a matter of debate, but everyone agrees that a balanced prosthetic knee will provide better results. Most of the authors state that the mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpen-

Technical flows are challenging for surgeons no matter the surgical strategy. A part of this issue is represented by the instruments' errors. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal respect the anatomic axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Alignment is critical to load transfer, both at the articular surface and at the implant-host interface, and hence essential for the success of total knee replacement (TKA). Most of the early failures

**44**

arthroplasty.

dicular to the mechanical axis of the tibia [8].

of TKAs are related to technical flaws. Valgus or varus malpositioning of the tibial component of a total knee implant may cause increased propensity for loosening or implant wear and they may eventually lead to revision surgery [9]. Experimental and clinical data indicate that, in order to achieve optimal mid-term and long-term results of a TKR, good alignment in the frontal plane of the lower limb is mandatory.

Releasing the superficial MCL can sometimes lead to a major instability of the knee and other surgical methods should be assessed for balancing the prosthetic knee in cases of severe varus deformity when aggressive MCL release is expected. A severe varus deformity (more than 15 degrees) is a challenge in terms of the type and extent of release required. More constrained types of implants may be needed if the MCL cannot be trusted.

A balanced knee must be the goal of every TKA because this will increase the chances for a better survivorship [10–13]. When malalignment is present, some parts of the soft tissue around the knee are contracted and must be released, thus leading to correction of the deformity [14, 15].

When severe varus deformity is present, medial structures become fibrous. Among the methods used to correct severe varus deformity, the most common are subperiosteal release of the superficial medial collateral ligament and joint line release of the medial collateral ligament. Some other methods like medial epicondyle osteotomy (MEO) and tibial reduction osteotomy are less used due to concerns regarding survivorship [16].

For this study, we used the medial epicondyle osteotomy technique because we believe that this method will allow early recovery, bone stock preservation, and a good overall alignment of the limb as we will show later in this chapter. Some authors also used the MEO technique in the past, but their method involves subsequently reattaching the medial epicondyle with screws, sutures, or anchors in an optimal position for balancing the prosthetic knee, which will not allow early rehabilitation after surgery. We did not reattach this fragment and early rehabilitation program was started. The goal of our study was to underline the results of TKA after using MEO as a balancing method for severe varus deformity. The results were compared with those of TKA after using additional resection of the tibial medial plateau to correct this deformity and to those of TKA for varus deformity less than 15 degrees when standard measures were used for balancing.

#### **2. Materials and methods**

Between April 2006 and April 2017, we performed 135 TKAs on patients with severe preoperative varus (of more than 15°). The control group included 50 patients with TKA for preoperative varus less than 15°. In 65 cases (40 female and 25 men), the MEO technique was used, and in 70 cases (45 female and 25 men), additional resection of the tibial medial plateau. The mean age at the time of the TKA in MEO group was 68.6; mean height, 1.72 m; and mean weight, 76 kg. In the resection group, the mean age was 65.4 years; mean height, 1.77 m; and mean weight, 76.9 kg. In the control group, there were 30 female and 20 male patients; mean age was 62.5; mean height was 1.71 m; and mean weight was 76 kg.

Patients with preoperative valgus and secondary OA to trauma or inflammatory diseases were not included in the study. All surgeries were performed by the same main surgeon, using the medial-parapatellar and subvastus approaches. The same type of cemented postero-stabilized knee prosthesis was implanted in all cases (Zimmer Nexgen).

No full weight bearing X Ray films were available for this study, so the distal femoral cut was performed at 5° of valgus relative to the anatomical axis of the

femur, using an intramedullary rod. The tibial cut was perpendicular to the tibial mechanical axis, also using an intramedullary guide. A 3° femoral external rotation was set in almost every case. Rotation of the femoral component was decided using Whiteside's line, transepicondylar axis, and posterior condylar reference. A combined anterior and posterior referencing was used for sizing of femur.

All patients underwent stepwise sequential medial soft tissue release consisting of deep MCL, posteromedial release, superficial MCL, and pes anserinus. All the osteophytes were removed. Bony defects were managed with the cement or structural bone grafts and screws. No stem extenders were used. For the control group, no further measures were necessary to balance the prosthetic knee.

For both study groups, these steps were insufficient for balancing the knee and therefore further action was necessary.

In the first group, the surgeon performed a medial epicondyle osteotomy, containing the insertion of the MCL, starting with a saw-blade and finishing with an osteotome (**Figure 1**). Then, a valgus stress was applied lowering the epicondyle to its new position. The inferior margin of the epicondyle was cut with a rongeur for not interfering with the articular part of the implant during movements. No fixation method was used for the epicondyle. The flexion and extension gaps were assessed for balance.

In the second group, as the medial compartment was still tight in extension and flexion, the surgeon performed a secondary asymmetrical tibial coronal recut using the specific instrument and removed an extra 2 mm of bone from the medial tibial plateau (**Figure 2**). Thus proceeding, the extension and flexion gaps were equal and the knee was balanced.

For all cases, the patella was resurfaced and no tourniquet was used. Rehabilitation started immediately after surgery, with alternative positioning of the knee in flexion-extension. On day 1 after surgery, all patients started active motion of the operated knee with flexion-extension exercises. Full weight bearing was allowed form day 1, using no brace for protection. No passive motion device was needed. Postoperative follow-up was scheduled 6 weeks, 3 months, 6 months, and 1 year after the surgery, and once per year afterward. The mean follow-up for the study was 7 years (± 3).

**47**

P = 0.005.

cance throughout testing.

motion, femoro-tibial angle, and frontal laxity. The results are summarized in **Table 1**.

**3. Results**

**Figure 2.**

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

The main inclusion criterion for the study group was preoperative varus deformity greater than 15°. The outcomes were measured: Knee Society score (KSS), the range of the motion (ROM), clinical frontal laxity of the knee, femoro-tibial angle, the mean thickness of the polyethylene insert, the amount of resected tibial medial plateau bone, and the union state of the osteotomy site. The amount of resected tibial medial plateau bone was defined as the difference between preoperative and postoperative distance from a perpendicular to the axis of tibia through the peroneal head and a perpendicular to the same axis through the lowermost point of the tibial medial plateau in anteroposterior Rx incidence. The choice of surgical technique was random and we did not use any criteria for performing one or other in this study, but we selected the patients who had a preoperative varus deformity greater than 15°. Statistical tests were performed using SPSS software. Paired Samples Test was used to compare the results. The 0.05 level was used to denote statistical signifi-

*Additional medial tibial resection (note the varus malposition of tibial component).*

There were no statistically significant differences regarding personal characteristics (age, sex, height, and weight) between the two groups and the control group. No differences were noted regarding postoperative outcomes of KSS, range of

We observed a significant statistical difference regarding positioning of tibial component between groups. The mean angle between tibial component and tibial mechanical axis was 1° ± 3.5°of varus for the MEO group, and 4° ± 2.5° of varus for the resection group (P < 0.001). In the control group, the angle was 0.7° ± 2.3°. The mean thickness of the polyethylene insert was 12.5 ± 1.24 mm in the MEO

group and 13.61 ± 1.59 mm in the second group, with statistically significant

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

**Figure 1.** *Medial epicondyle osteotomy with TKA.*

*Knee Surgery - Reconstruction and Replacement*

therefore further action was necessary.

the knee was balanced.

study was 7 years (± 3).

femur, using an intramedullary rod. The tibial cut was perpendicular to the tibial mechanical axis, also using an intramedullary guide. A 3° femoral external rotation was set in almost every case. Rotation of the femoral component was decided using Whiteside's line, transepicondylar axis, and posterior condylar reference. A com-

All patients underwent stepwise sequential medial soft tissue release consisting of deep MCL, posteromedial release, superficial MCL, and pes anserinus. All the osteophytes were removed. Bony defects were managed with the cement or structural bone grafts and screws. No stem extenders were used. For the control group,

For both study groups, these steps were insufficient for balancing the knee and

In the first group, the surgeon performed a medial epicondyle osteotomy, containing the insertion of the MCL, starting with a saw-blade and finishing with an osteotome (**Figure 1**). Then, a valgus stress was applied lowering the epicondyle to its new position. The inferior margin of the epicondyle was cut with a rongeur for not interfering with the articular part of the implant during movements. No fixation method was used for the epicondyle. The flexion and extension gaps were assessed for balance. In the second group, as the medial compartment was still tight in extension and flexion, the surgeon performed a secondary asymmetrical tibial coronal recut using the specific instrument and removed an extra 2 mm of bone from the medial tibial plateau (**Figure 2**). Thus proceeding, the extension and flexion gaps were equal and

For all cases, the patella was resurfaced and no tourniquet was used.

Rehabilitation started immediately after surgery, with alternative positioning of the knee in flexion-extension. On day 1 after surgery, all patients started active motion of the operated knee with flexion-extension exercises. Full weight bearing was allowed form day 1, using no brace for protection. No passive motion device was needed. Postoperative follow-up was scheduled 6 weeks, 3 months, 6 months, and 1 year after the surgery, and once per year afterward. The mean follow-up for the

bined anterior and posterior referencing was used for sizing of femur.

no further measures were necessary to balance the prosthetic knee.

**46**

**Figure 1.**

*Medial epicondyle osteotomy with TKA.*

**Figure 2.** *Additional medial tibial resection (note the varus malposition of tibial component).*

The main inclusion criterion for the study group was preoperative varus deformity greater than 15°. The outcomes were measured: Knee Society score (KSS), the range of the motion (ROM), clinical frontal laxity of the knee, femoro-tibial angle, the mean thickness of the polyethylene insert, the amount of resected tibial medial plateau bone, and the union state of the osteotomy site. The amount of resected tibial medial plateau bone was defined as the difference between preoperative and postoperative distance from a perpendicular to the axis of tibia through the peroneal head and a perpendicular to the same axis through the lowermost point of the tibial medial plateau in anteroposterior Rx incidence. The choice of surgical technique was random and we did not use any criteria for performing one or other in this study, but we selected the patients who had a preoperative varus deformity greater than 15°.

Statistical tests were performed using SPSS software. Paired Samples Test was used to compare the results. The 0.05 level was used to denote statistical significance throughout testing.

#### **3. Results**

There were no statistically significant differences regarding personal characteristics (age, sex, height, and weight) between the two groups and the control group. No differences were noted regarding postoperative outcomes of KSS, range of motion, femoro-tibial angle, and frontal laxity.

The results are summarized in **Table 1**.

We observed a significant statistical difference regarding positioning of tibial component between groups. The mean angle between tibial component and tibial mechanical axis was 1° ± 3.5°of varus for the MEO group, and 4° ± 2.5° of varus for the resection group (P < 0.001). In the control group, the angle was 0.7° ± 2.3°.

The mean thickness of the polyethylene insert was 12.5 ± 1.24 mm in the MEO group and 13.61 ± 1.59 mm in the second group, with statistically significant P = 0.005.

