KNEE
Iatrogenic popliteal artery injury in non arthroplasty knee surgery
K. Bernhoff, M. Björck From Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intraoperatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support. Cite this article: Bone Joint J 2015;97-B:192–6.
K. Bernhoff , MD, Consultant Orthopaedic Surgeon, Department of Surgical Sciences M. Björck , MD, PhD, Professor (Chair) in Vascular Surgery, Department of Surgical Sciences Uppsala University, SE 75185, Uppsala, Sweden. Correspondence should be sent to Mrs K. Bernhoff; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B2. 34353 $2.00 Bone Joint J 2015;97-B:192–6. Received 10 May 2014; Accepted after revision 27 October 2014
192
Vascular injury is a rare but potentially devastating complication after orthopaedic procedures. The reported incidence in the literature varies between 0.005 and 0.5%1-5 depending on the procedure. The popliteal artery is the most common major vessel involved in iatrogenic orthopaedic injuries. 1 Situated, in close relation to the posterior capsule of the knee, it is at risk of injury during common procedures such as knee arthroplasty or osteotomy.6 Knee arthroplasty is probably the most common orthopaedic procedure resulting in iatrogenic popliteal artery injury according to a previously reported population-based study.7 Vascular iatrogenic injuries have been increasing over time but probably only due to the increasing number of surgical procedures.8,9 The most common presentations of arterial injuries are intra-operative bleeding, acute ischaemia with loss of peripheral pulses, non-healing wounds, and limb oedema.10 Time to detection and repair of the vascular injury is crucial for limb salvage,2,11-14 but the reasons behind diagnostic and therapeutic
delays are poorly characterised. Outcomes in terms of functional impairment following limb salvage, have barely been investigated.13 The primary aim of this study was to investigate popliteal artery injuries in orthopaedic procedures other than knee arthroplasty and to define successful strategies for detection and action when iatrogenic injury occurs. Secondary aims were to study risk factors, methods of repair, long-term outcome and likelihood of litigation.
Patients and Methods The Swedish Vascular Registry (Swedvasc), established in 1987,15 which is a prospectively collected database, was searched to identify all iatrogenic popliteal artery injuries between 1987 and 2011. Clinical data were reviewed to determine the type of orthopaedic procedure, mechanism of injury, type of vascular repair and outcome. The identified cases were cross-referenced with the Swedish Patient Insurance (SPI) database where case records are archived. Prospective data from those databases were supplemented with retrospective data obtained from case record analysis. Both orthopaedic THE BONE & JOINT JOURNAL
IATROGENIC POPLITEAL ARTERY INJURY IN NON ARTHROPLASTY KNEE SURGERY
1070 iatrogenic vascular injuries
955 other 115 injuries to the anatomical locations popliteal artery
57 non orthopaedic injuries
53 orthopaedic injuries
32 after arthroplasty Bone Joint J 2013;95-B:1645–9
5 case records not identified
21 injuries non arthroplasty
Fig. 1 Flowchart showing injuries.
and vascular surgical case records were reviewed to determine the mechanism of injury, time to detection, time and method to restore the circulation, use of tourniquet and outcome. Patient health status before surgery was categorised using the American Society of Anesthesiologists (ASA) Physical Status Classification System.16 Long-term survival was obtained by linkage with the Swedish Population Registry (data sampling point: 2 January 2014) using the patients’ unique personal identity numbers and used in all the registries. Statistical analysis. Dichotomous variables were analysed with Fisher’s exact test, and continuous variables were analysed with two sample t-tests. The survival estimate with Kaplan-Meier analysis using 95 CIs set the endpoint at ten years of follow-up. A p-value < 0.05 was considered significant.This investigation was approved by the ethical committee of the Uppsala/Örebro region.
Results A total of 115 patients suffered iatrogenic injuries to the popliteal artery and were identified from the Swedvasc registry. It was possible to retrieve the case records from 110 of those patients (96%). In all, 57 were not due to orthopaedic procedures and were excluded. In the remaining 53 patients, all of whom suffered iatrogenic popliteal artery injury during orthopaedic surgery, 32 injuries occurred after knee arthroplasty and have been previously reported.7 This report is based on the 21 injuries (21 patients) which were associated with orthopaedic surgery other than arthroplasty (Fig. 1). The mean age of the 21 patients was 46 years (11 to 85) at the time of orthopaedic operation. There were 11 men and ten women. There were nine injuries to the left leg and 12 to the right. One patient had diabetes. Five patients had preexisting cardiovascular disease such as hypertension, angina or atrial fibrillation. None had undergone previous vascular VOL. 97-B, No. 2, FEBRUARY 2015
193
surgery. The ASA grading before surgery was seven patients classified as ASA 1, nine as ASA 2 and five as ASA 3. A total of 13 patients underwent elective orthopaedic surgery. The nature of the orthopaedic procedures associated with the iatrogenic injury is shown in Table I. The mean age of this group of patients was 41 years (15 to 63). Another eight patients underwent urgent surgery for either trauma or tumour resection (Table II). Their mean age was 54 years (12 to 85). There was no statistical difference in age between the two sample T-test groups (p = 0.14). Data on all 21 patients had been reported to the Swedvasc registry but only 12 to the SPI. Of the 13 injuries sustained during elective surgery, ten were reported to the SPI, but only two of the eight undergoing urgent surgery were reported (p = 0.029, Fisher exact test). The mean age in the group filing an insurance claim was 39 years (15 to 63), compared with 54 years (12 to 85) among those who did not file a claim (p = 0.098). The mechanism of vascular injury is described in Tables I and II. Procedures associated with popliteal artery injury. Arthroscopy: three arthroscopies with meniscal resection resulted in arterial injury. In two cases the surgeon describes difficulty in flexing the knee during the procedure. Meniscal resections were performed on the posterior parts of the lateral and medial menisci. One patient, who also suffered from haemophilia, developed recurrent haemarthrosis due to a