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

Contraindications for Total Knee Replacement (TKR)

Total knee replacement is contraindicated in patients with active knee infection, poor quadriceps function, poor vascular status, inadequate skin coverage, and in cases of unexplained knee pain. 1, 2, 3

Absolute Contraindications

• Active infection in the knee joint: This is a primary contraindication as implanting a prosthesis in an infected environment leads to prosthetic infection, a serious complication requiring revision surgery 2

• Poor quadriceps muscle function: Severely compromised quadriceps function prevents proper knee stability and function post-operatively 3

• Inadequate vascular status: Poor circulation compromises wound healing and increases infection risk 1, 2

• Poor skin coverage: Inadequate soft tissue envelope increases risk of wound complications and deep infection 2

• Unexplained knee pain: The American College of Radiology emphasizes that "in cases of unexplained pain, reoperation is unwise and frequently associated with suboptimal results" 1

Relative Contraindications

• High surgical risk: Patients with severe comorbidities that significantly increase perioperative mortality risk 3

• Neuropathic joint disease: Patients with diminished pain sensation and proprioception may have poorer outcomes 1

• Severe osteoporosis: Poor bone quality may compromise implant fixation and increase risk of periprosthetic fracture 1

• Morbid obesity: While not an absolute contraindication, extreme obesity increases technical difficulty and complication rates

• Unrealistic expectations: Patients expecting complete restoration of athletic function may be dissatisfied with outcomes

Considerations in Special Populations

• Younger patients: Higher activity levels may lead to earlier implant wear and need for revision

• Elderly patients with limited mobility: The risk-benefit ratio may not favor surgery if the patient has minimal functional demands

• Patients with contralateral limb amputation: Special consideration needed for alignment and biomechanical factors 4

Pre-operative Assessment to Identify Contraindications

1. Infection screening:

   • Laboratory markers (ESR, CRP)
   • Joint aspiration if infection suspected 1

2. Vascular assessment:

   • Particularly important in patients with diabetes or known vascular disease 1
   • Assess for adequate circulation for wound healing

3. Neurological evaluation:

   • Assess for neuropathy which may affect post-operative outcomes 1

4. Bone quality assessment:

   • Poor bone stock may require specialized implants or techniques 1

Common Pitfalls in Patient Selection

• Failure to identify infection: Thorough preoperative evaluation is essential to rule out occult infection

• Attributing pain to osteoarthritis when another cause exists: Pain may be referred from hip or spine pathology

• Underestimating the importance of quadriceps function: Adequate extensor mechanism is crucial for successful outcomes

• Proceeding with TKR in patients with unexplained pain: This often leads to poor outcomes and patient dissatisfaction 1

Decision-Making Algorithm

1. Confirm appropriate indication: severe pain and functional limitation with radiographic evidence of joint damage 5, 2
2. Rule out all contraindications, particularly active infection
3. Ensure adequate vascular status and soft tissue coverage
4. Verify sufficient quadriceps function
5. Assess patient's medical fitness for surgery
6. Consider patient expectations and likelihood of satisfaction

When properly selected, TKR provides substantial improvements in pain reduction and functional improvement in approximately 90% of patients, with about 85% reporting satisfaction with surgical results 2.