#### **Table 1.**

*Results after TKA for the study groups.*

**Figure 3.** *Medial epicondyle osteotomy Rx (3 months and 5 years follow up).*

#### **Figure 4.**

*The amount of tibial medial plateau resected bone- MEO.*

For all knees with medial epicondyle osteotomy, a fibrous union occurred at the site of osteotomy (**Figure 3**). In this group, the amount of resected tibial medial plateau bone (**Figures 4** and **5**) was statistically significantly smaller than in the other group (1.33 ± 0.46 mm in the MEO group and 3.73 ± 2.5 mm in the other group; P < 0,001).

**49**

follow-up.

**Figure 5.**

**4. Discussion**

this problem.

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

that bone and soft tissue are affected by the disease.

Residual frontal laxity was present in four cases, two in the MEO group and two in the second one. No revision surgery was necessary for any of the cases at the last

*The amount of tibial medial plateau resected bone (an additional resection of tibial medial plateau case).*

The varus knee is the most common deformity that requires total knee arthroplasty. Severe varus deformity grossly affects normal anatomy of the knee, meaning

For better survivorship of a knee implant, it is mandatory to achieve a proper alignment and a perfect balance of total knee prosthesis. It is a great challenge for surgeons to balance a severe varus knee due to changes in the anatomy of medial compartment. Fibrosis of the posteromedial complex, marginal osteophytes, extrusion of the medial meniscus, adhesion and thickening of the oblique ligament with all the posterior medial complex, and posterior bowing to the superficial MCL are problems that must be corrected during surgery. MCL release is very important in balancing the fixed varus deformity. The surgeon must progressively release the medial soft tissue until it reaches the length of lateral structures. The endpoint of the release is when the knee is stable and the alignment is optimal. In severe varus deformity, the separation of the periosteal layer from the tibia is distal to the MCL attachment. For this reason, some authors raised concerns about the integrity of the MCL after aggressive release. Releasing the superficial MCL can sometimes lead to a major instability of the knee, requiring a more constrained implant [7]. Our method of medial epicondyle osteotomy for severe varus deformity could prevent

There are few literature reports that describe MEO as a method of balancing the prosthetic knee. Engh has described his results after medial epicondyle osteotomy during TKA. He performed this procedure on 80 patients [16]. The clinical results showed the KSS improvement from 42 to 93 points after surgery and the range of motion increase from 101 to 111 degrees. He has found no instability in his patients group during the follow-up period. Regarding frontal laxity, the mean varus-valgus stability measured 14.2 points (Knee Society scale, 0–15 points). Improvement of function and patient satisfaction was found in 95% of the cases. In every case of his study, the osteotomized epicondyle was fixed during surgery at the optimal position for balance. Despite this, bone union occurred only in 54% of the knees and

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee DOI: http://dx.doi.org/10.5772/intechopen.89740*

#### **Figure 5.**

*Knee Surgery - Reconstruction and Replacement*

**Group KSS ROM F-T angle Frontal laxity** MEO Preop. 18.15 ± 15.6 72.3° ± 23.5° 25.3° ± 5.51° varus 12.43° ± 3.5°

Resection Preop. 21.44 ± 13.6 86.8° ± 15.5° 24.7° ± 5.1° varus 12.81° ± 3.9°

Control Preop. 25.15 ± 12.1 76.4° ± 24.3° 15.6° ± 7.41° varus 8.81° ± 2.8°

Postop. 94.1 ± 5.6 112.3° ± 10.8° 4.0° ± 1.18° valgus 0.32° ± 1.3°

Postop. 91.7 ± 7.6 115.4° ± 8.4° 4.1° ± 0.97° valgus 0.37° ± 1.2°

Postop. 96.3 ± 5.6 118.3° ± 9.7° 2.0° ± 1.2° valgus 1.34° ± 1.2°

*Medial epicondyle osteotomy Rx (3 months and 5 years follow up).*

*The amount of tibial medial plateau resected bone- MEO.*

For all knees with medial epicondyle osteotomy, a fibrous union occurred at the site of osteotomy (**Figure 3**). In this group, the amount of resected tibial medial plateau bone (**Figures 4** and **5**) was statistically significantly smaller than in the other group (1.33 ± 0.46 mm in the MEO group and 3.73 ± 2.5 mm in the other group; P < 0,001).

**48**

**Figure 4.**

**Figure 3.**

**Table 1.**

*Results after TKA for the study groups.*

*The amount of tibial medial plateau resected bone (an additional resection of tibial medial plateau case).*

Residual frontal laxity was present in four cases, two in the MEO group and two in the second one. No revision surgery was necessary for any of the cases at the last follow-up.

#### **4. Discussion**

The varus knee is the most common deformity that requires total knee arthroplasty. Severe varus deformity grossly affects normal anatomy of the knee, meaning that bone and soft tissue are affected by the disease.

For better survivorship of a knee implant, it is mandatory to achieve a proper alignment and a perfect balance of total knee prosthesis. It is a great challenge for surgeons to balance a severe varus knee due to changes in the anatomy of medial compartment. Fibrosis of the posteromedial complex, marginal osteophytes, extrusion of the medial meniscus, adhesion and thickening of the oblique ligament with all the posterior medial complex, and posterior bowing to the superficial MCL are problems that must be corrected during surgery. MCL release is very important in balancing the fixed varus deformity. The surgeon must progressively release the medial soft tissue until it reaches the length of lateral structures. The endpoint of the release is when the knee is stable and the alignment is optimal. In severe varus deformity, the separation of the periosteal layer from the tibia is distal to the MCL attachment. For this reason, some authors raised concerns about the integrity of the MCL after aggressive release. Releasing the superficial MCL can sometimes lead to a major instability of the knee, requiring a more constrained implant [7]. Our method of medial epicondyle osteotomy for severe varus deformity could prevent this problem.

There are few literature reports that describe MEO as a method of balancing the prosthetic knee. Engh has described his results after medial epicondyle osteotomy during TKA. He performed this procedure on 80 patients [16]. The clinical results showed the KSS improvement from 42 to 93 points after surgery and the range of motion increase from 101 to 111 degrees. He has found no instability in his patients group during the follow-up period. Regarding frontal laxity, the mean varus-valgus stability measured 14.2 points (Knee Society scale, 0–15 points). Improvement of function and patient satisfaction was found in 95% of the cases. In every case of his study, the osteotomized epicondyle was fixed during surgery at the optimal position for balance. Despite this, bone union occurred only in 54% of the knees and

fibrous union occurred in 46%. No symptoms like tenderness, restricted motion, or other were associated with fibrous union. Other authors like Sim and Kwak reported their results after using medial epicondylar osteotomy for treating varus deformity in 32 cases [17]. Clinical and radiological outcomes, including the Knee Society score (KSS), the function score (FS), the range of the motion (ROM), the union state of the osteotomy site, were measured. They found an improvement of KSS after surgery from 46.5 ± 7.6 to 89.1 ± 5.9 points (P < 0.001). The FS increased from 39.5 ± 9.2 to 84.2 ± 8.5 points (P < 0.001). Also the range of motion was better after the surgery (101.5° ± 28.2° to 116.0° ± 10.8°; P = 0.006). A significant number of patients presented fibrous union on the osteotomy site despite the fixation of the condyle during procedure (10 patients). Bone union occurred only in 22 knees. There was no significant difference regarding clinical outcomes between the bone union group and the fibrous union group (P = 0.175). The femoro-tibial angle was corrected from an 8.2° ± 5.0°-varus to a 5.6° ± 1.5°-valgus (P < 0.001). Despite the fact that in both studies the epicondyle was fixed with sutures or screws, a major part of the patients presented fibrous union of the epicondyle. The authors concluded that there was no significant difference between the bone union group and the fibrous union group. We do not consider that any reattachment of the epicondyle is necessary, and in consequence, we did not perform fixation in any of the cases. Also no splinting after the surgery was used and the rehab program was started immediately, avoiding knee stiffness and accelerating recovery.

Nobody could tell for sure the ideal positioning of the knee prosthetic components. The disagreement among surgeons is amplified by the significant number of unsatisfied patients with TKA.

Most of the authors state that mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpendicular to the mechanical axis of the tibia. If mechanical alignment is achieved, it means that mechanical axis of the leg passes through the center of the knee and the loads are equally distributed between medial and lateral compartments. The native knee interline is inclined about 3 degrees in varus, meaning that the mechanical alignment will change it to 0 degrees, changing the normal anatomy of the knee. The proximal tibial joint line is therefore converted from 87 degrees (3 degrees of varus) to 90 degrees and the distal femoral line from 87 degrees (3 degrees of valgus) to 90 degrees.

For these considerations, some authors proposed the so-called "anatomic alignment" when the tibial component was placed at 3 degrees of varus and the femoral component at 3 degrees of valgus, and overall alignment to be neutral [18]. There is an important variability in natural alignment among population. A significant part of neutral alignment is not normal, leading to distalization of the joint line on the lateral compartment, which can cause anterior knee pain. The concept of restoring constitutional alignment rather than mechanical has gained more interest recently. For the supplementary tibial resection group in our study, we have created the situation of placing the tibial component in varus. In case of a medio-lateral tibial plateau length of 8 cm, an additional resection of 2 mm from medial side lead to a maximum 3 degrees of varus positioning of tibial implant. Attention should be paid in cases where this additional cut adds to a previous unknown error of first cuts due to the instrument's or surgeon's mistake, and this could lead to a supplemental varus, and potential danger in terms of survivorship.

Other authors showed that a femoral component placed in 7° valgus, with tibial plateau placed at 90° to the long axis of the tibia, provides equal force distribution between the medial and lateral plateaus and consecutively best chances for

**51**

thetic knee.

**5. Conclusion**

any of the cases.

better for revision surgery.

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

survivorship [19]. According to Howell, kinematically aligning the knee means coaligning the transverse axis of the femoral component with the primary transverse axis in the femur about which the tibia flexes and extends and placing the tibial component so that the longitudinal axis of the tibia is perpendicular to the transverse axis in the femur, about which the tibia flexes and extends [20]. This means that the femoral cut is plus 1°–2° in valgus and tibial cut, plus 1°–2° in varus compared with the mechanically aligned total knee arthroplasty [21]. The authors who propose this approach state that restoring mechanical alignment is unnatural in patients with constitutional varus and valgus alignment and could cause higher strain in collateral ligaments [22]. They say that by restoring the native alignment, patients will have better clinical and functional outcome scores as compared with patients in whom the limb alignment is corrected to neutral [23]. The present general consensus is that overall mechanical femoro-tibial alignment should be 0 ± 3 degrees, thus providing the best survivorship chances for the knee implant [24]. No matter of the technique used for TKA, the next important problem for surgeons are technical flows. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal to be in line with anatomical axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Regarding tibial component alignment, we observed a significant difference between groups. For the MEO group, the alignment was neutral (1°± 3.5°) and in the resection group, the alignment was mainly in varus (4° ± 2.5°). In 90% of MEO group cases, the tibial component is placed in line with mechanical axis. Only 5% of the knees from the second group present 90° tibial component placement. The vast majority of them are outliers due to additional asymmetric tibial varus cut. The MEO is a method that increases chances for a mechanical alignment of the pros-

Based on our results, we suggest that the outcomes of TKA with MEO are similar to those with additional resection of the tibial medial plateau and to those from the control group. No revision surgery was needed at the last follow-up in

Some advantages of medial epicondyle osteotomy have resulted from this study. First of all, it avoids excessive weakening of the medial collateral ligament in cases of severe contracture of medial structures by lowering the epicondyle instead of aggressive releasing of the ligament. This will prevent also the need for a more constrained implant. The exposure during surgery is much easier and avoids complications like extensor mechanism disruption. It is a technique that provides optimal conditions for obtaining neutral overall alignment of the limb, minimizing the risk of malpositioning the tibial component, which is higher in cases of additional tibial resection. The tibial bone loss is less than that in additional resection group which is

This study highlights early and mid-term results of TKA with medial epicondyle osteotomy. Further analyses are necessary to assess the long-term results of this technique, especially in terms of survivorship. So far, there are no differences between groups regarding patient satisfaction, range of motion, or survivorship.