pseudo-aneurysm. In Sweden there were 98 084 arthroscopies with meniscal resection performed during the years 1998 to 2011.17 The incidence of popliteal artery injury was 0.003%. Cruciate ligament reconstruction: there were two anterior cruciate ligament (ACL) reconstructions and one combined ACL and posterior cruciate ligament (PCL) reconstruction. All three procedures were arthroscopically assisted with a patellar ligament autograft. The PCL reconstruction involved hamstring tendon autograft. All three patients had significant intra-articular procedures, such as resection of the posterior horn of the lateral meniscus, or shaving within the popliteal fossa. One reconstruction involved the removal of a loose intra-articular screw from previous ACL surgery. This operation was performed with a posterior approach through the popliteal fossa. In Sweden there were 36 695 cruciate ligament reconstructions performed during the years 1998 to 2011.17 The incidence of popliteal artery injury was 0.008%. Tibial tubercle osteotomy: there were two popliteal artery injuries sustained during tibial tubercle osteotomies, performed for recurrent patellar dislocation. Both injuries occurred during drilling of the posterior tibial cortex, prior to fixation of the osteotomy. In Sweden there were 1813 tibial tubercle osteotomies performed during the years 1998 to 2011.17 The incidence of arterial injury was 0.11%. High tibial osteotomy (HTO): in all three HTOs associated with popliteal artery injury, the damage to the vessel occurred during the osteotomy. They presented in three
194
K. BERNHOFF, M. BJÖRCK
Table I. Elective orthopaedic procedures associated with popliteal artery injury in 13 patients Procedure
Age
Type of injury
Repair
Time to repair
Outcome
ACL reconstruction ACL reconstruction ACL+ PCL reconstruction ACL screw extraction Tibial tubercle osteotomy Tibial tubercle osteotomy HTO
24 54 36 32 15 22 42
Sharp, pseudo-aneurysm Sharp Sharp Sharp Sharp Sharp Sharp, pseudo-aneurysm
Coiling Direct anastomosis By-pass Interposition graft By-pass Interposition graft Direct suture
7 days 7 hours Immediate 2 to 7 hours 3 hours to shunt 6 hours 30 days
HTO
40
Sharp
Interposition graft
48 hours
HTO Arthroscopy Arthroscopy
63 44 55
Sharp Sharp, pseudo-aneurysm Sharp
Patch Thrombin injection Patch
Immediate 52 days 26 hours
Arthroscopy Arthrodesis
52 48
Sharp, pseudo-aneurysm Sharp, AV-fistula
Patch By-pass
4 days 23 years
Excellent Pain, loss of sensation Excellent Sensory loss Excellent Sensory loss Drop foot, sensory loss Drop foot, sensory loss Excellent Excellent Nerve injury, sensory loss Swelling, sensory loss Wounds healed
ACL, Anterior Cruciate Ligament; PCL, Posterior Cruciate Ligament; HTO, High Tibial Osteotomy; AV, Arteriovenous
Table II. Urgent orthopaedic procedures associated with popliteal artery injury in eight patients Procedure
Age
Type of injury
Repair
Time to repair
Outcome
Tibial condylar fracture, nonunion Distal femoral fracture Distal femoral fracture Intramedullary nailing of tibial fracture Resection of sarcoma Resection of sarcoma Tibial fracture external fixation Pathological subtrochanteric fracture
83 75 85 39 12 21 53 67
Blunt Cerclage wire strangulating Cerclage wire strangulating Sharp, pseudo-anerysm Intimal tear Sharp Sharp Sharp
By-pass By-pass By-pass By-pass By-pass By-pass Interposition graft By-pass
12 days 25 hours Immediate 6 weeks 14 days Immediate 12 hours 1 hour
Unknown Dead within 2 months Excellent Sensory loss Necrosis, impairment Amputation Pain, loss of sensation Dead within 6 months
different ways. One was immediately detected due to bleeding, one presented with a compartment syndrome after 48 hours, and one developed a pseudo-aneurysm detected 29 days later. In Sweden there were 6047 HTOs performed during the years 1998 to 2011.17 The incidence of associated popliteal artery injury was 0.05%. In the group undergoing inevitable or acute surgery, the mechanism was a direct injury to the artery in six of the eight patients. In four patients the injury was through a laceration to or penetration of the artery, resulting in instant ischaemia in three patients, and formation of pseudo-aneurysm in one. The remaining two patients in the direct-laceration group were caused by cerclage wiring being used to reduce a femoral fracture. In both patients angiography demonstrated arterial occlusion due to the cerclage wire. Of the two remaining patients who did not suffer direct lacerations to the artery, one had an intimal tear leading to thrombosis after four days. The other was associated with nonunion of a tibial condylar fracture with pre-existing peripheral vascular disease causing thrombosis in the affected limb. The most common presentation in all patients was intraoperative bleeding with acute ischaemia (n = 9, 43%). All of these injuries were detected immediately. However, five patients were diagnosed after a delayed presentation with
cyanosis and pain (24%) and were diagnosed after 12 or more hours. One patient developed a compartment syndrome due to bleeding, and the arterial injury was diagnosed after 24 hours. In five patients pseudo-aneurysms developed, and four of them had progressive sensation of swelling and pain. One patient, with associated haemophilia, developed recurrent haemarthroses as the mode of presentation. One patient presented several years after a knee arthrodesis with wound breakdown due to an arteriovenous fistula. In one patient with a direct injury to the vessel which was detected immediately due to bleeding, the surgeon was excising a sarcoma and could visualise the injury to the popliteal artery. This injury resulted in a transfemoral amputation. Of the nine immediately recognised vascular injuries, six occurred in hospitals with on-site vascular surgery support, and four had successful immediate vascular repair within one hour and had no adverse outcome. The patient undergoing sarcoma excision had emergency by-pass surgery but subsequent graft occlusion led to transfemoral amputation. In one patient, vascular reconstruction was delayed by diagnostic angiography. The circulation was restored only after seven hours, resulting in limb salvage but with permanent sensory loss and major functional impairment. There were three popliteal artery injuries which occurred in hospitals without immediate vascular surgery support, THE BONE & JOINT JOURNAL
IATROGENIC POPLITEAL ARTERY INJURY IN NON ARTHROPLASTY KNEE SURGERY
1.00
0.75
0.50 Numbers at risk (yrs) 0.25
Baseline
1
3
5
10
21
19
17
16
16
0.00 0
2
4
6
8
10
Analysis time Fig. 2 Kaplan–Meier survival curve showing the ten-year estimate.
