Popliteal Aneurysm After Total Knee Arthroplasty Case Reports and Review of the Literature
W i l l i a m J. H o z a c k , M D , * P e t e r A. C o l e , B A t R o n a l d G a r d n e r , MD,-]- a n d A r t u r o Corces:l:
Abstract: Vascular complications after total knee arthropIasty include arterial occlusion, arterial severance, arleriovenous fistula, and arterial aneurysm. Both a false aneurysm and a true aneurysm of the popliteal artery are described. The false poplitea] aneurysm resulted from direct surgical trauma and required excision and repair. The true pop]iteM aneurysm was unsuccessfully treated with excision, transfemoral thrombectomy, and bypass surgery. Many of the vascular complications after total knee arthroplasty may be preventable and the following prudent guidelines are suggested. Careful preoperative evaluation is critical, including past medical history, palpation of pedal pulses, and review of radiographs 1o identify abnormal calcification in the vessels. Vascular consultation may be necessary. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative. Key words: arthroplasty, vascular complications, aneurysm, complications.
venous fistula (4, 15), damaged or severed popliteal artery (15), and late ischemia of the distal extremity (13). Two popliteal aneurysms of different etiologies are described here.
Vascular complications after total knee arthroplasty are u n c o m m o n . An incidence of 0.03% was recorded by the Mayo Clinic from 1971 to 1986 (13). On the other hand, the variety of vascular complications is impressive, including: femoral or poplrteaI artery thrombosis (7, 12, 13, 15), popliteal artery occlusion by fascial structures (8, 14), femoral-popliteal bypass graft thrombosis, "foot ischemia" (2), traumatic popliteal aneurysm (15), false aneurysm of the inferior medial geniculate artery (4), arterio-
Case Reports Case 1 A 62-year-old man with a 10-year history of progressively severe knee pain and occasional episodes of locking and giving way was scheduled for an arthroscopic debridement on March 30, 1988. The surgical findings included degenerative fibrillation of both menisci with a lateral tear and grade IV arthritic changes throughout the knee joint. The tourniquet
* FronI the Departnlent of Orthopaedic Surgery, Thomas Jefferson University and The Rothman Institute, Philadelphia, Pennsyh'ania. f From the University of Miami School of Medicine, Miami, Florida. From the Department of Orthopaedic Surgery, University of Miami School of Medicine, Mianli, Florida.
Reprint requests: W. J. Hozack, MD, Reconstructive Orthopaedic Associates, Incorporated, 800 Spruce Street, Philadelphia, PA 19107.
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time was 67 minutes. No complications ensued but the patient failed to note any improvement in symptoms and, with subsequent progression of his pain and disability, the patient was scheduled for total knee replacement o n November 9, 1988. Significant past medical history included a 30-pack-per-year history of smoking, but the patient had quit 10 years prior. Physical examination revealed a 17 ° varus deformity, 0 ° - 1 1 0 ° of motion, and no demonstrable knee instability. Dorsalis pedis pulses were 2 + bilaterally. Neither posterior tibial pulse was palpable. Both feet were pink and w a r m with normal nails and hair distribution. Preoperative radiographs revealed degenerative arthritic changes in the knee. Incidental note was made of calcification in the popliteal artery area (which had been present 1 year earlier prior to arthroscopic surgery) (Fig. 1). Uncemented total knee arthroplasty was performed using a minimally constrained posterior cruciate sparing system. Total tourniquet time was 107 minutes, which included a 15-minute reperfusion interval (with excellent bleeding noted) followed by
a 29-minute period of reischemia, during which time w o u n d closure was performed. Approximately 2 hours after operation, the patient was noted to have a cool left foot with bluish mottling below the ankle. Sensation was also decreased. The dorsalis pedis pulse was barely palpable. The dressing was released but progressive ischemia developed. Four hours after operation, Doppler studies failed to detect any pedal circulation; the left femoral pulse was 3 + . The vascular surgery team felt that popliteal artery thrombosis was the likely diagnosis and that immediate surgical intervention was indicated. No vascular angiographic studies were obtained. At surgery, thrombus was found extending from the superficial femoral artery to the anterior tibiaI artery. In the popliteal area, a large (3 × 2 cm) thrombosed popliteal artery aneurysm was found. Transfemoral thrombectomy was unsuccessful so a bypass from the left superficial femoral artery to the distal popliteal artery with a vein jump graft to the dorsalis pedis was performed. The popliteal aneurysm was excised. The postoperative course was difficult. The bypass grafts failed early and progressive ischemia developed. Ultimately an above-knee amputation was necessary.
Case 2
Fig. 1. Lateral radiograph of knee, showing calcification and enlargement in the area of the popliteal artery.