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

*Knee Surgery - Reconstruction and Replacement*

unsatisfied patients with TKA.

valgus) to 90 degrees.

varus, and potential danger in terms of survivorship.

fibrous union occurred in 46%. No symptoms like tenderness, restricted motion, or other were associated with fibrous union. Other authors like Sim and Kwak reported their results after using medial epicondylar osteotomy for treating varus deformity in 32 cases [17]. Clinical and radiological outcomes, including the Knee Society score (KSS), the function score (FS), the range of the motion (ROM), the union state of the osteotomy site, were measured. They found an improvement of KSS after surgery from 46.5 ± 7.6 to 89.1 ± 5.9 points (P < 0.001). The FS increased from 39.5 ± 9.2 to 84.2 ± 8.5 points (P < 0.001). Also the range of motion was better after the surgery (101.5° ± 28.2° to 116.0° ± 10.8°; P = 0.006). A significant number of patients presented fibrous union on the osteotomy site despite the fixation of the condyle during procedure (10 patients). Bone union occurred only in 22 knees. There was no significant difference regarding clinical outcomes between the bone union group and the fibrous union group (P = 0.175). The femoro-tibial angle was corrected from an 8.2° ± 5.0°-varus to a 5.6° ± 1.5°-valgus (P < 0.001). Despite the fact that in both studies the epicondyle was fixed with sutures or screws, a major part of the patients presented fibrous union of the epicondyle. The authors concluded that there was no significant difference between the bone union group and the fibrous union group. We do not consider that any reattachment of the epicondyle is necessary, and in consequence, we did not perform fixation in any of the cases. Also no splinting after the surgery was used and the rehab program was

started immediately, avoiding knee stiffness and accelerating recovery.

Nobody could tell for sure the ideal positioning of the knee prosthetic components. The disagreement among surgeons is amplified by the significant number of

Most of the authors state that mechanical alignment provides the best chances in terms of survivorship of TKA. Mechanical alignment means that femoral cut is perpendicular to the mechanical axis of the femur and tibial cut is perpendicular to the mechanical axis of the tibia. If mechanical alignment is achieved, it means that mechanical axis of the leg passes through the center of the knee and the loads are equally distributed between medial and lateral compartments. The native knee interline is inclined about 3 degrees in varus, meaning that the mechanical alignment will change it to 0 degrees, changing the normal anatomy of the knee. The proximal tibial joint line is therefore converted from 87 degrees (3 degrees of varus) to 90 degrees and the distal femoral line from 87 degrees (3 degrees of

For these considerations, some authors proposed the so-called "anatomic alignment" when the tibial component was placed at 3 degrees of varus and the femoral component at 3 degrees of valgus, and overall alignment to be neutral [18]. There is an important variability in natural alignment among population. A significant part of neutral alignment is not normal, leading to distalization of the joint line on the lateral compartment, which can cause anterior knee pain. The concept of restoring constitutional alignment rather than mechanical has gained more interest recently. For the supplementary tibial resection group in our study, we have created the situation of placing the tibial component in varus. In case of a medio-lateral tibial plateau length of 8 cm, an additional resection of 2 mm from medial side lead to a maximum 3 degrees of varus positioning of tibial implant. Attention should be paid in cases where this additional cut adds to a previous unknown error of first cuts due to the instrument's or surgeon's mistake, and this could lead to a supplemental

Other authors showed that a femoral component placed in 7° valgus, with tibial

plateau placed at 90° to the long axis of the tibia, provides equal force distribution between the medial and lateral plateaus and consecutively best chances for

**50**

survivorship [19]. According to Howell, kinematically aligning the knee means coaligning the transverse axis of the femoral component with the primary transverse axis in the femur about which the tibia flexes and extends and placing the tibial component so that the longitudinal axis of the tibia is perpendicular to the transverse axis in the femur, about which the tibia flexes and extends [20]. This means that the femoral cut is plus 1°–2° in valgus and tibial cut, plus 1°–2° in varus compared with the mechanically aligned total knee arthroplasty [21]. The authors who propose this approach state that restoring mechanical alignment is unnatural in patients with constitutional varus and valgus alignment and could cause higher strain in collateral ligaments [22]. They say that by restoring the native alignment, patients will have better clinical and functional outcome scores as compared with patients in whom the limb alignment is corrected to neutral [23]. The present general consensus is that overall mechanical femoro-tibial alignment should be 0 ± 3 degrees, thus providing the best survivorship chances for the knee implant [24]. No matter of the technique used for TKA, the next important problem for surgeons are technical flows. The accuracy of obtaining the desired angle of femoral distal cut is dependent on the ability to actually engage the intramedullary rod in the medullary canal to be in line with anatomical axis of the femor. This maneuver is influenced by the rod length and diameter and the intramedullary diameter of the femoral canal. The location of the entry hole also could have an impact upon alignment. Do to this, the surgeon must be aware that even if he/she is aiming for a mechanical alignment, for example, the instruments and placement of the entry holes could lead to errors. Regarding tibial component alignment, we observed a significant difference between groups. For the MEO group, the alignment was neutral (1°± 3.5°) and in the resection group, the alignment was mainly in varus (4° ± 2.5°). In 90% of MEO group cases, the tibial component is placed in line with mechanical axis. Only 5% of the knees from the second group present 90° tibial component placement. The vast majority of them are outliers due to additional asymmetric tibial varus cut. The MEO is a method that increases chances for a mechanical alignment of the prosthetic knee.

#### **5. Conclusion**

Based on our results, we suggest that the outcomes of TKA with MEO are similar to those with additional resection of the tibial medial plateau and to those from the control group. No revision surgery was needed at the last follow-up in any of the cases.

Some advantages of medial epicondyle osteotomy have resulted from this study. First of all, it avoids excessive weakening of the medial collateral ligament in cases of severe contracture of medial structures by lowering the epicondyle instead of aggressive releasing of the ligament. This will prevent also the need for a more constrained implant. The exposure during surgery is much easier and avoids complications like extensor mechanism disruption. It is a technique that provides optimal conditions for obtaining neutral overall alignment of the limb, minimizing the risk of malpositioning the tibial component, which is higher in cases of additional tibial resection. The tibial bone loss is less than that in additional resection group which is better for revision surgery.

This study highlights early and mid-term results of TKA with medial epicondyle osteotomy. Further analyses are necessary to assess the long-term results of this technique, especially in terms of survivorship. So far, there are no differences between groups regarding patient satisfaction, range of motion, or survivorship.

*Knee Surgery - Reconstruction and Replacement*

#### **Author details**

Gabriel Stan Carol Davila Faculty of Medicine, Elias University Hospital, Bucharest, Romania

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**53**

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee*

Clinical Orthopaedics and Related

[9] Werner F, Ayers D, Maletsky L. The effect of valgus/varus malalignment on load distribution in total knee replacements. Journal of Biomechanics.

[10] W-Dahl A, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthopaedica.

Research. 1985;**192**:13

2005;**38**:349-355

2010;**81**(2):161-164

2006;**30**(5):403-408

[11] Papachristou G, Plessas S, Sourlas J. Deterioration of longterm

osteotomy in patients under 60 years of age. International Orthopaedics.

postoperative collateral ligament laxity in total knee arthroplasty. Clinical Orthopaedics. 1998;**236**:44

[13] Hunt MA, Birmingham TB, Bryant D, et al. Lateral trunk lean explains variation in dynamic knee joint load in patients with medial compartment knee osteoarthritis. Osteoarthritis and Cartilage. 2008;**16**:591-599

[14] Mundermann A, Dyrby CO, Hurwitz DE. Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: Reduced walking speed. Arthritis and Rheumatism.

[15] Birmingham TB, Hunt MA, Jones IC. Test–retest reliability of the peak knee adduction moment during walking in patients with medial compartment knee osteoarthritis. Arthritis and Rheumatism.

[16] Engh GA. Medial epicondylar osteotomy: A technique used with

2004;**50**:1172-1178

2007;**57**:1012-1017

results following high tibial

[12] Edwards E. The eVect of

*DOI: http://dx.doi.org/10.5772/intechopen.89740*

[1] Amis AA. Biomechanics of high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**:197-205. DOI: 10.1007/

[2] Puthumanapully PK, Harris SJ, Leong A, Cobb JP, Amis AA, Jeffers J. A morphometric study of normal and varus knees. Knee Surgery, Sports Traumatology, Arthroscopy.

2014;**22**(12):2891-2899. DOI: 10.1007/

[4] Tönnis D, Heinecke A. Diminished femoral antetorsion syndrome: A cause of pain and osteoarthritis. Journal of Pediatric Orthopedics.

10.1097/01241398-199107000-00001

[5] Bretin P, O'Loughlin PF, Suero EM, Kendoff D, Ostermeier S, Hüfner T, et al. Influence of femoral malrotation on knee joint alignment and intraarticular contract pressures. Archives of Orthopaedic and Trauma Surgery. 2011;**131**:1115-1120. DOI: 10.1007/

[6] Papaioannou T, Digas G, Bikos C, Karamoulas V, Magnissalis E. Femoral neck version affects medial femorotibial loading. ISRN Orthopedics. 2013;**2013**:

[7] Haidar F, Tarabichi S, Osman A,

of varus knee on MRIcan lead to a better algorithm to balance the knee. Orthopaedic Proceedings.

[8] Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty.

Understanding the pathological changes

1-6. DOI: 10.1155/2013/328246

Elkabbani M, Mohamed T.

2019;**101-B**(SUPP\_4):85

[3] Cibulka MT. Determination and significance of femoral neck anteversion. Physical Therapy.

**References**

s00167-012-2122-3

s00167-014-3337-2

2004;**84**:550-558

1991;**11**:419-431. DOI:

s00402-010-1210-4

*Medial Epicondyle Osteotomy for Balancing Severe Varus Knee DOI: http://dx.doi.org/10.5772/intechopen.89740*

#### **References**

*Knee Surgery - Reconstruction and Replacement*

**52**

**Author details**

Carol Davila Faculty of Medicine, Elias University Hospital, Bucharest, Romania

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to<EMAIL_ADDRESS>
provided the original work is properly cited.

