Silent compartment syndrome complicating total knee arthroplasty: Continuous epidural anesthesia masked the pain

doi:10.1016/S0883-5403(00)90440-6

The Journal of Arthroplasty

Volume 15, Issue 2, February 2000, Pages 241-243

https://doi.org/10.1016/S0883-5403(00)90440-6 Get rights and content

Abstract

Posterior dislocation is an uncommon complication of total knee arthroplasty (TKA) using a posterior stabilized total knee prosthesis, and it usually results from flexion instability. Acute posterior dislocation of a posterior stabilized prosthesis complicated by compartment syndrome of the leg has not previously been reported in the literature. We report a 62-year-old woman with posterior dislocation of her posterior stabilized TKA when her knee was in extension. It was further complicated by compartment syndrome with severe muscle necrosis. The diagnosis of compartment syndrome was delayed, partly because of continuous epidural anesthesia that completely abolished the pain and partly because of the low index of suspicion, as compartment syndrome is not well recognized as a possible complication of TKA. This case report strongly emphasizes that continuous epidural anesthesia is contraindicated in the case of complicated TKA because important clinical cues to neurovascular complications could be masked.

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If well documented, almost all published cases showed that patient complained about increasing pain despite RA,70 loss of motor function despite reduction of local anesthetic concentration,68 or increasing analgesic demand.22 Only in 4 cases in literature, a dense motor block after EDA at the time of diagnosis was observed.93,94 Nerve blocks have been blamed for masking ACS in a territory the block did not even theoretically cover.69
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Nonetheless, treatment options with endovascular devices that can treat occlusions or even thrombi might not provide satisfactory results [4,11-14]. Some of these lesions can still be treated by open surgery with exploration and repair, mainly when the lesion produces ischemic changes or compartment syndrome, and fasciotomies are required [7-9,15,16,18,24]. Despite the need for amputation in our patient, studies report a low incidence of amputations as definitive management for these patients, and it must come as an option after multiple surgical procedures that include debridement of necrotic tissue, failed fasciotomy closure, failed revascularization, among others [4,7,11].
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Accurate ICP measurement is especially important when assessing for ACS in patients who are incapacitated or unable to provide reliable answers. Vigilant monitoring of ICP is also critical in patients in whom epidural anesthesia is in use because motor and sensory symptoms of ACS can be easily masked.10,14,15 Other diagnostic considerations including the use of ancillary testing such as laboratory testing or imaging are briefly discussed.
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Case reportSilent compartment syndrome complicating total knee arthroplasty: Continuous epidural anesthesia masked the pain

Abstract

J Arthroplasty

Arthroscopy

J Arthroplasty

The total condylar knee prosthesis: a report of two hundred and twenty cases

J Bone Joint Surg Am

Posterior dislocation of a posterior-stabilized total knee arthroplasty: a report of two cases

Am J Orthop

Posterior dislocation of total knee arthroplasty

Clin Orthop

Common complications of total knee arthroplasty

J Bone Joint Surg Am

Case report
Silent compartment syndrome complicating total knee arthroplasty: Continuous epidural anesthesia masked the pain