title: The value of immediate preoperative vascular examination in an at-risk patient for total knee arthroplasty.
abstract: Arterial complications associated with total knee arthroplasty (TKA), although infrequent, may be associated with the following sequelae: infection, limb loss, and rarely, death. When revascularization is undertaken in the postoperative setting, additional complications may be encountered including postischemic reperfusion injury necessitating prophylactic fasciotomies. The end result is a prolonged postoperative course leading to worse functional outcome. A preoperative history and physical examination performed by the orthopedic surgeon can determine if the patient is at increased risk for vascular complications and whether the at-risk limb can withstand the stress of the operation. Consideration should be given to obtaining ankle-brachial indexes in this patient population, noting that arterial calcification may elevate the value. This article presents a case of an immediate preoperative vascular examination, performed at the time of surgical site marking, in an at-risk patient prior to TKA. We detail the clinical course of a patient with peripheral vascular disease and indwelling superficial femoral artery stent, who developed stent thrombosis in the 2-week period between his last clinic visit and date of surgery, with no change in symptoms. This restenosis was detected on routine preoperative physical examination and resulted in cancellation of the TKA in the preoperative area, allowing the patient to undergo emergent revascularization. We emphasize the importance of an immediate preoperative vascular examination in the setting of TKA and provide a comprehensive review of the literature with guidelines on the perioperative management of antiplatelet agents and appropriate use of the tourniquet.
authors.affiliation: Department of Orthopedic Surgery, Marshall University, 1600 Medical Center Dr, Ste G-500, Huntington, WV 25701, USA.
authors.forename: Tigran
authors.initials: T
authors.lastname: Garabekyan
authors.forename: Ali
authors.initials: A
authors.lastname: Oliashirazi
authors.forename: Kristie
authors.initials: K
authors.lastname: Winters
mesh_terms: D000368:Aged; D000792:Angiography; D019645:Arthroplasty, Replacement, Knee; D005263:Femoral Artery / Q000473:pathology; D006801:Humans; D007511:Ischemia / Q000175:diagnosis; D007719:Knee Joint / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D007866:Leg / Q000098:blood supply*; D008297:Male; D058729:Peripheral Arterial Disease / Q000150:complications / Q000175:diagnosis*; D011183:Postoperative Complications; D011300:Preoperative Care; D012017:Referral and Consultation; D013927:Thrombosis / Q000175:diagnosis* / Q000209:etiology