Gabriel Stan

[1] Amis AA. Biomechanics of high tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**:197-205. DOI: 10.1007/ s00167-012-2122-3

[2] Puthumanapully PK, Harris SJ, Leong A, Cobb JP, Amis AA, Jeffers J. A morphometric study of normal and varus knees. Knee Surgery, Sports Traumatology, Arthroscopy. 2014;**22**(12):2891-2899. DOI: 10.1007/ s00167-014-3337-2

[3] Cibulka MT. Determination and significance of femoral neck anteversion. Physical Therapy. 2004;**84**:550-558

[4] Tönnis D, Heinecke A. Diminished femoral antetorsion syndrome: A cause of pain and osteoarthritis. Journal of Pediatric Orthopedics. 1991;**11**:419-431. DOI: 10.1097/01241398-199107000-00001

[5] Bretin P, O'Loughlin PF, Suero EM, Kendoff D, Ostermeier S, Hüfner T, et al. Influence of femoral malrotation on knee joint alignment and intraarticular contract pressures. Archives of Orthopaedic and Trauma Surgery. 2011;**131**:1115-1120. DOI: 10.1007/ s00402-010-1210-4

[6] Papaioannou T, Digas G, Bikos C, Karamoulas V, Magnissalis E. Femoral neck version affects medial femorotibial loading. ISRN Orthopedics. 2013;**2013**: 1-6. DOI: 10.1155/2013/328246

[7] Haidar F, Tarabichi S, Osman A, Elkabbani M, Mohamed T. Understanding the pathological changes of varus knee on MRIcan lead to a better algorithm to balance the knee. Orthopaedic Proceedings. 2019;**101-B**(SUPP\_4):85

[8] Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clinical Orthopaedics and Related Research. 1985;**192**:13

[9] Werner F, Ayers D, Maletsky L. The effect of valgus/varus malalignment on load distribution in total knee replacements. Journal of Biomechanics. 2005;**38**:349-355

[10] W-Dahl A, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthopaedica. 2010;**81**(2):161-164

[11] Papachristou G, Plessas S, Sourlas J. Deterioration of longterm results following high tibial osteotomy in patients under 60 years of age. International Orthopaedics. 2006;**30**(5):403-408

[12] Edwards E. The eVect of postoperative collateral ligament laxity in total knee arthroplasty. Clinical Orthopaedics. 1998;**236**:44

[13] Hunt MA, Birmingham TB, Bryant D, et al. Lateral trunk lean explains variation in dynamic knee joint load in patients with medial compartment knee osteoarthritis. Osteoarthritis and Cartilage. 2008;**16**:591-599

[14] Mundermann A, Dyrby CO, Hurwitz DE. Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: Reduced walking speed. Arthritis and Rheumatism. 2004;**50**:1172-1178

[15] Birmingham TB, Hunt MA, Jones IC. Test–retest reliability of the peak knee adduction moment during walking in patients with medial compartment knee osteoarthritis. Arthritis and Rheumatism. 2007;**57**:1012-1017

[16] Engh GA. Medial epicondylar osteotomy: A technique used with primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity. Instructional Course Lectures. 1999;**48**:153-156

[17] Sim JA, Kwak JH. Short-term follow-up results of medial epicondylar osteotomy for the varus knee in TKA. Journal of Korean Knee Society. 2009;**21**:194-204

[18] Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clinical Orthopaedics and Related Research. 1985;**192**:23

[19] Hsu RW, Himeno S, Coventry MB. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clinical Orthopaedics. 1990;**255**:215-227

[20] Howell SM, Roth JD, Hull ML. Kinematic alignment in total knee arthroplasty. Definition, history, principle, surgical technique, and results of an alignment option for TKA. Art. 2014;**1**:44-53

[21] Scott W. Kinematic alignment in total knee arthroplasty. In: Insall & Scott Surgery of the Knee. 5th ed. Vol. 121. Churchill Livingstone; 2012. pp. 1255-1268

[22] Gu Y, Roth JD, Howell SM, Hull ML. How frequently do four methods for mechanically aligning a total knee arthroplasty cause collateral ligament imbalance and change alignment from normal in white patients? Journal of Bone and Joint Surgery. 2014;**96**(12):e101

[23] Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;**21**(10):2325-2330

[24] HD1 C, Math KR, Scuderi GR. Polyethylene post failure in posterior stabilized total knee arthroplasty. The Journal of Arthroplasty. 2004;**19**(5):652-657

**55**

**Chapter 5**

Arthroplasty

*and Orkun Gül*

knee replacement surgery.

Some of these are listed below:

• Medical error.

• Nurse error.

• Trauma.

• Error in surgical technique.

• Patient non-compliance.

• Associated comorbid diseases.

**1. Introduction**

**Abstract**

Complications after Total Knee

*Muhammet Salih AYAS, Muhammet Kalkışım, Ahmet Köse*

Nowadays, the incidence of knee arthritis increases with the prolongation of human life and the increase in world population. As a result, total knee arthroplasty application rates increased and surgeons gained more experience. There have also been technical advances and total knee arthroplasty operations have been performed using better implants. However, despite these developments, the number and variety of complications are increasing. In addition to performing total knee arthroplasty correctly, it is now becoming more important to recognize complications that may or may develop. Variety of complications after total knee replacement; from minor skin problems to life-threatening complications. In this review article, we aimed to investigate early and late complications during and after total

Total knee arthroplasty is an effective treatment option which has been applied with increasing rates in recent years with its highly satisfactory results. Recently increased total knee arthroplasty (TKA) procedures increase the number of complications too. In addition to proper patient selection, an accurate surgical technique, early diagnosis, and proper management of complications are required. Complications of TKA have a wide range. Complications vary from small skin problems to mortality. The development of complications may be due to many factors.

**Keywords:** knee, total knee arthroplasty, survival, complications

### **Chapter 5**

*Knee Surgery - Reconstruction and Replacement*

[24] HD1 C, Math KR, Scuderi GR. Polyethylene post failure in posterior stabilized total knee arthroplasty. The Journal of Arthroplasty.

2004;**19**(5):652-657

primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity.

Instructional Course Lectures.

[17] Sim JA, Kwak JH. Short-term follow-up results of medial epicondylar

osteotomy for the varus knee in TKA. Journal of Korean Knee Society.

[18] Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clinical Orthopaedics and Related Research.

[19] Hsu RW, Himeno S, Coventry MB. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clinical Orthopaedics.

[20] Howell SM, Roth JD, Hull ML. Kinematic alignment in total knee arthroplasty. Definition, history, principle, surgical technique, and results of an alignment option for

[21] Scott W. Kinematic alignment in total knee arthroplasty. In: Insall & Scott Surgery of the Knee. 5th ed. Vol. 121. Churchill Livingstone; 2012.

[22] Gu Y, Roth JD, Howell SM, Hull ML. How frequently do four methods for mechanically aligning a total knee arthroplasty cause collateral ligament imbalance and change alignment from normal in white patients? Journal of Bone and Joint

Surgery. 2014;**96**(12):e101

2013;**21**(10):2325-2330

[23] Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surgery, Sports Traumatology, Arthroscopy.

1999;**48**:153-156

2009;**21**:194-204

1985;**192**:23

1990;**255**:215-227

TKA. Art. 2014;**1**:44-53

pp. 1255-1268

**54**

## Complications after Total Knee Arthroplasty

*Muhammet Salih AYAS, Muhammet Kalkışım, Ahmet Köse and Orkun Gül*

#### **Abstract**

Nowadays, the incidence of knee arthritis increases with the prolongation of human life and the increase in world population. As a result, total knee arthroplasty application rates increased and surgeons gained more experience. There have also been technical advances and total knee arthroplasty operations have been performed using better implants. However, despite these developments, the number and variety of complications are increasing. In addition to performing total knee arthroplasty correctly, it is now becoming more important to recognize complications that may or may develop. Variety of complications after total knee replacement; from minor skin problems to life-threatening complications. In this review article, we aimed to investigate early and late complications during and after total knee replacement surgery.

**Keywords:** knee, total knee arthroplasty, survival, complications

#### **1. Introduction**

Total knee arthroplasty is an effective treatment option which has been applied with increasing rates in recent years with its highly satisfactory results. Recently increased total knee arthroplasty (TKA) procedures increase the number of complications too. In addition to proper patient selection, an accurate surgical technique, early diagnosis, and proper management of complications are required. Complications of TKA have a wide range. Complications vary from small skin problems to mortality. The development of complications may be due to many factors. Some of these are listed below:

Reviewing all the risk factors before surgery and being prepared for the complications that may occur may be lifesaving in TKA, which is currently applied frequently. It is important to recognize, identify, and classify the complications in a timely manner in the correct and effective management of complications. The ambiguity about the complications of TKA in the literature helped identify and classify the complications in a study conducted in 2013 by the knee community [1]. According to this study, 22 complications were described. These are [1]:

When the complications are examined, it is seen that some of them are simple and easy to overcome with a short-term solution, while some of them can be serious and can go to revision arthroplasty. The number of complications such as implant

**57**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

Extensor mechanism injury Patellar tendon injury Quadriceps tendon injury Patella fractures

tions (**Table 1).**

**Table 1.**

**2.1 Vascular injuries**

**2. Intraoperative complications**

fracture and polyethylene surface wear has been reduced due to the techniques and innovations in implant materials and designs. In a study, it was shown that the most common cause of revisions in the first 5 years postop was infection, and the reasons for revision in the next 5 years were polyethylene loosening [2]. Complications will be classified as intraoperative, early postoperative, and late postoperative complica-

Medial collateral ligament injury Patellofemoral joint problems

Deep skin problems Periprosthetic joint infection Deep vein thrombosis Periprosthetic fractures Pulmonary embolism Aseptic loosening

Osteolysis

**Intraoperative Early postoperative Late postoperative**

Vascular injuries Bleeding Instability Neurological complications Superficial skin problems Joint stiffness

Although arterial injury during knee replacement is rare, it may have serious results from limb loss to mortality. Arterial injuries can be seen as thromboembolism, direct vascular laceration, pseudoaneurysm, and arteriovenous fistula [3]. The

Vascular injuries may develop due to the thermal effect of cement polymerization, joint manipulations, dislocations, and excessive manipulation [5]. Considering the issue as specific to the total knee arthroplasty, care should be taken against vascular injury during posterior cruciate ligament and posterior capsular release during femoral condylar cutting. Atypical localization of vascular structures due to changes in adhesions and normal anatomy in revision cases increases the risk of vascular injury twice as compared to primary cases [6]. Nowadays, increasing procedures of TKA bring about the possibility of vascular injuries although they are rare. Therefore, it is necessary to take precautions against vascular injuries that may develop, to identify risky patients and to make an early diagnosis. For this, a good anamnesis and physical examination are essential. It is important to examine the presence of hypertension, diabetes, smoking, and vascular claudication. Coldness of the extremities to be operated during physical examination, skin atrophy and thinning, prominent vascular structures, ulcerative wound, and distal arterial pulse weakness are the findings that need attention. In addition to these findings, the presence of vascular calcifications in radiological scanning, a history of bypass, and an ankle-brachial index below 0.9 are other findings that should be considered. No tourniquet should be used in patients with the abovementioned conditions [7]. Embolism and arterial insufficiency may develop due to tourniquet effect in patients with vascular disease and atheroma plaque in the superficial artery [8]. It has been shown that during the manipulation of the superficial femoral artery fixed during tourniquet effect, intimal damage may occur [9]. Improper placement of retractors can also cause damage by direct mechanical trauma [10]. Particularly during insertion of the posterior retractor, a 1 cm area

incidence is reported to be 0.03–0.2% in the literature [4].

