Cognitive Dysfunction After Total Knee Arthroplasty: Effects of Intraoperative Cerebral Embolization and Postoperative Complications

doi:10.1016/j.arth.2005.05.004

The Journal of Arthroplasty

Volume 20, Issue 6, September 2005, Pages 763-771

https://doi.org/10.1016/j.arth.2005.05.004 Get rights and content

Abstract

Cerebral emboli identified as high-intensity transient signals (HITS) occur during total knee arthroplasty (TKA). Their effects on cognitive outcome remain speculative. Intraoperative HITS and postoperative complications were correlated with the cognitive function of TKA patients. Cognitive function was assessed both before and after surgery (1 week and 3 months). High-intensity transient signals occurred in 22 of 37 patients. Counts of HITSs were higher in patients with sonographically detected intracardiac shunts. Cognitive dysfunction was found in 41% of patients at 1 week, but in only 18% at 3 months. High-intensity transient signal counts were not associated with the prevalence of cognitive deficits. At 1 week, 58% of patients with cognitive deficits had at least 1 postoperative complication (6% in nondeficit patients). All cognitively impaired patients at 3 months had complications (17% in the nondeficit group). This raises the possibility that postoperative complications might be associated with cognitive dysfunction in TKA patients.

Section snippets

Patient Population and Study Design

After approval from the institutional ethics review board and after obtaining informed consent, we enrolled patients who were undergoing elective unilateral TKA and were free of neurologic disease, psychiatric illness, or history of deep venous thrombosis, stroke, or cardiac or neurologic surgery. Only patients who had completed at least grade 6 education and could read were included. We arbitrarily selected a convenience sample of 37 patients in this observational study.

Neuropsychological Assessment

A baseline assessment

Demographics

Thirty-seven patients (20 women) participated in the study. The average age of our population was 69 ± 9 years (range, 45-82 years). Six patients refused cognitive assessment and consented only to TTE and TCD. Of the 31 patients who had baseline cognitive testing, 29 underwent a second assessment before discharge (1 week), but only 28 were tested at 3 months after the surgery. Twenty-seven patients completed all 3 cognitive assessments. The refusals before discharge (n = 2) were due to pain and

Discussion

Several studies 1, 4, 5, 6, 7 have suggested that postoperative clinical manifestations associated with systemic embolization after TKA range from no complications to coma or death. Although cerebral embolization is a relatively frequent phenomenon during these procedures [4], it is not clear whether the presence of these embolic elements in the brain may affect the postoperative cognitive function of these patients. Forty-one percent of our patients showed cognitive dysfunction 1 week

Acknowledgments

We thank the surgical staff of the Division of Orthopedic Surgery for their cooperation in this investigation. We also acknowledge the support of the Department of Surgery at the University of Ottawa for data analysis. The cooperation of echocardiography technicians, anesthesia staff, nurses, and Mr Carlos D. Rodriguez is gratefully appreciated.

