Injury Risk to Extraosseous Knee Vasculature During Osteotomies: A Cadaveric Study With CT and Dissection Analysis

Abstract

Background Realignment osteotomies about the knee may be performed as distal femoral or proximal tibial osteotomies; both may be performed either on the medial or lateral sides of the knee, in closing-or opening-wedge fashion. Although rare, injury to neurovascular structures may occur, and the proximity of the vascular structures to the osteotomy saw cuts has been incompletely characterized. Questions/purposes We performed a cadaver study to assess the risk of vascular injury in patients undergoing realignment osteotomies by (1) quantifying the distances between osteotomy saw cuts and blood vessels using threedimensional CT reconstruction after distal femoral and proximal tibial osteotomies; and (2) qualitatively describing the small-and medium-sized vasculature around the knee, to provide the link between the CT analysis and wedge incision measures, and better show the potential extraosseous supply to the regions investigated. Methods Twelve human cadaveric knees were injected with a latex and barium sulfate suspension into the superficial femoral artery. Each specimen underwent CT to evaluate vascular perfusion and was randomized to either a lateral opening-wedge distal femoral osteotomy and medial opening-wedge proximal tibial osteotomy group, or a medial closing-wedge distal femoral osteotomy and lateral closing-wedge proximal tibial osteotomy group. Postoperatively, knees underwent CT in extension to measure the shortest distance between the osteotomies and the popliteal artery, anterior and posterior tibial arteries, and genicular arteries. Vessels between 5 mm and 10 mm from the osteotomy cut were considered in a zone of moderate risk for damage, while vessels less than 5 mm from the cut were considered in a zone of high risk for damage. Vessels more than 10 mm from the cut were not considered to be at risk. Subsequently, knees underwent dissection and chemical débridement to qualitatively describe the smaller One of the authors certifies that he (SB) has received grants during the study period, an amount of USD 10,000 to 100,000 from ''Fondazione Enrico ed Enrica Sovena'' (Rome, Italy), a nonprofit foundation that partially sponsored his fellowship at the Department of Orthopaedics vessels. This part of the study added visual information and gave a comprehensive overview of the vessels at risk. Results All variations of the osteotomies put at least one artery at risk. The popliteal artery was found in a risk zone for injury in two specimens during closing-wedge distal femoral osteotomy (median distance, 11.6 mm; range, 5.2-14.6 mm). The superior lateral genicular artery was in a risk zone in all the specimens during opening-wedge distal femoral osteotomy (median distance, 3.0 mm; range, 0.7-6.5 mm), and in five specimens during closing-wedge distal femoral osteotomy (median distance, 4.5 mm; range, 1.3-11.2 mm). A concomitant risk for superior medial genicular artery injury was observed in five specimens during opening-wedge distal femoral osteotomy (median distance, 8.7 mm; range, 0.8-13.9 mm) ...

CORR Insights®: Injury Risk to Extraosseous Knee Vasculature During Osteotomies: A Cadaveric Study With CT and Dissection Analysis

“…More studies, similar to those of Bisicchia et al [3] and others investigating the blood supply around the knee [10,12,18], are required to expand our knowledge on the patterns and distribution of blood supply in these regions. Such studies have the capacity to create a representative database, which may then facilitate improvements in the surgical techniques for knee osteotomies, enhance osteotomy and wound healing and reduce complications.…”

“…Bisicchia et al [3] investigated the extraosseous blood supply of the knee and assessed the risk of damage to these vessels during DFO and PTO. They showed that, in every one of the 12 osteotomies investigated, one or more arteries were at risk.…”

“…The study of Bisicchia et al [3] brings important new information to this area, not only by identifying which vessels are more susceptible to injury during knee osteotomies, but also by describing the poor blood supply of the tissues covering the medial tibia. This information complements the finding that a PTO performed through an oblique incision over the medial tibia has an increased infection risk [9].…”

Periosteal vascularization of the distal femur in relation to distal femoral osteotomies: a cadaveric study

“…Osteotomies may cause bleeding complications not only as periosteal vessels are cut in the trajectory of the osteotomy bone cuts, but also when larger vessels near to the bone are not protected. Previous conducted cadaveric studies mainly have focused on high tibial osteotomy and the associated risk to the larger vessels (Darnis et al 2014 ; Kim et al 2010 ; Bisicchia et al 2015 ; Tindall et al 2006 ; Georgoulis et al 1999 ; Ebraheim et al 1998 ). With respect to the medial side of the distal femur, the vascular anatomy has been studied in the midvastus approach in total knee replacement surgery (Başarir et al 2006 ; Scheibel et al 2002 ).…”

“…Specific literature on the vascular anatomy related to distal femoral osteotomies is scarce (Visser et al 2013 ; Bisicchia et al 2015 ). Visser et al ( 2013 ) described a less invasive approach to the distal medial aspect of the femur in biplanar medial closed-wedge distal femoral osteotomy, which proved to be feasible and safe.…”