*Intraoperative, early postoperative, and late postoperative complications.*

**Table 1.**

*Knee Surgery - Reconstruction and Replacement*

• Bleeding

• Wound problems

• Thromboembolism

• Neural deficit

• Vascular issues

• Instability

• Fracture

• Osteolysis

• Malalignment

• Medial collateral ligament injury

• Stiffness-toughness-contracture

• Deep wound infection

• Extensor mechanism injury

• Patellofemoral dislocation

• Tibiofemoral dislocation

• Bearing surface wear

• Implant loosening

• Implant breakage

• Re-hospitalization and mortality [1]

When the complications are examined, it is seen that some of them are simple and easy to overcome with a short-term solution, while some of them can be serious and can go to revision arthroplasty. The number of complications such as implant

• Reoperation

• Revision

Reviewing all the risk factors before surgery and being prepared for the complications that may occur may be lifesaving in TKA, which is currently applied frequently. It is important to recognize, identify, and classify the complications in a timely manner in the correct and effective management of complications. The ambiguity about the complications of TKA in the literature helped identify and classify the complications in a study conducted in 2013 by the knee community [1].

According to this study, 22 complications were described. These are [1]:

**56**

*Intraoperative, early postoperative, and late postoperative complications.*

fracture and polyethylene surface wear has been reduced due to the techniques and innovations in implant materials and designs. In a study, it was shown that the most common cause of revisions in the first 5 years postop was infection, and the reasons for revision in the next 5 years were polyethylene loosening [2]. Complications will be classified as intraoperative, early postoperative, and late postoperative complications (**Table 1).**

#### **2. Intraoperative complications**

#### **2.1 Vascular injuries**

Although arterial injury during knee replacement is rare, it may have serious results from limb loss to mortality. Arterial injuries can be seen as thromboembolism, direct vascular laceration, pseudoaneurysm, and arteriovenous fistula [3]. The incidence is reported to be 0.03–0.2% in the literature [4].

Vascular injuries may develop due to the thermal effect of cement polymerization, joint manipulations, dislocations, and excessive manipulation [5]. Considering the issue as specific to the total knee arthroplasty, care should be taken against vascular injury during posterior cruciate ligament and posterior capsular release during femoral condylar cutting. Atypical localization of vascular structures due to changes in adhesions and normal anatomy in revision cases increases the risk of vascular injury twice as compared to primary cases [6]. Nowadays, increasing procedures of TKA bring about the possibility of vascular injuries although they are rare. Therefore, it is necessary to take precautions against vascular injuries that may develop, to identify risky patients and to make an early diagnosis. For this, a good anamnesis and physical examination are essential. It is important to examine the presence of hypertension, diabetes, smoking, and vascular claudication. Coldness of the extremities to be operated during physical examination, skin atrophy and thinning, prominent vascular structures, ulcerative wound, and distal arterial pulse weakness are the findings that need attention. In addition to these findings, the presence of vascular calcifications in radiological scanning, a history of bypass, and an ankle-brachial index below 0.9 are other findings that should be considered. No tourniquet should be used in patients with the abovementioned conditions [7]. Embolism and arterial insufficiency may develop due to tourniquet effect in patients with vascular disease and atheroma plaque in the superficial artery [8]. It has been shown that during the manipulation of the superficial femoral artery fixed during tourniquet effect, intimal damage may occur [9]. Improper placement of retractors can also cause damage by direct mechanical trauma [10]. Particularly during insertion of the posterior retractor, a 1 cm area

in the lateral portion of the midline was identified as a risky area [11]. In a cadaver study, neurovascular structures on the tibial side were mapped on a clock diagram. Accordingly, the popliteal vein at 12 o'clock, the popliteal artery at 1 o'clock, and the anterior tibial artery at 2 o'clock for the left knee were shown as in place [12]. Cautious use of the saw between 11 and 3 o'clock defined in the tibial cutting is important in protecting vascular structures [12].

If vascular injury is suspected the tourniquet should be deflated, and bleeding control should be performed before the incision is closed. The possibility of arterial injury should be taken into consideration in the presence of excessive and pulsatile bleeding and in the absence of peripheral pulses. Although recent studies suggest bleeding control after routine tourniquet deflation prior to incision, its benefit is controversial [13]. The surgeon should perform a postoperative peripheral pulse examination routinely, suspect acute ischemia in the presence of cold and delayed distal capillary filling, and request cardiovascular consultation [14]. Acute ischemia cases with delayed diagnosis of 4–6 hours cause irreversible damage. Prophylactic fasciotomy is performed after revascularization [14].

Pseudoaneurysm may present with pulsatile swelling in the popliteal fossa due to direct damage to the popliteal artery during surgery. Doppler ultrasonography is useful in the diagnosis. In the treatment, excision of the lesion and repair with vascular graft is applied after embolization [15]. Arteriovenous fistula is less common. It usually occurs due to injury to the medial and lateral geniculate arteries and its branches. It may present with pulsatile swelling in the popliteal region that gives "trill." Hemarthrosis or pseudoaneurysm may develop. Ultrasound and angiography are used for diagnosis [16]. The detected lesions should be evaluated together with cardiovascular surgery, and treatment should be planned. Embolization, lesion excision, and graft repair are treatment options [15].

#### **2.2 Neurologic complications**

Nerve injuries are rare during TKA. Peroneal nerve injury is the most common of these [17]. Sacral plexopathy and sciatica neuropathy are also seen, although rarely [18]. Risk factors for neurological injury are [19]:

It has been shown that the risk of nerve injury is increased in patients with rheumatoid arthritis [20]. However, none of these risk factors is directly related to nerve injury [18]. Nerve injury is associated not only with the surgical procedure but also with the anesthesiologist-induced regional anesthesia [21]. Hypertension, diabetes, nerve compression history, presence of tethered cord, and rheumatoid arthritis in the patients increase the risk of neural complications secondary to regional anesthesia [22]. The duration of tourniquet use was associated with nerve injuries. According to this, in the tourniquet applications exceeding 2 hours, the risk of peroneal and tibial nerve injuries including 89% peroneal nerve was determined as 7%. All of these have been shown to get recovery. In procedures exceeding 2 hours, the 10–30-minute break and deflation of the tourniquet reduces the complication rate [19]. Although there is a minimal effect on the functional results of the patients effect on the functional results of the patients during the follow-up, paresthesia and numbness are seen in the distal and lateral site of incision due to the injury of the infrapatellar branch of

**59**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

**2.3 Extensor mechanism injuries**

are not satisfactory.

• Patella baja

be used [28–30].

*2.3.2 Quadriceps tendon rupture*

• Previous surgery

*2.3.1 Patellar tendon rupture*

tendon mobility decreases. These are [26]:

• Severe limitation of movement in the knee

repeated contact of the polyethylene insert [27].

palpable defect at the infrapatellar side are detected.

the saphenous nerve. It is seen in the literature at a rate of 25–76%, and most of these recover spontaneously [23]. Nerve injuries are difficult to detect intraoperatively. In the presence of postoperative nerve injury, physical therapy should be planned immediately. EMG examination is recommended after 3 months [20]. If no improve-

The extensor mechanism in the knee joint consists of quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar tendon, and tuberositas tibia. Extensor mechanism integrity may be impaired during surgery [20]. Although extensor mechanism injuries occur more frequently postoperatively, they may also occur intraoperative. The incidence is reported to be between 1 and 12% [24]. The treatment of extensor mechanism injuries is quite difficult and the results

Rupture usually occurs at the site of insertion to the tuberositas tibia. The risk of development is less than 1% [25]. Less frequently, intratendinous and infrapatellar tendon rupture may also occur [25]. The risk of injury increases when patellar

The risk of tendon injury especially on stiffness knees due to forced manipulations and during the tibial bone cutting increases during surgery. The most common injury mechanism after surgery is falling onto the knee while knee is flexed [27]. Patellar tendon injury without trauma is seen by weakening the tendon after

In patients with patellar tendon rupture, pain, swelling, loss of extension, and a

Age, functional status, tendon rupture localization, and soft tissue status are the determinants of the treatment. Splitting and bracing are considered in patients who do not have functional expectations and are unsuitable for surgery [28]. Treatment of acute patellar tendon rupture intraoperative is primary repair [26]. Several techniques have been described using staple and suture anchors for this purpose [28]. Reconstruction techniques are used in patients with poor soft tissue quality. For this purpose, biological materials (hamstring tendon autograft, achilles, peroneal tendon autograft, and extensor mechanism allograft) and synthetic materials can

It is very rare. It is especially seen as a rupture from the intersion side to the patella. Excessive patella cutting, previous quadriceps snip, or V-Y tipping are risk

Good results have been reported with plaster cast in partial tears [31]. Extensor loss greater than 20° is considered a complete tear and should be treated surgically.

factors [28]. The clinical finding is similar to patellar tendon rupture.

ment is observed, nerve exploration may be planned in the future.