two were private clinics and one a rural public hospital. In two of these patients, significant delays occurred before revascularisation was achieved (three and seven hours post injury) which resulted in significant long-term morbidity due to neurological injury. The early revascularisation of one of the three patients’ was performed with a temporary shunt followed by transfer to a regional vascular unit for definitive reconstruction. A full recovery was achieved. A total of five patients were diagnosed within 12 to 48 hours after surgery. Three of them presented with cyanosis and pain, one with a compartment syndrome, and one had a painful expanding pseudo-aneurysm in the popliteal fossa. There were seven patients who were diagnosed later than 48 hours (4 days to 23 years). Five of them had pseudoaneurysms and one an arteriovenous fistula detected 23 years after the surgical procedure. Finally, one patient had an intimal tear with thrombosis four days after surgery. The types of vascular intervention are described in Tables I and II. Nine patients (43%) had bypass surgery. In the urgent surgery group this was the most common operation, with seven of eight cases undergoing it (88%). A total of nine patients of the total group underwent fasciotomy as part of their treatment (43%). Long-term chronic residual symptoms were documented in 12 patients after one year or longer follow-up. The mean follow-up was 590 days (53 to 8527). In one patient there were incomplete data on outcome; although the graft was known to be patent, functional outcome was unknown. Two patients in the urgent group died within six months from the orthopaedic procedure (53 and 125 days). Both had undergone complicated and extensive surgery following hip fractures. One sustained a further fracture below the sliding hip screw and plate, and one underwent revision surgery with a proximal femoral replacement after a pathologic subtrochanteric fracture surgery. Overall survival of the patient at ten years is shown in Figure 2. In total, only six patients recovered fully. VOL. 97-B, No. 2, FEBRUARY 2015
195
Discussion We found a low incidence of popliteal arterial injury in non arthroplasty knee surgery in Sweden as recorded in national databases. In elective surgery there are four common procedures that were associated with this vascular injury: arthroscopy with meniscal removal, ACL/PCL reconstruction, tibial tubercle osteotomy and HTO. Arterial injury during arthroscopic procedures has been previously reported18-20 as well as after HTO.21,22 When addressing the question whether knee flexion protects the popliteal vessels from injury, Zaidi, Cobb and Bentley21 suggested that the popliteal artery comes closer to the tibia in flexion, while Nishimura et al6 concluded that the safest position to suture the lateral meniscus was in the ‘figure four’ position. Others support the opinion that the popliteal artery is safer when the knee is flexed.23,24 Our study shows that in general when arterial injury occurs in the absence of on-site vascular surgical support, outcomes will be poorer due to delay in time to revascularisation. When vascular injury was diagnosed in the early postoperative period, the signs of cyanosis and compartment syndrome appear to be the key findings. Delay greater than 12 hours is always associated with poor outcome. Regular documented examination of the peripheral pulses in the post-operative period remains an essential observation. Patients suffering vascular injury during an elective surgical procedure are more likely to pursue litigation. This finding was expected and concurs with previous reports.9,25 The limitations of this study include possible underreporting to the Swedvasc registry. The registry has been validated on several occasions comparing data with the Inpatient registry used for reimbursement; showing excellent external validity, well above 90% for core surgery.26-28 Even though these particular vascular surgical repairs have not been validated specifically, there is no reason to believe that under-reporting has occurred. Popliteal artery injuries are uncommon after non arthroplasty knee surgery but can occur during both elective and urgent orthopaedic surgery. Outcome is better when the injury is detected during the operation and repair is timely. Delay in diagnosis and surgical reconstruction, including the need to transfer patients to other hospitals for vascular intervention, increases the likelihood of poor outcome. Strategies for the early identification and the improvement of outcome when injury has occurred include routine post-operative assessment of peripheral pulses and circulation. Orthopaedic surgeons should have a strategy on how they would manage a suspected arterial injury in their practice. Author contributions K. Bernhoff: Data collection, Design of study protocol, Data analysis, Writing manuscript. M. Björck: Initiated the study, Provided the study design, Helped with ethical approval, Co-author, Provided guidance in statistical analysis. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
196
K. BERNHOFF, M. BJÖRCK
This article was primary edited by D. Johnstone and first proof edited by G. Scott.