A 70-year-old obese w o m a n with a history of hypertension and diverticulitis, and severe osteoarthritis of her left knee was admitted to the hospital on May 20, 1987, for a total knee arthroplasty. Physical examination of the left knee showed severe pain on range of motion from 5 ° to 100 °, a varus deformity of 5 °, and a moderate synovitis. The patient underwent an uncomplicated cemented Miller-Galante total knee arthroplasty with an unremarkable postoperative course. Five months after the surgery, the patient noted discomfort in the posterior aspect of her knee which had been increasing over the past several months, more so in the immediate past 2week period. Physical examination at this time was remarkable for a firm pulsating mass associated with a bruit iri the popliteal area. Peripheral pulses were intact. Aspiration of the mass yielded blood. An arteriogram demonstrated a popliteal aneurysm. (Fig. 2). The vascular surgeons subsequently explored the popliteal area and found a false aneurysm of the popliteal artery, requiring excision and repair. After operation the patient did well, with no evidence of infection, good w o u n d healing, and 0 ° - 9 0 ° of motion.
Popliteal Aneurysm After TKA
lb
Fig. 2. Subtraction arteriogram of the left knee, showing large popliteal mass consistent with a popliteal aneurysm.
Discussion The following general categories of vascular complications after total knee arthroplasty can be identified: arterial occlusion, arterial severance, arteriovenous fistula, and arterial aneurysm. Arterial occlusion usually is identified in the early postoperative period and can be caused by thrombosis, fascial obstruction, or embolization of plaquhs. Many different cases of thrombosis have been described. Rush (15) reported three cases of femoral artery thrombosis, all of which resulted in amputation (1 above-knee, 1 below-knee, 1 mid-tarsal). Seven cases of popliteal artery thrombosis have been reported (7, 13, 15). Bypass surgery salvaged only one case and thrombectomy another; three required amputations, one patient died, and one was lost to follow-up study. The potential causes of arterial thrombosis include tourniquet use (resulting in either direct trauma to the atherosclerotic vessels, fracture of plaques with e mbolization or direct thrombosis related to cessation of blood flow), or
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arterial damage created by knee manipulation during surgery (this could result directly in thrombosis or create intimal tears which then to on to thrombosis). Other authors (9, 10) have described literal fractures of calcified atherosclerotic arteries by application of a pneumatic tourniquet. Fascial obstruction of the popliteal artery was described by Robson (15). Before operation this patient had a 52 ° flexion contracture; after operation angiographic studies revealed no intra-anerial pathology, but rather occlusion of the artery occurred as the knee was extended. Surgical release of the tight fascial structures solved the problem. A similar etiology m a y have been at work in the two patients described by Arden (2) w h o had immediate postoperative ischemia of the foot, which was relieved by splitting the postoperative cast and flexing the knee. Embolization of an atherosclerotic plaque with subsequent thrombosis was proposed as the cause in one patient. After surgical repair, pathologic examination of the resected arterial segment showed a pre-existing 50% atherosclerotic occlusion with a fragment of plaque associated with the more distal thrombosis. Thrombosis of a pre-existing bypass graft was described by Rand (13). One case of late arterial occlusion was discussed by McAuley (12). He felt that local intimal injury sustained at surgery had lead to an acceleration of atherosclerosis at that location and subsequent ischemia. While direct arterial damage is usually unappreciated and usually presents as thrombosis, more dramatic presentations have been described. Rush (15) mentioned two cases of severed popliteal arteries. Fortunately both were salvaged with vascular repair. A false aneurysm is another iatrogenic complication related to direct trauma. In such a case, the trauma causes a hemorrhagic event with blood extravasating into the surrounding tissue. The resultant h e m a t o m a organizes with the intrusion of fibrin and connective tissue while a central cavity becomes endothelialized from the mother vessel. The false aneurysm and compromised vessel communicate through the defect. Such a situation was likely in case 2. A possible extension of this pathology is that an arteriovenous fistula can form. Dennis et al. (4) report two cases of aneriovenous fistulas with false aneurysm following total knee anhroplasty. Both cases resulted from laceration o f t h e inferior medial geniculate artery that occurred at the time of medial ligament release. In both cases a cystic mass medial to the tibial tubercle was palpable and an associated bruit could be heard. Surgical excision of the lesion with ligation of the inferior medial geniculate artery was necessaD'. Rush (15) briefly describes a similar case of an arteriovenous fistula of the inferior geniculate artery.
