Arterial and ischemic aspects of total knee arthroplasty.

Prospective and retrospective analyses of 1,182 consecutive patients undergoing primary total knee arthroplasty (TKA) were performed to determine (1) the incidence of chronic lower extremity ischemia (CLEI); (2) the effect of tourniquet occlusion; and (3) guidelines that will allow TKA to be performed safely. Despite the appropriately advanced age of our patients, the incidence of CLEI was only 2%. All ischemic complications occurred in six patients with CLEI (25%), but none resulted in death or amputation. The ischemic complications consisted of pressure-induced necrosis of toes, heel, or foot, atheroembolism, femoral-popliteal graft occlusion, and asymptomatic popliteal occlusion. Tourniquet compression in the 1,158 patients without CLEI produced no untoward effects. Patients with mild CLEI can have a TKA performed safely with a tourniquet if there is no femoropopliteal calcification. When the ischemia is severe or there is a femoropopliteal aneurysm, arterial reconstruction should precede the TKA. In patients with patent femoral-popliteal bypasses or calcification without ischemia, TKA should be performed without a tourniquet. Ischemic pressure necrosis is an additional mechanism of injury.