A 72-year-old gentleman presented with end stage osteoarthritic symptoms affecting his right knee and had failed conservative management. He had a medical history of obstructive sleep apnoea, ulcerative colitis and ischaemic heart disease. He had no known allergies. He underwent a routine right total knee replacement (NexGen LPS Flex, Zimmer Inc., Warsaw). This is the standard default implant used by the senior surgeon. It is a cemented, cruciate sacrificing implant. The senior surgeon routinely does not resurface the patella as part of the procedure. The procedure was performed under a spinal anaesthetic. As per routine, a high thigh tourniquet was applied (inflated following draping to a pressure of 300 mmHg). The skin was prepped with alcoholic Chlorhexidine and draped as per standard. The procedure was carried out by the senior surgeon as per routine.
The enhanced recovery protocol was followed which included the infiltration of 150 ml Ropivocaine with Adrenaline 1:1000 (1 mg/2 ml) into the surgical site including the deep posterior capsule and peri-articular tissue. As is routine practice in our institution, no surgical drain was utilised and prior to tourniquet release, an Opsite dressing (Smith & Nephew) was applied to the wound with the knee in 90° flexion. The leg was also bandaged with cotton wool and crepe bandage.
The patient, 2 h post-operatively, developed large haemorrhagic blisters throughout the operated limb starting at the level of the thigh. This was monitored on the ward and his leg was elevated. He was given venous thrombo-embolic prophylaxis with Enoxaparin 40 mg subcutaneously once daily at night.
The patient was improving his range of movement to 0-80° by day 3 post-operative, with the aid of the physiotherapists. However, he was developing an increasing number of blisters of increasing size in his operated side lower limb which was giving rise to concern. He was started on prophylactic intravenous antibiotics as these blisters were de-roofing. He had an inpatient stay of 14 days to keep a close supervision of the wound and blistering.
This patient was followed up in the outpatient clinic. The blistering did eventually settle at four weeks and without a resulting deep infection. The patient was followed up in the outpatient clinic regularly till 12 months post-operatively where he was discharged from clinic with Oxford Knee Scores comparable to other satisfied patients following knee arthroplasty.
Figure 1 shows a clinical photograph of the profound blistering at day 10 and Figure 2 shows the same at 6 months.