Popliteal artery injury during knee replacement

Abstract

Popliteal artery injury (PAI) is a feared complication during knee replacement. Our aim was to investigate those injuries that occurred in association with knee replacement in terms of the type of injury, treatment and outcomes. From our national vascular registry (Swedvasc) and the Swedish Patient Insurance databases a total of 32 cases were identified. Prospective data from the registries was supplemented with case-records, including long-term follow-up. We estimated the incidence during 1998 to 2010 to be 0.017%. In our series of 32 patients with PAI occurring between 1987 and 2011, 25 (78%) were due to penetrating trauma and seven were caused by blunt trauma. The patients presented in three ways: bleeding (14), ischaemia (7) and false aneurysm formation (11), and five occurred during revision surgery. A total of 12 injuries were detected intra-operatively, eight within 24 hours (3 to 24) and 12 at more than 24 hours post-operatively (2 to 90 days). Treatment comprised open surgery in 28 patients. Patency of the vascular repair at 30 days was 97% (31 of 32, one amputation). At the time of follow-up (median 546 days, mean 677 days (24 to 1251)), 25 patients had residual symptoms. Of seven patients with a complete recovery, six had had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital. PAI is a rare adverse event during knee replacement surgery. The outcome following such events is often adversely affected by diagnostic and therapeutic delay. Bleeding and false aneurysm were the most common clinical presentations.

The national incidence of iatrogenic popliteal artery injury during total knee replacement

“…7-10 Unfortunately, as this was a database study the cause of popliteal artery injury could not be ascertained but previous reports have stated that the utilization of tourniquets, thrombosis via blunt injury or direct penetrating injury with orthopedic instruments are all causes of popliteal injury. 2 The detection of injury early is associated with limb salvage as prompt vascular intervention may be instituted. 2 We had no amputations in our patient population and that may be related to the fact that 96% of patients had their injury noted either intra-operatively during TKR or during the same day of TKR.…”

“…2 The detection of injury early is associated with limb salvage as prompt vascular intervention may be instituted. 2 We had no amputations in our patient population and that may be related to the fact that 96% of patients had their injury noted either intra-operatively during TKR or during the same day of TKR. It is also important to note that the NIS database is a 20% weighted sample of the entire in-hospital admission patient population and hence this 0% amputation rate underestimates the actual incidence; 100% of patients had their vascular injury detected by 3 days post TKR.…”

“…There are currently 4.0 million patients in the US with a TKR. 1,2 One of the most dreaded complications of TKR is injury to the popliteal vessels that are in close proximity to the joint. Popliteal artery injury is associated with the highest rates of amputation of all extremity vasculature injuries as tibial run-off to the distal extremity may be dependent on this single vessel.…”

“…3,4 Trauma to the popliteal artery and/or vein during a TKR can result in hemorrhage, infection, graft loss, functional abnormalities and even loss of the limb. [1][2][3][4][5] In the elderly patient population injury and manipulation of the popliteal vasculature may result in immobilization which could lead to higher rates of deep vein thrombosis and/or pulmonary embolism which are already highest for the orthopedic patient population. 6 Popliteal artery injury during TKR is a rare occurrence making studying the incidence of this complication challenging.…”

“…Case series from single institutions or and small multicenter studies place the incidence between 0.03 and 0.17%. 2,[7][8][9][10] This uncommonness of popliteal vasculature injury during TKR makes studies about its overall incidence, trends and outcomes difficult at a local level. The National Inpatient Sample (NIS) is a large, national database inclusive of a 20% stratified sample of all inpatient hospital admissions to non-governmental hospitals in the USA.…”