Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy

Abstract

Purpose Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF). Methods Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined. Results Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication. Conclusion Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

Exploration of the relationship between the level of popliteal artery injury and the risk of amputation

“…A high level of injury often means that the adequate collateral circulation of the affected limb is preserved less, the distal limb is severely ischemic, and the risk of amputation is high. It is recommended that the surgeon should strive to establish adequate circulation as soon as possible [27][28][29][30] and choose external xation brackets to initially x the fracture and immediately treat the blood vessels [3,[31][32][33]. For patients with low injury planes, due to the presence of more collateral circulation to provide blood for the distal ischemic limb, the risk of amputation is relatively low.…”

“…Therefore, in cases of mild contamination and acceptable soft tissue conditions, the surgeon should try to choose a one-stage fracture internal xation surgery to facilitate early functional exercise of the knee joint after surgery [31][32][33].…”

“…Popliteal artery injury (PAI) is a di cult-to-treat lower limb injury [1] and one of the most threatening peripheral vascular injuries [2,3]. When accompanied by severe soft tissue damage or prolonged limb ischemia, there is often a higher risk of amputation [4][5][6][7].…”

Vascular Injury After Knee Dislocation: A Meta-Analysis Update

“…Studies by Held et al 36 and Plancher and Siliski 37 found higher amputation rates between 10% and 25% in patients with PA injury from KD. Hundersmarck et al 38 showed positive long-term outcomes of (1) early revascularization and (2) bone stabilization before vascular repair if ischemia duration allows.…”

Popliteal Artery Injuries: Incidence, Clinical Patterns and Outcomes (A Single Center Study in Yemen)

“…Treatment of popliteal artery injuries requires prompt and effective action to prevent further damage and potential loss of limb [4]. Diagnosis of popliteal artery injuries involves a thorough physical exam, imaging studies, and assessment of blood flow to the affected area [5].…”