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

*Knee Surgery - Reconstruction and Replacement*

protecting vascular structures [12].

fasciotomy is performed after revascularization [14].

excision, and graft repair are treatment options [15].

rarely [18]. Risk factors for neurological injury are [19]:

• Presence of an intra-articular hematoma

**2.2 Neurologic complications**

• Flexion deformity

• Advanced valgus deformity

in the lateral portion of the midline was identified as a risky area [11]. In a cadaver study, neurovascular structures on the tibial side were mapped on a clock diagram. Accordingly, the popliteal vein at 12 o'clock, the popliteal artery at 1 o'clock, and the anterior tibial artery at 2 o'clock for the left knee were shown as in place [12]. Cautious use of the saw between 11 and 3 o'clock defined in the tibial cutting is important in

If vascular injury is suspected the tourniquet should be deflated, and bleeding control should be performed before the incision is closed. The possibility of arterial injury should be taken into consideration in the presence of excessive and pulsatile bleeding and in the absence of peripheral pulses. Although recent studies suggest bleeding control after routine tourniquet deflation prior to incision, its benefit is controversial [13]. The surgeon should perform a postoperative peripheral pulse examination routinely, suspect acute ischemia in the presence of cold and delayed distal capillary filling, and request cardiovascular consultation [14]. Acute ischemia cases with delayed diagnosis of 4–6 hours cause irreversible damage. Prophylactic

Pseudoaneurysm may present with pulsatile swelling in the popliteal fossa due to direct damage to the popliteal artery during surgery. Doppler ultrasonography is useful in the diagnosis. In the treatment, excision of the lesion and repair with vascular graft is applied after embolization [15]. Arteriovenous fistula is less common. It usually occurs due to injury to the medial and lateral geniculate arteries and its branches. It may present with pulsatile swelling in the popliteal region that gives "trill." Hemarthrosis or pseudoaneurysm may develop. Ultrasound and angiography are used for diagnosis [16]. The detected lesions should be evaluated together with cardiovascular surgery, and treatment should be planned. Embolization, lesion

Nerve injuries are rare during TKA. Peroneal nerve injury is the most common of these [17]. Sacral plexopathy and sciatica neuropathy are also seen, although

It has been shown that the risk of nerve injury is increased in patients with rheumatoid arthritis [20]. However, none of these risk factors is directly related to nerve injury [18]. Nerve injury is associated not only with the surgical procedure but also with the anesthesiologist-induced regional anesthesia [21]. Hypertension, diabetes, nerve compression history, presence of tethered cord, and rheumatoid arthritis in the patients increase the risk of neural complications secondary to regional anesthesia [22]. The duration of tourniquet use was associated with nerve injuries. According to this, in the tourniquet applications exceeding 2 hours, the risk of peroneal and tibial nerve injuries including 89% peroneal nerve was determined as 7%. All of these have been shown to get recovery. In procedures exceeding 2 hours, the 10–30-minute break and deflation of the tourniquet reduces the complication rate [19]. Although there is a minimal effect on the functional results of the patients effect on the functional results of the patients during the follow-up, paresthesia and numbness are seen in the distal and lateral site of incision due to the injury of the infrapatellar branch of

**58**

the saphenous nerve. It is seen in the literature at a rate of 25–76%, and most of these recover spontaneously [23]. Nerve injuries are difficult to detect intraoperatively. In the presence of postoperative nerve injury, physical therapy should be planned immediately. EMG examination is recommended after 3 months [20]. If no improvement is observed, nerve exploration may be planned in the future.

#### **2.3 Extensor mechanism injuries**

The extensor mechanism in the knee joint consists of quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar tendon, and tuberositas tibia. Extensor mechanism integrity may be impaired during surgery [20]. Although extensor mechanism injuries occur more frequently postoperatively, they may also occur intraoperative. The incidence is reported to be between 1 and 12% [24]. The treatment of extensor mechanism injuries is quite difficult and the results are not satisfactory.

#### *2.3.1 Patellar tendon rupture*

Rupture usually occurs at the site of insertion to the tuberositas tibia. The risk of development is less than 1% [25]. Less frequently, intratendinous and infrapatellar tendon rupture may also occur [25]. The risk of injury increases when patellar tendon mobility decreases. These are [26]:

The risk of tendon injury especially on stiffness knees due to forced manipulations and during the tibial bone cutting increases during surgery. The most common injury mechanism after surgery is falling onto the knee while knee is flexed [27]. Patellar tendon injury without trauma is seen by weakening the tendon after repeated contact of the polyethylene insert [27].

In patients with patellar tendon rupture, pain, swelling, loss of extension, and a palpable defect at the infrapatellar side are detected.

Age, functional status, tendon rupture localization, and soft tissue status are the determinants of the treatment. Splitting and bracing are considered in patients who do not have functional expectations and are unsuitable for surgery [28]. Treatment of acute patellar tendon rupture intraoperative is primary repair [26]. Several techniques have been described using staple and suture anchors for this purpose [28]. Reconstruction techniques are used in patients with poor soft tissue quality. For this purpose, biological materials (hamstring tendon autograft, achilles, peroneal tendon autograft, and extensor mechanism allograft) and synthetic materials can be used [28–30].

#### *2.3.2 Quadriceps tendon rupture*

It is very rare. It is especially seen as a rupture from the intersion side to the patella. Excessive patella cutting, previous quadriceps snip, or V-Y tipping are risk factors [28]. The clinical finding is similar to patellar tendon rupture.

Good results have been reported with plaster cast in partial tears [31]. Extensor loss greater than 20° is considered a complete tear and should be treated surgically. It has unsatisfactory results due to high complication rates and tendency to rerupture depending on tendon quality and soft tissue condition.

#### *2.3.3 Patella fractures*

Patellar fractures are the most common injury among the extensor mechanism injuries [24, 32]. In general, the risk increases with excessive bone cutting while preparing for patellar component. Patellar fracture may occur by direct trauma to the anterior knee or as an avulsion due to the pull of the quadriceps muscle [32].

 Lateral knee radiography and tomography in case of clinical suspicion are helpful imaging methods for the diagnosis.

A classification has been developed to assess implant stability and extensor mechanism continuity for periprosthetic patella fractures [33]. Type 1, a stable implant and continuous extensor mechanism; Type 2, a stable implant but a discontinuous extensor mechanism; and Type 3, which indicates instable implant and discontinuous extensor mechanism. Patellar bone stock is classified as 3A if good and 3B if poor. Treatment is also determined according to this classification. Conservative treatment methods are preferred for type 1 cases, while surgical treatments are preferred for types 2 and 3 [33]. In recent studies, it is reported that 40–50% of complications occur and more than half strength loss of extensor mechanism is observed [34].

#### **2.4 Medial collateral ligament injury**

During total knee replacement, medial collateral ligament (MCL) is important for soft tissue stabilization and coronal plan stability. The incidence of iatrogenic MCL injury is 2.2–2.7% [35]. In the case of surgical injuries, direct repair, constrained prosthesis use, and even revision at the same session are among the options [36]. Unrecognized MCL injuries during surgery cause early instability. This leads to early implant wear and consequently the need for early revision. Therefore, it is important to diagnose and repair the injury during surgery [37]. Sudden instability in the valgus stress test during knee stabilization indicates MCL injury. Injury may occur from femoral insertion, within the tendon or tibial insertion [38]. Primary repair technique varies according to injury level. Fixation with screw is recommended if MCL injury occurs from its femoral insertion site. Otherwise, if it is through tendon, repairing with insoluble suture technique is recommended. Finally, if MCL injury occurs from its tibial insertion site, both insoluble suture anchor technique and fixation with staple technic are recommended [39, 40]. Factors that increase the risk of medial collateral ligament injury during surgery are as follows [39]:

Patient-related risk factors include obesity and severe deformities [41, 42]. A certain algorithm has not yet been established for the treatment of iatrogenic MCL injuries that occur intraoperative. Many treatment methods with

**61**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

**3. Early postoperative complications**

• Use of femoral intramedullary plugs [48]

• Cryotherapy and Jones bandage [50]

• Use of fibrin tissue adhesive [50, 51]

• Application of tranexamic acid [55]

• Hypotensive anesthesia [49]

• Clamping the drain [52–54]

due to transfusion are reduced.

**3.1 Bleeding**

are as follows:

disadvantages and advantages have been used [39, 43, 44]. The traditional method is using constrained prosthesis. However, in this method, it was shown that the stress load on the implant increased and direct repair and treatment with nonconstrained prosthesis were recommended instead. In addition, augmentation or increase in polyethylene thickness has been proposed [45]. In one study, it was shown that the risk of instability was 57% in the use of non-constrained prostheses independent of the repair technique after MCL injury [37]. In a 2016 study, four treatment modalities were compared after MCL injury. These are the use of nonconstrained prosthesis only, the use of non-constrained prosthesis with primary repair, the use of non-constrained prosthesis only, and the use of constrained prosthesis with primary repair. In 23 patients, the most appropriate treatment method according to the knee community scoring was found to be the use of constrained prosthesis only [46]. However, due to the small number of patients, larger series of

studies are needed to determine which treatment is most appropriate.

Bleeding is seen in varying rates between 0 and 39% after TKA [47]. This naturally increases the need for blood transfusion. Intraoperatively, care should be taken about bleeding and good bleeding control is established. Thus, the amount of bleeding is reduced to a minimum. As a result, the risks of immunological reaction

Bleeding tolerance is low in patients with comorbid disease and in patients with insufficient cardiac capacity, and the risk of complications increases even in small amounts of bleeding. Preoperative blood preparation before surgery and limitation of the use of anticoagulants are among the measures that can be taken. Precautions during and after TKA surgery can reduce the amount of bleeding. These methods

Fibrinolysis is activated by surgical trauma and tourniquet use [56]. Increased fibrinolytic activity causes increased bleeding during TKA. Tranexamic acid shows an anti-fibrinolytic effect by inhibiting the conversion of plasmin to plasminogen [57]. Tranexamic acid can be administered in four different ways: intravenous, oral, intramuscular, and intra-articular [55]. Transition to maximum plasma levels is 30 minutes for intramuscular use, 5–15 minutes for intravenous use, and 2 hours after oral use [58]. Patients with total knee arthroplasty may be treated with a fast-acting intravenous route. Many studies have shown that administration of tranexamic acid after tourniquet deflation and postoperative dose repeat reduces the amount of

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

disadvantages and advantages have been used [39, 43, 44]. The traditional method is using constrained prosthesis. However, in this method, it was shown that the stress load on the implant increased and direct repair and treatment with nonconstrained prosthesis were recommended instead. In addition, augmentation or increase in polyethylene thickness has been proposed [45]. In one study, it was shown that the risk of instability was 57% in the use of non-constrained prostheses independent of the repair technique after MCL injury [37]. In a 2016 study, four treatment modalities were compared after MCL injury. These are the use of nonconstrained prosthesis only, the use of non-constrained prosthesis with primary repair, the use of non-constrained prosthesis only, and the use of constrained prosthesis with primary repair. In 23 patients, the most appropriate treatment method according to the knee community scoring was found to be the use of constrained prosthesis only [46]. However, due to the small number of patients, larger series of studies are needed to determine which treatment is most appropriate.

### **3. Early postoperative complications**

#### **3.1 Bleeding**

*Knee Surgery - Reconstruction and Replacement*

helpful imaging methods for the diagnosis.

mechanism is observed [34].

