Acute arterial thrombosis associated with total knee arthroplasty

Acute arterial thrombosis associated with total knee arthroplasty (TKA) is a rare but limb-threatening complication. The purpose of this report was to determine the incidence and optimal management of these complications by reviewing our extensive orthopedic experience and the English-language literature.

Between April 1989 and March 1994 seven (0.17%) patients had development of acute limb-threatening ischemia after 4097 TKAs that were performed at our hospital. Management of these complications included (1) emergency arteriography to define inflow and outflow arteries, (2) use of autologous vein from the contralateral leg when arterial bypasses were necessary (because TKAs are associated with a high incidence of deep vein thrombosis), and (3) early, aggressive revascularization that often required difficult distal bypasses to achieve limb salvage. Management of our cases are compared with treatment of 13 patients described in the literature.

Ten patients treated at other hospitals by arterial thrombectomy alone (six cases), sympathectomy alone (two cases), fasciotomy alone (one case) or delayed arterial bypass resulted in seven major amputations and one death. All seven of our patients and three patients treated elsewhere underwent emergency femorodistal bypasses (six tibial, three below-knee popliteal, one pedal). All 10 patients had limb salvage after long-term follow-up (average 18 months; range 1 to 58).

Thrombectomy alone for acute arterial thrombosis associated with TKA generally is unsuccessful and associated with unacceptably high amputation rates. Dismal results without emergency bypass is due to underlying chronic occlusive atherosclerotic disease found in these patients and intimal plaque disruption that can occur with knee manipulation or tourniquet compression. Acute arterial occlusion after TKA is best managed by emergency arteriography and a femoroinfrageniculate bypass.