What are the contraindications for Total Knee Replacement (TKR)?

Contraindications of Total Knee Replacement (TKR)

Total knee replacement is contraindicated in patients with active knee infection, poor quadriceps function, and severe peripheral vascular disease that would compromise wound healing.

Absolute Contraindications

• Active infection in the knee joint: Active infection presents a significant risk of prosthetic infection, which is one of the most serious complications of TKR 1
• Poor function of the quadriceps muscle: Inadequate quadriceps function severely compromises postoperative rehabilitation and functional outcomes 1
• Severe peripheral vascular disease: Poor vascular status can lead to wound healing complications and increased risk of infection 2
• Poor skin coverage around the knee: Inadequate soft tissue coverage increases the risk of wound complications and infection 2

Relative Contraindications

Medical Conditions

• Uncontrolled or poorly controlled systemic infection: Increases risk of seeding the prosthesis
• Significant medical comorbidities: High surgical risk patients who may not tolerate the procedure 1
• Severe immunocompromise: Higher risk of infection and poor healing
• Neuropathic joint (Charcot joint): Risk of prosthetic failure due to lack of proprioception

Anatomical/Functional Issues

• Painless, well-functioning knee fusion/arthrodesis: No functional benefit to converting to TKR
• Severe ligamentous instability: May require more constrained prosthesis or be unsuitable for standard TKR
• Recurrent or unreconstructable extensor mechanism disruption: Critical for knee function post-TKR

Patient Factors

• Unrealistic expectations: Patient satisfaction is a key outcome measure, with satisfaction rates ranging from 75% to 89% 3
• Non-compliance with rehabilitation: Rehabilitation is essential for optimal outcomes
• Morbid obesity: While not an absolute contraindication, extreme obesity increases technical difficulty and complication rates

Risk Factors for Poor Outcomes

• Infection history: Previous septic arthritis or osteomyelitis increases risk of prosthetic infection
• Multiple previous knee surgeries: Increased scarring and altered anatomy
• Severe deformity: Requires more complex surgical planning and may need specialized implants
• Young, high-demand patients: Higher risk of early implant failure due to increased activity levels

Preoperative Considerations

Before proceeding with TKR, patients should undergo:

1. Thorough evaluation for infection: Including laboratory markers (ESR, CRP) and joint aspiration if infection is suspected
2. Vascular assessment: Especially in patients with diabetes or known vascular disease
3. Evaluation of bone quality: Poor bone stock may require specialized implants or techniques
4. Assessment of neurological status: Particularly important in patients with neuropathy

Perioperative Risk Management

For patients who do undergo TKR, several interventions improve outcomes 2:

• Systemic antibiotic prophylaxis
• Aggressive postoperative pain management
• Perioperative risk assessment and management of medical conditions
• Preoperative education
• Thromboprophylaxis with appropriate anticoagulation 4

Special Considerations

• Technical factors: Proper alignment of the prosthesis is critical for long-term success 2
• Surgeon experience: Higher surgeon and hospital procedure volumes are associated with better outcomes 2
• Revision TKR: Has inferior outcomes compared to primary TKR, with contraindications including persistent infection, poor bone quality, limited quadriceps function, poor skin coverage, and poor vascular status 2

Common Pitfalls

• Underestimating infection risk: Always thoroughly evaluate for infection before proceeding with TKR
• Inadequate preoperative planning: Failure to account for deformity or bone defects can lead to poor outcomes
• Proceeding with surgery in cases of unexplained pain: "In cases of unexplained pain, reoperation is unwise and frequently associated with suboptimal results" 3
• Neglecting to assess quadriceps function: Critical for postoperative success

Understanding these contraindications is essential for appropriate patient selection, which is a key factor in achieving the high success rates (93-98% at 10 years, 85-95% at 15 years) reported for TKR 1.