**2.4 Medial collateral ligament injury**

• Using a larger saw blade than femoral condyle

• Delayed excision of medial side osteophytes

• Patients with flexion contractures [39]

• Performing challenging manipulations of varus-valgus

Patient-related risk factors include obesity and severe deformities [41, 42]. A certain algorithm has not yet been established for the treatment of iatrogenic MCL injuries that occur intraoperative. Many treatment methods with

*2.3.3 Patella fractures*

It has unsatisfactory results due to high complication rates and tendency to re-

Patellar fractures are the most common injury among the extensor mechanism injuries [24, 32]. In general, the risk increases with excessive bone cutting while preparing for patellar component. Patellar fracture may occur by direct trauma to the anterior knee or as an avulsion due to the pull of the quadriceps muscle [32].  Lateral knee radiography and tomography in case of clinical suspicion are

A classification has been developed to assess implant stability and extensor mechanism continuity for periprosthetic patella fractures [33]. Type 1, a stable implant and continuous extensor mechanism; Type 2, a stable implant but a discontinuous extensor mechanism; and Type 3, which indicates instable implant and discontinuous extensor mechanism. Patellar bone stock is classified as 3A if good and 3B if poor. Treatment is also determined according to this classification. Conservative treatment methods are preferred for type 1 cases, while surgical treatments are preferred for types 2 and 3 [33]. In recent studies, it is reported that 40–50% of complications occur and more than half strength loss of extensor

During total knee replacement, medial collateral ligament (MCL) is important for soft tissue stabilization and coronal plan stability. The incidence of iatrogenic MCL injury is 2.2–2.7% [35]. In the case of surgical injuries, direct repair, constrained prosthesis use, and even revision at the same session are among the options [36]. Unrecognized MCL injuries during surgery cause early instability. This leads to early implant wear and consequently the need for early revision. Therefore, it is important to diagnose and repair the injury during surgery [37]. Sudden instability in the valgus stress test during knee stabilization indicates MCL injury. Injury may occur from femoral insertion, within the tendon or tibial insertion [38]. Primary repair technique varies according to injury level. Fixation with screw is recommended if MCL injury occurs from its femoral insertion site. Otherwise, if it is through tendon, repairing with insoluble suture technique is recommended. Finally, if MCL injury occurs from its tibial insertion site, both insoluble suture anchor technique and fixation with staple technic are recommended [39, 40]. Factors that increase the risk of medial collateral ligament injury during surgery are

rupture depending on tendon quality and soft tissue condition.

**60**

as follows [39]:

Bleeding is seen in varying rates between 0 and 39% after TKA [47]. This naturally increases the need for blood transfusion. Intraoperatively, care should be taken about bleeding and good bleeding control is established. Thus, the amount of bleeding is reduced to a minimum. As a result, the risks of immunological reaction due to transfusion are reduced.

Bleeding tolerance is low in patients with comorbid disease and in patients with insufficient cardiac capacity, and the risk of complications increases even in small amounts of bleeding. Preoperative blood preparation before surgery and limitation of the use of anticoagulants are among the measures that can be taken. Precautions during and after TKA surgery can reduce the amount of bleeding. These methods are as follows:

Fibrinolysis is activated by surgical trauma and tourniquet use [56]. Increased fibrinolytic activity causes increased bleeding during TKA. Tranexamic acid shows an anti-fibrinolytic effect by inhibiting the conversion of plasmin to plasminogen [57]. Tranexamic acid can be administered in four different ways: intravenous, oral, intramuscular, and intra-articular [55]. Transition to maximum plasma levels is 30 minutes for intramuscular use, 5–15 minutes for intravenous use, and 2 hours after oral use [58]. Patients with total knee arthroplasty may be treated with a fast-acting intravenous route. Many studies have shown that administration of tranexamic acid after tourniquet deflation and postoperative dose repeat reduces the amount of

bleeding and the need for transfusion [59–61]. However, many different protocols for the use of tranexamic acid have been implemented. Preoperative single dose and repeated dose every 8 hours for 3 days have been described in the literature and shown to be effective [62]. In a study conducted in 2011, tranexamic acid was administered at a dose of 10 mg/kg 10 minutes before the tourniquet was opened, and the same dose was repeated 3 hours postoperatively. Five hundred mg tranexamic acid was administered orally 3 times a day for 5 days. At the end of this study, it was shown that the amount of hemorrhage and the rate of transfusion decreased effectively [55].

#### **3.2 Skin healing problems: superficial and deep infections**

The incidence of wound problems after TKA is 1–25% [63]. The skin problems may be delayed wound healing, skin necrosis, traumatic or atraumatic separation of the lips of the wound, prolonged serous discharge at the wound site, formation of superficial or deep hematoma, allergic reaction to patch, suture material or dressing materials, bullae formation, fat necrosis, bleeding, keloid formation, and superficial or deep infection [64].

Etiologic reasons that may develop the problem before TKA should be determined in advance, and appropriate measures should be taken [65]. Presence of systemic diseases such as diabetes, hypertension, rheumatoid arthritis, and vascular insufficiency, which may adversely affect wound healing before TKA, should be questioned. Since the soft tissues around the knee are thinner than the other parts of the body, even the smallest problem that may occur at the wound site can cause serious complications. Incision planning should be made carefully in the case of a history of operation from the same place and scarring beforehand, and if necessary, plastic surgery assistance should be taken.

#### *3.2.1 Skin healing problems*

Factors adversely affecting wound healing are obesity, hypertension, diabetes, smoking, chronic drug use, steroid use, previous radiotherapy, scarring, inflammatory disease, malnutrition, albumin levels below 3.5 g/dl, and hemoglobin levels below 10 g/dl. Transferrin and lymphocyte levels may also contribute to wound healing problems [66]. Therefore, a detailed anamnesis and physical examination and laboratory examination before surgery give an idea about possible skin problems. Accordingly, measures are taken, replacement therapies are given, and surgery may be postponed until the current pathology is corrected, if necessary. Adjustment of fasting blood sugar levels below 200 g/dl and keeping HbA1C below 6.5 in patients with diabetes will reduce the risk of possible wound problems [67].

Patients with a body mass index above 30 kg/m<sup>2</sup> are 6 times more likely to have infection and wound problems [66]. In obese patients, dietician support should be given before surgery; unnecessary exclusion should be avoided during surgery, and soft tissue surgery should be applied carefully.

A study of smoking patients showed that there were 2 times more wound problems [65]. Because of the vasoconstrictor effect of nicotine in the cigarette, it is recommended to quit smoking 60 days before surgery due to decreased blood supply at the wound site.

Incision planning should be performed in the presence of scar after previous surgery. In the presence of a single longitudinal incision without problems, the same incision should be used. If the old incision cannot be used, a distance of at least 7–8 cm should be left. If there is more than one old incision scar in the anterior part of the knee, the most lateral scar is used considering that the anterior knee feeding is from the medial perforating artery. In addition, the lateral soft tissue flap should not be dissected too

**63**

*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

debridement [70].

*3.2.2 Superficial and deep infections*

be planned through detailed examination.

much [65]. Unnecessary retractors and additional soft tissue damage should be avoided during surgery. The wound lips should be exactly opposite to each other. Overstretched

Especially in patients with risk factors, it should be performed without tourniquet

Despite all current precautions, surgical site infections remain the most serious and feared complications of TKA. After TKA, patients should be followed up with daily dressings, and wound discharge should be evaluated carefully. Prolonged wound discharge is defined as a discharge that lasts more than 48 hours regardless of the amount of drainage [64].  They are reported as 1–10% after primary knee replacement [65]. In the early stage of treatment, usually dressing and immobilization for 3–5 days is recommended [71]. Continuous discharge for 72 hours is dangerous. If it exceeds 5 days, debridement should be applied in operating room

conditions as it will increase the risk of superficial or deep infection [64]. Superficial infection: It is defined as infection of the soft tissue above the skin—subcutaneous and deep fascia that has not passed under the deep fascia, not opened into the joint cavity. It occurs most frequently in the first 30 days after surgery. The incidence of superficial infection after TKA has been reported as 10% [72]. It may occur through direct contamination or blood. Improper preparation of direct contamination sterilization environment, inadequate surgical field preparation, presence of sloppy surgical team, non-sterile dressing materials, and application may occur as a result of the presence of infected patients in the same environment [73]. The risk of direct contamination can be minimized by precautions. Hematogen contamination can occur if there is any other focus of infection in the body. Therefore, in the presence of a possible infection focus with detailed anamnesis and examination before the operation, the current focus treatment can

Infection after TKA can be evaluated as patient-related risk factors, surgical

• *Patient-related risk factors* include advanced age, previous knee surgery, previous knee infection, steroid use, presence of inflammatory disease, obesity, diabetes, smoking, intravenous drug use, hematologic diseases, oncologic

intervention-related factors, and postoperative factors [66, 68, 74–77].

closing should be avoided. This should be checked with capillary filling time.

or at low pressures [65]. Difficult rehabilitation in the early postoperative period should be postponed if possible until it is ensured that there are no wound problems. Hematoma formation increases the risk of infection [65]. Therefore, measures should be taken to prevent the formation of hematoma. These include no dead space during wound closure, good bleeding control, use of a Jones bandage, and avoidance of overdose of the prophylactic anticoagulants used [65, 68]. Once the hematoma has developed, a needle aspiration can be performed. However, if the hematoma is organized and the drainage cannot be achieved, discharge and debridement can be achieved by arthrotomy under operating room conditions. The presence of necrosis in the wound leads to catastrophic consequences. Respect to soft tissue is the most important step to prevent necrosis development. The depth of necrosis is important. Superficial necrosis can be treated by local intervention. If larger, debridement and full-thickness skin grafts or fasciocutaneous flaps are required [69]. If necrosis includes full-thickness soft tissue, closure with fascial skin or muscular skin graft should be performed after urgent aggressive

#### *Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

*Knee Surgery - Reconstruction and Replacement*

cial or deep infection [64].

*3.2.1 Skin healing problems*

supply at the wound site.

plastic surgery assistance should be taken.

Patients with a body mass index above 30 kg/m<sup>2</sup>

soft tissue surgery should be applied carefully.

bleeding and the need for transfusion [59–61]. However, many different protocols for the use of tranexamic acid have been implemented. Preoperative single dose and repeated dose every 8 hours for 3 days have been described in the literature and shown to be effective [62]. In a study conducted in 2011, tranexamic acid was administered at a dose of 10 mg/kg 10 minutes before the tourniquet was opened, and the same dose was repeated 3 hours postoperatively. Five hundred mg tranexamic acid was administered orally 3 times a day for 5 days. At the end of this study, it was shown that the amount of hemorrhage and the rate of transfusion decreased effectively [55].