References 1. Wilson JS, Miranda A, Johnson BL, et al. Vascular injuries associated with elective orthopedic procedures. Ann Vasc Surg 2003;17:641–644. 2. Calligaro KD, Dougherty MJ, Ryan S, et al. Acute arterial complications associated with total hip and knee arthroplasty. J Vasc Surg 2003;38:1170–1177. 3. Nachbur B, Meyer RP, Verkkala K, et al. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res 1979;141:122–133. 4. Kickuth R, Anderson S, Kocovic L, et al. Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery. J Vasc Interv Radiol 2006;17:791–799. 5. Rossi G, Mavrogenis A, Angelini A, et al. Vascular complications in orthopaedic surgery. J Long Term Eff Med Implants 2011;21:127–137. 6. Nishimura A, Fukuda A, Kato K, et al. Vascular safety during arthroscopic allinside meniscus suture. Knee Surg Sports Traumatol Arthrosc 2013;(Epub ahead of print)PMID:24253374. 7. Bernhoff K, Rudström H, Gedeborg R, et al. Popliteal artery injury during knee replacement: a population-based nationwide study. Bone Joint J 2013;95-B:1645– 1649. 8. Björck M, Bergqvist D, Eliasson K, et al. Twenty years with the Swedvasc Registry. Eur J Vasc Endovasc Surg 2008;35:129–130. 9. Rudström H, Bergqvist D, Ogren M, et al. Iatrogenic vascular injuries in Sweden; a nationwide study 1987-2005. Eur J Vasc Endovasc Surg 2008;35:131–138. 10. Freischlag JA, Sise M, Quinones-Baldrich WJ, et al. Vascular complications associated with orthopedic procedures. Surg Gynecol Obstet 1989;169:147–152. 11. Abularrage CJ, Weiswasser JM, Dezee KJ, et al. Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. J Vasc Surg 2008;47:803–807. 12. Rand JA. Vascular complications of total knee arthroplasty; report of three cases. J Arthroplasty 1987;2:89–93. 13. Butt U, Samuel R, Sahu A, et al. Arterial injury in total knee arthroplasty. J Arthroplasty 2010;25:1311–1318. 14. Da Silva MS, Sobel M; Surgeons of the Southern Association of Vascular Surgery. Popliteal vascular injury during total knee arthroplasty. J Surg Res 2003;109:170–174.
15. No authors listed Na. Swedvasc, Swedish Vasular Registry 1987-2011 http:// www.ucr.uu.se/swedvasc/ (date last accessed 27 October 2014). 16. No authors listed. American Society of Anesthesiologists: ASA Physical Status Classification System, 2014. http://www.asahq.org/Home/For-Members/ClinicalInformation/ASA-Physical-Status-Classification-System (date last accessed 27 October 2014). 17. No authors listed. The National [Swedish] Board of Health and Welfare. http:// www.socialstyrelsen.se (date last accessed 27 October 2014). 18. Potter D, Morris-Jones W. Popliteal artery injury complicating arthroscopic meniscectomy. Arthroscopy 1995;11:723–726. 19. Spalding TJ, Botsford DJ, Ford M, et al. Popliteal artery compression: a complication of Gore-Tex anterior cruciate ligament reconstruction. J Bone Joint Surg [Br] 1996;78-B:151–152. 20. Roth JH, Bray RC. Popliteal artery injury during anterior cruciate ligament reconstruction: brief report. J Bone Joint Surg [Br] 1988;70-B:840. 21. Zaidi SH, Cobb AG, Bentley G. Danger to the popliteal artery in high tibial osteotomy. J Bone Joint Surg [Br] 1995;77-B:384–386. 22. Georgoulis AD, Makris CA, Papageorgiou CD, et al. Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: a clinically relevant anatomic study. Knee Surg Sports Traumatol Arthrosc 1999;7:15–19. 23. Shiomi J, Takahashi T, Imazato S, et al. Flexion of the knee increases the distance between the popliteal artery and the proximal tibia: MRI measurements in 15 volunteers. Acta Orthop Scand 2001;72:626–628. 24. Shetty AA, Tindall AJ, Qureshi F, et al. The effect of knee flexion on the popliteal artery and its surgical significance. J Bone Joint Surg [Br] 2003;85-B:218–222. 25. Rudström H, Bergqvist D, Ahlberg J, et al. Insurance claims after vascular surgery in Sweden. Eur J Vasc Endovasc Surg 2011;42:498–505. 26. Troëng T, Malmstedt J, Björck M. External validation of the Swedvasc registry: a first-time individual cross-matching with the unique personal identity number. Eur J Vasc Endovasc Surg 2008;36:705–712. 27. Ravn H, Bergqvist D, Björck M; Swedish Vascular Registry. Nationwide study of the outcome of popliteal artery aneurysms treated surgically. Br J Surg 2007;94:970–977. 28. Kragsterman B, Pärsson H, Lindbäck J, et al. Outcomes of carotid endarterectomy for asymptomatic stenosis in Sweden are improving: Results from a populationbased registry. J Vasc Surg 2006;44:79–85.
