Arterial Complications following Total Knee Arthroplasty (TKA): A Systematic Review and Proposal for Improved Monitoring

INTRODUCTION: Total knee arthroplasty (TKA) is a common operation and is becoming more common due to population aging and increasing BMI. TKA provides excellent improvement in quality of life but carries risk of arterial complications in the perioperative period. This systematic review aims to provide a greater understanding of the incidence of such complications, and time taken to diagnose arterial injury.

MATERIALS AND METHODS: PubMed, Medline, Ovid SP and EMBASE databases were searched with the following MeSH keywords: 'complication', 'vascular injury', 'ischaemia', 'spasm', 'thrombosis', 'pseudoaneurysm', 'transection', 'pulse', 'ABPI OR ABI', 'Doppler', 'amputation'. All arterial vascular events in the perioperative state of the total knee replacement were included. Records were independently screened by two reviewers, and data was extracted according to a pre-determined proforma. Overall incidence and time to diagnosis was calculated for complications. Systematic review registration PROSPERO: CRD42018086643. No funding was received.

RESULTS: Twelve studies were selected for inclusion. A total of 3325 cases of arterial complications were recorded across all studies, and were divided into three categories, pseudoaneurysms (0.06%); ischaemia and thrombosis (0.17%); haemorrhage and arterial transections (0.07%). Time taken to reach the diagnosis for each complication was longest in the ischaemia and thrombosis group (6.8 days), followed by pseudoaneurysm (3.5 days) and haemorrhage and transections (3.0 days).

CONCLUSION: TKA post-operative vascular complications are rare, but when they do occur they lead to limb and life threatening complications. This should be discussed with patients during the consent process. Current times to diagnosis represent missed opportunities to recognise arterial injury and facilitate rapid treatment of the complication. A very low threshold for seeking specialist input should be adopted, and any concern for vascular injury, such as unexplained perioperative bleeding, absent lower limb pulses in the post-operative period or unexplained severe pain should warrant immediate review by a vascular surgeon, and in centres where this is not possible, immediate blue-light transfer to the closest vascular centre.