Chapter 15: Technical Errors and Bail-Out Strategies in Joint Replacement Surgery

INTRODUCTION

• Complications of concern in total joint arthroplasty are related to technical errors and non-technical perioperative system issues

• Proper attention to evidence-based techniques and appropriate surgical training can mitigate preventable complications in total joint arthroplasty

STATE OF THE ART

The volume of total joint arthroplasty cases in the United States continues to grow; this includes a considerable burden of surgical revisions. Despite scientific and technological advances in total joint arthroplasty, complication rates remain unreasonably high. The learning curve of surgical trainees and midcareer surgeons with newly described techniques contributes to complications in total joint arthroplasty.

The vast success of total hip and knee arthroplasty is apparent as observed in the number of procedures performed each year in the United States, now totaling nearly 1 million.¹ Despite the observed success, many challenges in total joint arthroplasty remain. Complications related to total joint arthroplasty may be divided into those that occur in direct relation to the surgical procedure, and those that occur as a result of limitations in implant survivability. Of present concern are complications that occur intraoperatively and perioperatively. Such events have a wide range of impact including extended hospitalization, hospital readmission, and in some cases, mortality.

There are several groups of recognized complications that occur following total joint arthroplasty, some temporary, and others, permanent. Neurologic injuries result in minor neuralgia, paresthesia, disabling pain or frank paralysis, and may be related to intraoperative events or underlying neurologic conditions aggravated by nerve tissue manipulation. Thromboembolic disease may result in small, nondetectible thromboses or significant deep venous thrombosis with risk of pulmonary embolic events, possibly fatal. Lack of satisfactory visualization, common with less invasive approaches, may allow bone fractures or tissue insult to occur and, in severe cases, result in a need for reoperation.

TECHNICAL COMPLICATIONS VS PATIENT FACTORS

A distinction important to make is whether intraoperative complications are a result of errors in technique, lack of proper planning, or complications due to underlying patient disease. It is of considerable importance for surgeons to develop a technique or plan and stick with it to the best of their ability; this strategy will give surgeons the most control they may have to avoid adverse events. Medical decision making related to patient indication and selection is also of significant importance. It is opportune to explore a variety of common total joint arthroplasty scenarios that surgeons may consider relevant to patient selection.

TOTAL KNEE ARTHROPLASTY (TKA)

As the adage ...