THE BONE & JOINT JOURNAL
Iatrogenic popliteal artery injury in non arthroplasty knee surgery
K. Bernhoff, M. Björck From Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intraoperatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support. Cite this article: Bone Joint J 2015;97-B:192–6.
K. Bernhoff , MD, Consultant Orthopaedic Surgeon, Department of Surgical Sciences M. Björck , MD, PhD, Professor (Chair) in Vascular Surgery, Department of Surgical Sciences Uppsala University, SE 75185, Uppsala, Sweden. Correspondence should be sent to Mrs K. Bernhoff; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B2. 34353 $2.00 Bone Joint J 2015;97-B:192–6. Received 10 May 2014; Accepted after revision 27 October 2014
192
Vascular injury is a rare but potentially devastating complication after orthopaedic procedures. The reported incidence in the literature varies between 0.005 and 0.5%1-5 depending on the procedure. The popliteal artery is the most common major vessel involved in iatrogenic orthopaedic injuries. 1 Situated, in close relation to the posterior capsule of the knee, it is at risk of injury during common procedures such as knee arthroplasty or osteotomy.6 Knee arthroplasty is probably the most common orthopaedic procedure resulting in iatrogenic popliteal artery injury according to a previously reported population-based study.7 Vascular iatrogenic injuries have been increasing over time but probably only due to the increasing number of surgical procedures.8,9 The most common presentations of arterial injuries are intra-operative bleeding, acute ischaemia with loss of peripheral pulses, non-healing wounds, and limb oedema.10 Time to detection and repair of the vascular injury is crucial for limb salvage,2,11-14 but the reasons behind diagnostic and therapeutic
delays are poorly characterised. Outcomes in terms of functional impairment following limb salvage, have barely been investigated.13 The primary aim of this study was to investigate popliteal artery injuries in orthopaedic procedures other than knee arthroplasty and to define successful strategies for detection and action when iatrogenic injury occurs. Secondary aims were to study risk factors, methods of repair, long-term outcome and likelihood of litigation.
Patients and Methods The Swedish Vascular Registry (Swedvasc), established in 1987,15 which is a prospectively collected database, was searched to identify all iatrogenic popliteal artery injuries between 1987 and 2011. Clinical data were reviewed to determine the type of orthopaedic procedure, mechanism of injury, type of vascular repair and outcome. The identified cases were cross-referenced with the Swedish Patient Insurance (SPI) database where case records are archived. Prospective data from those databases were supplemented with retrospective data obtained from case record analysis. Both orthopaedic THE BONE & JOINT JOURNAL
IATROGENIC POPLITEAL ARTERY INJURY IN NON ARTHROPLASTY KNEE SURGERY
1070 iatrogenic vascular injuries
955 other 115 injuries to the anatomical locations popliteal artery
57 non orthopaedic injuries
53 orthopaedic injuries
32 after arthroplasty Bone Joint J 2013;95-B:1645–9
5 case records not identified
21 injuries non arthroplasty
Fig. 1 Flowchart showing injuries.
and vascular surgical case records were reviewed to determine the mechanism of injury, time to detection, time and method to restore the circulation, use of tourniquet and outcome. Patient health status before surgery was categorised using the American Society of Anesthesiologists (ASA) Physical Status Classification System.16 Long-term survival was obtained by linkage with the Swedish Population Registry (data sampling point: 2 January 2014) using the patients’ unique personal identity numbers and used in all the registries. Statistical analysis. Dichotomous variables were analysed with Fisher’s exact test, and continuous variables were analysed with two sample t-tests. The survival estimate with Kaplan-Meier analysis using 95 CIs set the endpoint at ten years of follow-up. A p-value < 0.05 was considered significant.This investigation was approved by the ethical committee of the Uppsala/Örebro region.
Results A total of 115 patients suffered iatrogenic injuries to the popliteal artery and were identified from the Swedvasc registry. It was possible to retrieve the case records from 110 of those patients (96%). In all, 57 were not due to orthopaedic procedures and were excluded. In the remaining 53 patients, all of whom suffered iatrogenic popliteal artery injury during orthopaedic surgery, 32 injuries occurred after knee arthroplasty and have been previously reported.7 This report is based on the 21 injuries (21 patients) which were associated with orthopaedic surgery other than arthroplasty (Fig. 1). The mean age of the 21 patients was 46 years (11 to 85) at the time of orthopaedic operation. There were 11 men and ten women. There were nine injuries to the left leg and 12 to the right. One patient had diabetes. Five patients had preexisting cardiovascular disease such as hypertension, angina or atrial fibrillation. None had undergone previous vascular VOL. 97-B, No. 2, FEBRUARY 2015
193
surgery. The ASA grading before surgery was seven patients classified as ASA 1, nine as ASA 2 and five as ASA 3. A total of 13 patients underwent elective orthopaedic surgery. The nature of the orthopaedic procedures associated with the iatrogenic injury is shown in Table I. The mean age of this group of patients was 41 years (15 to 63). Another eight patients underwent urgent surgery for either trauma or tumour resection (Table II). Their mean age was 54 years (12 to 85). There was no statistical difference in age between the two sample T-test groups (p = 0.14). Data on all 21 patients had been reported to the Swedvasc registry but only 12 to the SPI. Of the 13 injuries sustained during elective surgery, ten were reported to the SPI, but only two of the eight undergoing urgent surgery were reported (p = 0.029, Fisher exact test). The mean age in the group filing an insurance claim was 39 years (15 to 63), compared with 54 years (12 to 85) among those who did not file a claim (p = 0.098). The mechanism of vascular injury is described in Tables I and II. Procedures associated with popliteal artery injury. Arthroscopy: three arthroscopies with meniscal resection resulted in arterial injury. In two cases the surgeon describes difficulty in flexing the knee during the procedure. Meniscal resections were performed on the posterior parts of the lateral and medial menisci. One patient, who also suffered from haemophilia, developed recurrent haemarthrosis