The incidence of wound problems after TKA is 1–25% [63]. The skin problems may be delayed wound healing, skin necrosis, traumatic or atraumatic separation of the lips of the wound, prolonged serous discharge at the wound site, formation of superficial or deep hematoma, allergic reaction to patch, suture material or dressing materials, bullae formation, fat necrosis, bleeding, keloid formation, and superfi-

Etiologic reasons that may develop the problem before TKA should be determined in advance, and appropriate measures should be taken [65]. Presence of systemic diseases such as diabetes, hypertension, rheumatoid arthritis, and vascular insufficiency, which may adversely affect wound healing before TKA, should be questioned. Since the soft tissues around the knee are thinner than the other parts of the body, even the smallest problem that may occur at the wound site can cause serious complications. Incision planning should be made carefully in the case of a history of operation from the same place and scarring beforehand, and if necessary,

Factors adversely affecting wound healing are obesity, hypertension, diabetes, smoking, chronic drug use, steroid use, previous radiotherapy, scarring, inflammatory disease, malnutrition, albumin levels below 3.5 g/dl, and hemoglobin levels below 10 g/dl. Transferrin and lymphocyte levels may also contribute to wound healing problems [66]. Therefore, a detailed anamnesis and physical examination and laboratory examination before surgery give an idea about possible skin problems. Accordingly, measures are taken, replacement therapies are given, and surgery may be postponed until the current pathology is corrected, if necessary. Adjustment of fasting blood sugar levels below 200 g/dl and keeping HbA1C below 6.5 in patients with diabetes will reduce the risk of possible wound problems [67].

infection and wound problems [66]. In obese patients, dietician support should be given before surgery; unnecessary exclusion should be avoided during surgery, and

A study of smoking patients showed that there were 2 times more wound problems [65]. Because of the vasoconstrictor effect of nicotine in the cigarette, it is recommended to quit smoking 60 days before surgery due to decreased blood

In the presence of a single longitudinal incision without problems, the same incision should be used. If the old incision cannot be used, a distance of at least 7–8 cm should be left. If there is more than one old incision scar in the anterior part of the knee, the most lateral scar is used considering that the anterior knee feeding is from the medial perforating artery. In addition, the lateral soft tissue flap should not be dissected too

Incision planning should be performed in the presence of scar after previous surgery.

are 6 times more likely to have

**3.2 Skin healing problems: superficial and deep infections**

**62**

much [65]. Unnecessary retractors and additional soft tissue damage should be avoided during surgery. The wound lips should be exactly opposite to each other. Overstretched closing should be avoided. This should be checked with capillary filling time.

Especially in patients with risk factors, it should be performed without tourniquet or at low pressures [65]. Difficult rehabilitation in the early postoperative period should be postponed if possible until it is ensured that there are no wound problems.

Hematoma formation increases the risk of infection [65]. Therefore, measures should be taken to prevent the formation of hematoma. These include no dead space during wound closure, good bleeding control, use of a Jones bandage, and avoidance of overdose of the prophylactic anticoagulants used [65, 68]. Once the hematoma has developed, a needle aspiration can be performed. However, if the hematoma is organized and the drainage cannot be achieved, discharge and debridement can be achieved by arthrotomy under operating room conditions.

The presence of necrosis in the wound leads to catastrophic consequences. Respect to soft tissue is the most important step to prevent necrosis development. The depth of necrosis is important. Superficial necrosis can be treated by local intervention. If larger, debridement and full-thickness skin grafts or fasciocutaneous flaps are required [69]. If necrosis includes full-thickness soft tissue, closure with fascial skin or muscular skin graft should be performed after urgent aggressive debridement [70].

#### *3.2.2 Superficial and deep infections*

Despite all current precautions, surgical site infections remain the most serious and feared complications of TKA. After TKA, patients should be followed up with daily dressings, and wound discharge should be evaluated carefully. Prolonged wound discharge is defined as a discharge that lasts more than 48 hours regardless of the amount of drainage [64].  They are reported as 1–10% after primary knee replacement [65]. In the early stage of treatment, usually dressing and immobilization for 3–5 days is recommended [71]. Continuous discharge for 72 hours is dangerous. If it exceeds 5 days, debridement should be applied in operating room conditions as it will increase the risk of superficial or deep infection [64].

Superficial infection: It is defined as infection of the soft tissue above the skin—subcutaneous and deep fascia that has not passed under the deep fascia, not opened into the joint cavity. It occurs most frequently in the first 30 days after surgery. The incidence of superficial infection after TKA has been reported as 10% [72]. It may occur through direct contamination or blood. Improper preparation of direct contamination sterilization environment, inadequate surgical field preparation, presence of sloppy surgical team, non-sterile dressing materials, and application may occur as a result of the presence of infected patients in the same environment [73]. The risk of direct contamination can be minimized by precautions. Hematogen contamination can occur if there is any other focus of infection in the body. Therefore, in the presence of a possible infection focus with detailed anamnesis and examination before the operation, the current focus treatment can be planned through detailed examination.

Infection after TKA can be evaluated as patient-related risk factors, surgical intervention-related factors, and postoperative factors [66, 68, 74–77].

• *Patient-related risk factors* include advanced age, previous knee surgery, previous knee infection, steroid use, presence of inflammatory disease, obesity, diabetes, smoking, intravenous drug use, hematologic diseases, oncologic

diseases, above ASA score 2, immunosuppressive use, regional skin problems, old incision scars, previous radiotherapy procedures, malnutrition, vascular insufficiency, albumin level below 3.5 g/dl, transferrin level below 200 mg/dl, hemoglobin level below 10 g/dl [78, 79].

Superficial wound infection is considered with the presence of at least one of the following: discharge from the wound incision, culture of the wound from aseptic conditions, suspicion of infection in clinical evaluation, disproportionate pain, increased temperature, erythema, and localized swelling [79].

In superficial wound infection, unlike deep infection, there is no progressive change in erythrocyte sedimentation rate, C-reactive protein level, and peripheral leukocyte count; the increase is below 25% [82]. In addition, leukocytes in synovial fluid are detected less than 2000/ml, and polymorphonuclear leukocytes are detected under 50%. Alpha defensin and leukocyte esterase tests are negative [71].

When superficial wound infection is detected, the development of deep infection can be prevented by early intervention. Otherwise, it may develop into periprosthetic infection and cause catastrophic results. In the presence of superficial infection, local wound care due to the underlying cause and debridement should be performed if appropriate anti-therapy is required [80]. In the selection of antibiotics, consultation with infectious diseases should be requested. Antibiotherapy is continued after reproduction. If deep infection is excluded in surgical debridement, the joint should not be opened, and the implant should not be touched [83]. Hyperbaric oxygen therapy has a positive effect on appropriate patient selection [84].

#### **3.3 Deep vein thrombosis and pulmonary embolism**

Deep vein thrombosis is the general name of thrombosis in the venous circulatory system. It occurs most commonly in the deep veins of the lower extremity [85]. From asymptomatic deep vein thrombosis to pulmonary embolism, which can be fatal, it can be confused with clinical manifestations of varying degrees [85]. It is one of the important complications that increase morbidity and mortality after TKA [86]. Even with mechanical or pharmacological methods, the incidence of asymptomatic DVT is 5.1%, and the incidence of symptomatic DVT is 0.4% [87]. The mortality rate due to pulmonary embolism after TKA is 0.08% [88].

It is important to understand the Virchow triad in the pathogenesis of DVT development. There is a slowdown in blood flow (stasis), endothelial damage, and hypercoagulability [89]. The admixture of fat and bone marrow particles into the venous system after engraving of the femoral canal during TKA explains the hypercoagulability branch of the Virchow triad. Hyperflexion of the leg during surgery and anterior manipulation of the tibia with retractors explain endothelial damage. In addition, this manipulation causes obstruction of the popliteal veins and prolonged immobilization of the leg, leading to venous pooling and stasis [89].

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*Complications after Total Knee Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.89818*

• VTE risk increases after age of 40 and doubles every 10 years after that age [90]. Age increases the risk of VTE regardless of other risk factors.

• Genetic factors are also an important parameter that increases the risk of

DVT. Factor V Leiden mutation that causes thrombophilia, as well as protein C, protein S, and antithrombin III deficiency are among the factors that increase

• Although tourniquet use has been reported to cause venous stasis, it has been shown that it does not significantly increase the risk of DVT because of its

• The type of anesthesia also affects the risk of developing DVT. General anesthesia has been shown to increase the risk of DVT compared to neuraxial anesthesia (spinal or epidural). Neuroaxial blockade causes vasodilatation in the lower extremities and reduces venous pooling; therefore it explains the mechanism of action [93].

• Other risk factors that increase the risk of DVT are immobilization, smoking, oral contraceptive and hormone use, history of VTE, obesity, malignancy, and

A painful, swollen, and reddened leg after TKA should suggest the possibility of DVT. Incomplete DVTs usually do not show signs. Incomplete DVTs are seen especially after arthroplasty. Clinical findings are seen in 1% of all DVT cases. Physical examination findings include redness, swelling, and Homan's sign test and Pratt test positivity. Clinical Wells risk score was established for the diagnosis of deep vein thrombosis [94]. Clinical Wells Scoring criteria are malignancy, paralysis (paresthesia or splinting lower extremity), immobilization for more than 3 days, localized tenderness in the deep venous system, swelling of the lower extremity, 3-cm-diameter differentiation from the other leg, pretibial gode positive edema, history of deep vein thrombosis, and collateral superficial veins. The presence of each risk factor was evaluated as 1 point, and clinical scoring of 3 and above was found to

Clinical data are not sufficient for the diagnosis of DVT. Therefore, further examination with clinical risk scoring, D-dimer level, Doppler ultrasonography, contrast-enhanced venography, CT, and MRI should be performed. Venography is the best method for the diagnosis of DVT in the lower extremities. The accuracy rate was 97% in the lower extremity veins and 70% in the iliac veins [95]. Venography is not preferred as first-line imaging because it has a 3% risk of DVT and is an invasive method, and also it requires contrast matter that can be toxic to the kidneys. Doppler USG is the most commonly used first-line imaging method because of its cheapness, reproducibility, and patient comfort in the suspicion of DVT. Proximal DVT sensitivity was 96%, distal DVT sensitivity was 44%, and DVT specificity was 93% [96]. Pulmonary embolism should be suspected in the case of sudden shortness of breath, tachypnea, tachycardia, and chest pain after TKA. However, since there are many other diseases with these findings, risk factor assessment and effective differential diagnosis should be made. Wells pulmonary embolism clinical probability scoring was established [97]. Pulmonary angiography is the gold standard for the

*3.3.1 Risk factors*

the risk of DVT.

fibrinolytic effect [91, 92].

difficult knee manipulations.

diagnosis of pulmonary embolism [85].

be a high risk for the development of deep vein thrombosis.

*3.3.2 Diagnosis*

#### *3.3.1 Risk factors*

*Knee Surgery - Reconstruction and Replacement*

sterility rules [80].

negative [71].

hemoglobin level below 10 g/dl [78, 79].

diseases, above ASA score 2, immunosuppressive use, regional skin problems, old incision scars, previous radiotherapy procedures, malnutrition, vascular insufficiency, albumin level below 3.5 g/dl, transferrin level below 200 mg/dl,

• *Surgical intervention related risk factors* include prolonged surgical time of more than 2 hours, absence of laminar flow in the operating room, transfusion, use of hinged knee prosthesis, failure of surgical team to comply with asepsis, and

• *Operative period related risk factors* include prolonged hospital stay pre- and postoperative, lack of appropriate antibiotic prophylaxis, hematoma forma-

Superficial wound infection is considered with the presence of at least one of the following: discharge from the wound incision, culture of the wound from aseptic conditions, suspicion of infection in clinical evaluation, disproportionate pain,

In superficial wound infection, unlike deep infection, there is no progressive change in erythrocyte sedimentation rate, C-reactive protein level, and peripheral leukocyte count; the increase is below 25% [82]. In addition, leukocytes in synovial fluid are detected less than 2000/ml, and polymorphonuclear leukocytes are detected under 50%. Alpha defensin and leukocyte esterase tests are