Total Knee Replacement and untreated IHD

PIG Meeting: 29th April 2021

60-year-old man for TKR

Background

  • Severe Rheumatoid arthritis, neck subluxation – stable on Humira
  • Dasi 3.6 METs. No exertional symptoms
  • CVA- on DAPT. Residual hemianopia, ataxia, and seizures
  • Aortic root dilatation – stable on TTE no intervention required at present.

Issues

1. IHD

  • RMWA noted on previous TTE, nil hx of IHD
  • Unable to exert himself due to physical limitations
  • Sestamibi showed a large LAD territory perfusion defect
  • Discussed at cardiology-anaesthetics meeting -> angio
  • Angio – occluded LAD, filling via collaterals, not amenable to PCI and therefore no strategies to reduce his perioperative M&M risks.
  • Cardiologist’s letter suggests PCI may be required in the future if he develops exertional symptoms post TKR.

2. Should surgery proceed?

  • Risk of MACE 6.6% (moderate).
  • SORT score <1% risk of death, NSQIP 5.5% serious complication
  • Risks of poor wound healing or infection with immunosuppression, or flair of RA with known severe disease may not be captured by these scoring systems.
  • Main complaint is pain, mobility is already severely limited by RA
  • Noted that the rate of persistent knee pain after TKR is not insignificant
  • Given significant perioperative risks, proceeding with TKR needs careful consideration.
  • Geniculate nerve block is a possibility if main issue is pain (rather than function)

3. Postoperative location if OT proceeds?

Extended period in recovery to ensure excellent pain relief, electrolytes normal and Hb adequate, as this man is at high risk of demand ischaemia.

Plan:

  • For discussion with patient and surgical team re. definitive analgesic options ?geniculate neurolysis

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