due to a pseudo-aneurysm. In Sweden there were 98 084 arthroscopies with meniscal resection performed during the years 1998 to 2011.17 The incidence of popliteal artery injury was 0.003%. Cruciate ligament reconstruction: there were two anterior cruciate ligament (ACL) reconstructions and one combined ACL and posterior cruciate ligament (PCL) reconstruction. All three procedures were arthroscopically assisted with a patellar ligament autograft. The PCL reconstruction involved hamstring tendon autograft. All three patients had significant intra-articular procedures, such as resection of the posterior horn of the lateral meniscus, or shaving within the popliteal fossa. One reconstruction involved the removal of a loose intra-articular screw from previous ACL surgery. This operation was performed with a posterior approach through the popliteal fossa. In Sweden there were 36 695 cruciate ligament reconstructions performed during the years 1998 to 2011.17 The incidence of popliteal artery injury was 0.008%. Tibial tubercle osteotomy: there were two popliteal artery injuries sustained during tibial tubercle osteotomies, performed for recurrent patellar dislocation. Both injuries occurred during drilling of the posterior tibial cortex, prior to fixation of the osteotomy. In Sweden there were 1813 tibial tubercle osteotomies performed during the years 1998 to 2011.17 The incidence of arterial injury was 0.11%. High tibial osteotomy (HTO): in all three HTOs associated with popliteal artery injury, the damage to the vessel occurred during the osteotomy. They presented in three
194
K. BERNHOFF, M. BJÖRCK
Table I. Elective orthopaedic procedures associated with popliteal artery injury in 13 patients Procedure
Age
Type of injury
Repair
Time to repair
Outcome
ACL reconstruction ACL reconstruction ACL+ PCL reconstruction ACL screw extraction Tibial tubercle osteotomy Tibial tubercle osteotomy HTO
24 54 36 32 15 22 42
Sharp, pseudo-aneurysm Sharp Sharp Sharp Sharp Sharp Sharp, pseudo-aneurysm
Coiling Direct anastomosis By-pass Interposition graft By-pass Interposition graft Direct suture
7 days 7 hours Immediate 2 to 7 hours 3 hours to shunt 6 hours 30 days
HTO
40
Sharp
Interposition graft
48 hours
HTO Arthroscopy Arthroscopy
63 44 55
Sharp Sharp, pseudo-aneurysm Sharp
Patch Thrombin injection Patch
Immediate 52 days 26 hours
Arthroscopy Arthrodesis
52 48
Sharp, pseudo-aneurysm Sharp, AV-fistula
Patch By-pass
4 days 23 years
Excellent Pain, loss of sensation Excellent Sensory loss Excellent Sensory loss Drop foot, sensory loss Drop foot, sensory loss Excellent Excellent Nerve injury, sensory loss Swelling, sensory loss Wounds healed
ACL, Anterior Cruciate Ligament; PCL, Posterior Cruciate Ligament; HTO, High Tibial Osteotomy; AV, Arteriovenous
Table II. Urgent orthopaedic procedures associated with popliteal artery injury in eight patients Procedure
Age
Type of injury
Repair
Time to repair
Outcome
Tibial condylar fracture, nonunion Distal femoral fracture Distal femoral fracture Intramedullary nailing of tibial fracture Resection of sarcoma Resection of sarcoma Tibial fracture external fixation Pathological subtrochanteric fracture
83 75 85 39 12 21 53 67
Blunt Cerclage wire strangulating Cerclage wire strangulating Sharp, pseudo-anerysm Intimal tear Sharp Sharp Sharp
By-pass By-pass By-pass By-pass By-pass By-pass Interposition graft By-pass
12 days 25 hours Immediate 6 weeks 14 days Immediate 12 hours 1 hour
Unknown Dead within 2 months Excellent Sensory loss Necrosis, impairment Amputation Pain, loss of sensation Dead within 6 months
different ways. One was immediately detected due to bleeding, one presented with a compartment syndrome after 48 hours, and one developed a pseudo-aneurysm detected 29 days later. In Sweden there were 6047 HTOs performed during the years 1998 to 2011.17 The incidence of associated popliteal artery injury was 0.05%. In the group undergoing inevitable or acute surgery, the mechanism was a direct injury to the artery in six of the eight patients. In four patients the injury was through a laceration to or penetration of the artery, resulting in instant ischaemia in three patients, and formation of pseudo-aneurysm in one. The remaining two patients in the direct-laceration group were caused by cerclage wiring being used to reduce a femoral fracture. In both patients angiography demonstrated arterial occlusion due to the cerclage wire. Of the two remaining patients who did not suffer direct lacerations to the artery, one had an intimal tear leading to thrombosis after four days. The other was associated with nonunion of a tibial condylar fracture with pre-existing peripheral vascular disease causing thrombosis in the affected limb. The most common presentation in all patients was intraoperative bleeding with acute ischaemia (n = 9, 43%). All of these injuries were detected immediately. However, five patients were diagnosed after a delayed presentation with
cyanosis and pain (24%) and were diagnosed after 12 or more hours. One patient developed a compartment syndrome due to bleeding, and the arterial injury was diagnosed after 24 hours. In five patients pseudo-aneurysms developed, and four of them had progressive sensation of swelling and pain. One patient, with associated haemophilia, developed recurrent haemarthroses as the mode of presentation. One patient presented several years after a knee arthrodesis with wound breakdown due to an arteriovenous fistula. In one patient with a direct injury to the vessel which was detected immediately due to bleeding, the surgeon was excising a sarcoma and could visualise the injury to the popliteal artery. This injury resulted in a transfemoral amputation. Of the nine immediately recognised vascular injuries, six occurred in hospitals with on-site vascular surgery support, and four had successful immediate vascular repair within one hour and had no adverse outcome. The patient undergoing sarcoma excision had emergency by-pass surgery but subsequent graft occlusion led to transfemoral amputation. In one patient, vascular reconstruction was delayed by diagnostic angiography. The circulation was restored only after seven hours, resulting in limb salvage but with permanent sensory loss and major functional impairment. There were three popliteal artery injuries which occurred in hospitals without immediate vascular surgery support, THE BONE & JOINT JOURNAL
IATROGENIC POPLITEAL ARTERY INJURY IN NON ARTHROPLASTY KNEE SURGERY
1.00
0.75
0.50 Numbers at risk (yrs) 0.25
Baseline
1
3
5
10
21
19
17
16
16
0.00 0
2
4
6
8
10
Analysis time Fig. 2 Kaplan–Meier survival curve showing the ten-year estimate.
