Case series and literature review: Popliteal artery injury following total knee replacement

Abstract

We present a case series and literature review of injury to the popliteal vessels during total knee replacement (TKR). This is rare but may be limb-threatening with devastating consequences for the patient. An individual surgeon will see few cases. Over a 28-month period 3913 elective TKRs were performed at three hospitals in East Anglia, United Kingdom. We present nine cases (0.23%) of popliteal artery injury following TKR. All required further investigation and intervention. The range of pathology included intra-operative haemorrhage (3 cases), thrombosis (2 cases), pseudo-aneurysm (3 cases) and arteriovenous fistula (1 case). Definitive treatment of the arterial injury was by primary repair (4 cases), interposition graft (2 cases), bypass graft (2 cases), endovascular stenting (1 case) and primary above-knee amputation (AKA; 1 case). There was morbidity in four patients: two AKAs, one case of foot-drop, and one unsightly fasciotomy scar. There was no mortality. Compared to other published studies (totalling 141 cases) complications resulting from direct arterial injury were significantly more common in our series. Incidence remains steady. More careful surgical technique may be the most effective preventative measure. Ongoing awareness is therefore essential for early diagnosis and management of this rare but serious complication.

Popliteal artery injury during knee replacement

“…Blunt trauma (one third of cases) led to thrombosis and occlusion. This supports some previous reports suggesting that penetrating, direct injury is a more common mechanism of injury, 15,16 and contradicts other reports. [10][11][12] There was no indication that the blunt injuries were caused by the tourniquet in any of the patients.…”

“…Others have confirmed thrombosis and indirect injury to be the main causes of ischaemia. 15,16 Time to detection and repair of the vascular injury seems to be crucial for limb salvage, 7-9,15,17 but the reasons behind diagnostic and therapeutic delays are poorly understood. Outcome in terms of functional impairment despite limb salvage has been barely investigated.…”

Pseudoaneurysm of a high-division anterior tibial artery following primary TKA

“…The authors believe that the laceration occurred during retraction of the lateral soft tissue, which may have occurred if the retractor was inserted too deeply or at an incorrect angle. Pseudoaneurysms usually develop after arterial laceration or transection caused by direct injury by sharp instruments [9, 10]. With the exception of a misplaced retractor, any instrument, including a vibrating saw, scalpel blade, or diathermy device, could lead to direct injury.…”

Popliteal artery thrombosis following total knee arthroplasty managed successfully with percutaneous intervention

“…Hyperextension of the knee joint during preparation of the patella leads to tensing and kinking of the popliteal artery, thereby predisposing to PAT in an atherosclerotic vessel. A recent case series reported two cases of PAT among 3913 elective total knee replacements, with the first patient having acute PAT on the second postoperative day and the latter having subacute PAT at 6 weeks 2. Both patients were managed surgically with venous bypass grafts.…”