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Citation Excerpt :
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To investigate the effects of dobutamine hydrochloride on early postoperative cognitive dysfunction (POCD) and plasma tumor necrosis factor (TNF)-α concentration in patients undergoing hip arthroplasty, 124 patients undergoing unilateral total hip arthroplasty, aged 70–92 years old, were randomly assigned to four groups (n=31) as follows: a control group of patients receiving only saline (intravenous infusion, i.v.); and groups receiving 2, 4, or 6 μg kg⁻¹ min⁻¹ (i.v.) of dobutamine hydrochloride. Cognitive functions were assessed on the day before surgery (T1), and the 1st day (T2), 3rd day (T3), and 7th day (T4) postsurgery using the Mini Mental State Examination (MMSE). The plasma TNF-α protein level was determined 10 min before anesthesia (Ta), and 10 min (Tb), 30 min (Tc), and 60 min (Td) after anesthesia by an enzyme-linked immunosorbent assay. Cognitive disorder was observed within the first 3 days after hip arthroplastic surgery, and it had recovered 7 days after the operation in the control group of patients. Administration of 2 or 4 μg kg⁻¹ min⁻¹ dobutamine hydrochloride was able to reverse the early POCD. Simultaneously, an increase of plasma TNF-α levels 30 min after anesthesia was observed (41.34±9.61 vs. 27.75±5.45), which was significantly suppressed by the administration of low-dose dobutamine hydrochloride (29.23±7.32 vs. 41.34±9.61) but not by high-dose dobutamine hydrochloride (45.9±12.11 vs. 41.34±9.61). Together, our data indicated that the plasma concentration of TNFα was engaged in the effect of dobutamine hydrochloride on POCD.
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This meta-analysis consolidated the research on postoperative cognitive dysfunction (POCD) following total joint arthroplasty (TJA). Data from 17 studies that assessed cognition pre- and post-surgery in TJA patients alone (15 studies) or matched TJA and control groups (2 studies) were analysed. Results were grouped by cognitive domain (memory, attention, language, speed, general cognition) and follow-up interval (pre-discharge, 3-6 months post-surgery). The TJA data revealed small declines in reaction time and general cognition pre-discharge, but no evidence of decline 3–6 months post-surgery. Very limited TJA and Control data indicated no group differences in the changes to performance over time; however, the TJA group was cognitively compromised pre- and post-surgery compared to Controls. Further appropriately controlled research is required to clarify whether POCD commonly occurs after TJA.
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Bilateral total knee replacement is becoming one of the more commonly performed orthopedic procedures for patients with advanced arthritis of both knees. The surgeon may decide to operate on both knees simultaneously, sequentially, or in a staged manner. The safety of this procedure is still debated due to wide variation in the studies and their endpoints. Although there are advantages with bilateral procedures such as reduced cost and improved rehabilitation, there is definite evidence of increased cardiopulmonary, thromboembolic, neurological, bleeding, and transfusion complications with bilateral knee replacement versus unilateral knee replacement, particularly in elderly patients with comorbidities.
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To estimate the accuracy of regional cerebral oxygen saturation (rSO₂) in predicting postoperative cognitive dysfunction (POCD) for patients undergoing total hip arthroplasty, 46 patients aged more than 50 years old were enrolled. We measured the patients’ cognitive function by using a battery of six neuropsychological tests before surgery and then 7 days after surgery again. rSO₂ was continuously monitored by near-infrared spectroscopy during surgery. POCD was present in 9 (19.6%) patients 1 week after surgery. Logistic regression analysis showed that increasing age [OR = 1.224, P = 0.035] and maximum percentage drop in rSO₂ (rSO_2%max) [OR = 1.618, P = 0.011] were significant risk factors for POCD. The area under the receiver operating characteristic curve of rSO_2%max was 0.833 [95% confidence interval (CI) 0.615–1.051] at cutoff value of 11%. The specificity and sensitivity of rSO_2%max > 11% in predicting POCD were 77.8% and 86.5%, respectively. rSO_2%max more than 11% was a potential predictor for POCD.
A Prospective Randomized Study to Compare Systemic Emboli Using the Computer-Assisted and Conventional Techniques of Total Knee Arthroplasty
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Original ArticleCognitive Dysfunction After Total Knee Arthroplasty: Effects of Intraoperative Cerebral Embolization and Postoperative Complications

Abstract

Section snippets

Patient Population and Study Design

Neuropsychological Assessment

Demographics

Discussion

Acknowledgments

J Arthroplasty

J Arthroplasty

J Psychiatr Res

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Br J Anaesth

Br J Anaesth

Ann Thorac Surg

Patent foramen ovale and brain microembolization during scoliosis surgery in adolescents

Spine

Transpulmonary systemic fat embolism. Studies in mongrel dogs after cemented arthroplasty

Am J Respir Crit Care Med

Cerebral microembolism diagnosed by transcranial Doppler during total knee arthroplasty: correlation with transesophageal echocardiography

Anesthesiology

Cerebral infarction after deflation of a pneumatic tourniquet during total knee replacement

Anesthesiology

Acute brain fat embolization occurring after total hip arthroplasty in the absence of a patent foramen ovale

Anesthesiology

The Quick Test (QT)

Provisional Manual Psychol Rep

Geriatric depression scale

Psychopharmacol Bull

Original Article
Cognitive Dysfunction After Total Knee Arthroplasty: Effects of Intraoperative Cerebral Embolization and Postoperative Complications