two were private clinics and one a rural public hospital. In two of these patients, significant delays occurred before revascularisation was achieved (three and seven hours post injury) which resulted in significant long-term morbidity due to neurological injury. The early revascularisation of one of the three patients’ was performed with a temporary shunt followed by transfer to a regional vascular unit for definitive reconstruction. A full recovery was achieved. A total of five patients were diagnosed within 12 to 48 hours after surgery. Three of them presented with cyanosis and pain, one with a compartment syndrome, and one had a painful expanding pseudo-aneurysm in the popliteal fossa. There were seven patients who were diagnosed later than 48 hours (4 days to 23 years). Five of them had pseudoaneurysms and one an arteriovenous fistula detected 23 years after the surgical procedure. Finally, one patient had an intimal tear with thrombosis four days after surgery. The types of vascular intervention are described in Tables I and II. Nine patients (43%) had bypass surgery. In the urgent surgery group this was the most common operation, with seven of eight cases undergoing it (88%). A total of nine patients of the total group underwent fasciotomy as part of their treatment (43%). Long-term chronic residual symptoms were documented in 12 patients after one year or longer follow-up. The mean follow-up was 590 days (53 to 8527). In one patient there were incomplete data on outcome; although the graft was known to be patent, functional outcome was unknown. Two patients in the urgent group died within six months from the orthopaedic procedure (53 and 125 days). Both had undergone complicated and extensive surgery following hip fractures. One sustained a further fracture below the sliding hip screw and plate, and one underwent revision surgery with a proximal femoral replacement after a pathologic subtrochanteric fracture surgery. Overall survival of the patient at ten years is shown in Figure 2. In total, only six patients recovered fully. VOL. 97-B, No. 2, FEBRUARY 2015
195
Discussion We found a low incidence of popliteal arterial injury in non arthroplasty knee surgery in Sweden as recorded in national databases. In elective surgery there are four common procedures that were associated with this vascular injury: arthroscopy with meniscal removal, ACL/PCL reconstruction, tibial tubercle osteotomy and HTO. Arterial injury during arthroscopic procedures has been previously reported18-20 as well as after HTO.21,22 When addressing the question whether knee flexion protects the popliteal vessels from injury, Zaidi, Cobb and Bentley21 suggested that the popliteal artery comes closer to the tibia in flexion, while Nishimura et al6 concluded that the safest position to suture the lateral meniscus was in the ‘figure four’ position. Others support the opinion that the popliteal artery is safer when the knee is flexed.23,24 Our study shows that in general when arterial injury occurs in the absence of on-site vascular surgical support, outcomes will be poorer due to delay in time to revascularisation. When vascular injury was diagnosed in the early postoperative period, the signs of cyanosis and compartment syndrome appear to be the key findings. Delay greater than 12 hours is always associated with poor outcome. Regular documented examination of the peripheral pulses in the post-operative period remains an essential observation. Patients suffering vascular injury during an elective surgical procedure are more likely to pursue litigation. This finding was expected and concurs with previous reports.9,25 The limitations of this study include possible underreporting to the Swedvasc registry. The registry has been validated on several occasions comparing data with the Inpatient registry used for reimbursement; showing excellent external validity, well above 90% for core surgery.26-28 Even though these particular vascular surgical repairs have not been validated specifically, there is no reason to believe that under-reporting has occurred. Popliteal artery injuries are uncommon after non arthroplasty knee surgery but can occur during both elective and urgent orthopaedic surgery. Outcome is better when the injury is detected during the operation and repair is timely. Delay in diagnosis and surgical reconstruction, including the need to transfer patients to other hospitals for vascular intervention, increases the likelihood of poor outcome. Strategies for the early identification and the improvement of outcome when injury has occurred include routine post-operative assessment of peripheral pulses and circulation. Orthopaedic surgeons should have a strategy on how they would manage a suspected arterial injury in their practice. Author contributions K. Bernhoff: Data collection, Design of study protocol, Data analysis, Writing manuscript. M. Björck: Initiated the study, Provided the study design, Helped with ethical approval, Co-author, Provided guidance in statistical analysis. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
196
K. BERNHOFF, M. BJÖRCK
This article was primary edited by D. Johnstone and first proof edited by G. Scott.
References 1. Wilson JS, Miranda A, Johnson BL, et al. Vascular injuries associated with elective orthopedic procedures. Ann Vasc Surg 2003;17:641–644. 2. Calligaro KD, Dougherty MJ, Ryan S, et al. Acute arterial complications associated with total hip and knee arthroplasty. J Vasc Surg 2003;38:1170–1177. 3. Nachbur B, Meyer RP, Verkkala K, et al. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res 1979;141:122–133. 4. Kickuth R, Anderson S, Kocovic L, et al. Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery. J Vasc Interv Radiol 2006;17:791–799. 5. Rossi G, Mavrogenis A, Angelini A, et al. Vascular complications in orthopaedic surgery. J Long Term Eff Med Implants 2011;21:127–137. 6. Nishimura A, Fukuda A, Kato K, et al. Vascular safety during arthroscopic allinside meniscus suture. Knee Surg Sports Traumatol Arthrosc 2013;(Epub ahead of print)PMID:24253374. 7. Bernhoff K, Rudström H, Gedeborg R, et al. Popliteal artery injury during knee replacement: a population-based nationwide study. Bone Joint J 2013;95-B:1645– 1649. 8. Björck M, Bergqvist D, Eliasson K, et al. Twenty years with the Swedvasc Registry. Eur J Vasc Endovasc Surg 2008;35:129–130. 9. Rudström H, Bergqvist D, Ogren M, et al. Iatrogenic vascular injuries in Sweden; a nationwide study 1987-2005. Eur J Vasc Endovasc Surg 2008;35:131–138. 10. Freischlag JA, Sise M, Quinones-Baldrich WJ, et al. Vascular complications associated with orthopedic procedures. Surg Gynecol Obstet 1989;169:147–152. 11. Abularrage CJ, Weiswasser JM, Dezee KJ, et al. Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. J Vasc Surg 2008;47:803–807. 12. Rand JA. Vascular complications of total knee arthroplasty; report of three cases. J Arthroplasty 1987;2:89–93. 13. Butt U, Samuel R, Sahu A, et al. Arterial injury in total knee arthroplasty. J Arthroplasty 2010;25:1311–1318. 14. Da Silva MS, Sobel M; Surgeons of the Southern Association of Vascular Surgery. Popliteal vascular injury during total knee arthroplasty. J Surg Res 2003;109:170–174.
15. No authors listed Na. Swedvasc, Swedish Vasular Registry 1987-2011 http:// www.ucr.uu.se/swedvasc/ (date last accessed 27 October 2014). 16. No authors listed. American Society of Anesthesiologists: ASA Physical Status Classification System, 2014. http://www.asahq.org/Home/For-Members/ClinicalInformation/ASA-Physical-Status-Classification-System (date last accessed 27 October 2014). 17. No authors listed. The National [Swedish] Board of Health and Welfare. http:// www.socialstyrelsen.se (date last accessed 27 October 2014). 18. Potter D, Morris-Jones W. Popliteal artery injury complicating arthroscopic meniscectomy. Arthroscopy 1995;11:723–726. 19. Spalding TJ, Botsford DJ, Ford M, et al. Popliteal artery compression: a complication of Gore-Tex anterior cruciate ligament reconstruction. J Bone Joint Surg [Br] 1996;78-B:151–152. 20. Roth JH, Bray RC. Popliteal artery injury during anterior cruciate ligament reconstruction: brief report. J Bone Joint Surg [Br] 1988;70-B:840. 21. Zaidi SH, Cobb AG, Bentley G. Danger to the popliteal artery in high tibial osteotomy. J Bone Joint Surg [Br] 1995;77-B:384–386. 22. Georgoulis AD, Makris CA, Papageorgiou CD, et al. Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: a clinically relevant anatomic study. Knee Surg Sports Traumatol Arthrosc 1999;7:15–19. 23. Shiomi J, Takahashi T, Imazato S, et al. Flexion of the knee increases the distance between the popliteal artery and the proximal tibia: MRI measurements in 15 volunteers. Acta Orthop Scand 2001;72:626–628. 24. Shetty AA, Tindall AJ, Qureshi F, et al. The effect of knee flexion on the popliteal artery and its surgical significance. J Bone Joint Surg [Br] 2003;85-B:218–222. 25. Rudström H, Bergqvist D, Ahlberg J, et al. Insurance claims after vascular surgery in Sweden. Eur J Vasc Endovasc Surg 2011;42:498–505. 26. Troëng T, Malmstedt J, Björck M. External validation of the Swedvasc registry: a first-time individual cross-matching with the unique personal identity number. Eur J Vasc Endovasc Surg 2008;36:705–712. 27. Ravn H, Bergqvist D, Björck M; Swedish Vascular Registry. Nationwide study of the outcome of popliteal artery aneurysms treated surgically. Br J Surg 2007;94:970–977. 28. Kragsterman B, Pärsson H, Lindbäck J, et al. Outcomes of carotid endarterectomy for asymptomatic stenosis in Sweden are improving: Results from a populationbased registry. J Vasc Surg 2006;44:79–85.
THE BONE & JOINT JOURNAL