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The first case we have reported is a rather unique finding in the literature on total knee arthroplasty. In contrast to the second case, in which a false aneurysm developed secondary to the t r a u m a of surgery, the first represents a true arterial a n e u r y s m that was already present and in which subsequent thrombosis led to severe consequences. Popliteal a n e u r y s m s account for the majority of all peripheral atherosclerotic aneurysms and are the second most c o m m o n type after aneurysms of abdominal aorta. Twenty-nine percent of popliteal aneurysms are bilateral, and, according to Englund (6), almost half of all patients presenting with popliteal a n e u r y s m are likely to h a v e an a n e u r y s m at some other site. The most c o m m o n sequela of such aneurysms are not rupture (approximately 6%) (3), but rather thrombosis and embolization (42%) (8). Once t h r o m b o e m o b l i c complications develop, a m p u t a t i o n rates vary from 20% to 50% (8, 16). Therefore, presymptomatic prophylactic intervention is considered the treatment of choice for patients with diagnosed popliteal aneurysm, with long-term success rates as high as 96% (1, 3, 11). Diagnosis of this problem is therefore critical. Downing et al. (5) feel that palpation alone (of a pulsating popliteal mass) will pick up 94% of existing popliteal aneurysms. Additional information can be helpful, as in decreased pedal pulses, calcification of the artery seen on radiographs, and suggestive family history of atherosclerotic vascular disease. Our patient did not have a palpable mass and the absence of posterior tibial pulses was a symmetric finding. On surgical exploration of the left leg during the early postoperative course it was found that no such artery existed in this patient (a congenital a n o m a l y of very low incidence). However, calcification of the popliteal artery was present bilaterally and, finally, it was discovered later that the patient h a d two sisters severely affected by arteriovascular d i s e a s e - - o n e w h o had lost a foot and o n e with a cerebrovascular stroke. Surprisingly, this patient had already endured an arthroscopic procedure on the left knee with a" tourniquet time similar to the subsequent total knee arthroplasty. Most of these vascular complications m a y be preventable and the following prudent guidelines are suggested. As the arthritic population is elderly and also the most likely to h a v e atherosclerotic vascular disease, careful preoperative evaluation is important. A past medical history of vascular disease might be significant. Careful d o c u m e n t a t i o n of pedal and popliteal pulses is advisable. Review of radiographs m a y reveal abnormal calcification within arteries. Vascular consultation should.be considered if any questions arise regarding the peripheral circulation. Tour-
niquets may be contraindicated in certain patients with documented significant peripheral vascular disease. Similarly, pre-existing patent bypass grafts may not survive the application of a tourniquet for total knee arthroplasty. Accordingly, if both total knee arthroplasty and vascular bypass are being considered, it might be advisable to perform the bypass surgery after the total knee arthroplasty. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative.
Acknowledgment The authors thank Paul A. Lotke, MD, for contributing the case material on the second patient in this report.
References 1. Anton GE, ttertzer NR, Beven EG et al: Surgical management of popliteal aneurysms: trends in presentation, treatment, and results from 1952 to 1984. J Vase Surg 3:125, 1986 2. Arden GP: Total knee replacement. Clin Orthop 94:92, 1973 3. Barroy JP, Banhel J, Locufier JL et ah Atherosclerotic popliteal aneurysms; report of one ruptured popliteal aneurysm. J Cardiovasc Surg 27:42, 1986 4. Dennis DA, Neumann RD, Toma P e t al: Arteriovenous fistula with false aneurysm of the inferior medial geniculate artery. Clin Orthop 222:255, 1987 5. Downing R, Ashton F, Grimley RP, Slaney G: Problems in diagnosis of popliteal aneurysms. J R Soc Med 78:440, 1985 6. Englund R, Schache D, Magee HR: Atherosclerotic popliteal aneurysms with particular regard to the contralateral side. Aust NZ J Surg 57:387, 1987 7. Fortune WP: Complications of total and partial arthroplasty in the knee. p. 949. In Epps CH (ed): Complications in orthopaedic surgery. J. B. Lippincott, Philadelphia, 1986 8. Imparato AM, Riles TS: Peripheral artery disease, p. 988. In Schwartz St, Shires TG, Spencer FC (eds): Principles of surgery. McGraw-Hill, New York, 1989 9. Jayasellan S, Stevenson TM, Pfitzner J: Tourniquet failure'and arterial calcification: case report and theoretical dangers. Anaesthesia 36:48, 1981 10. Klenerman L, Lewis JD: Incompressible vessels. Lancet 1:811, 1976 11. Lilly MP, Flinn WR, McCarthy WJ et al: J Vase Surg 7:653, 1988 12. McAuley CE, Steed DL, Webster MW: Arterial complications of total knee replacement. Arch Surg 119:960, 1984
Popliteal Aneurysm After TKA 13. Rand JA: Vascular complications of total knee arthroplasty. J Arthroplasty 2:89, 1987 14. Robson LI, Walls CE, Swanson AB: Popliteal artery obstruction following Shiers total knee replacement: a case report. Clin Orthop 109:I30, 1975
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15. Rush JH, Vidovich JD, Johnson MA: Arterial complications of total knee replacement: the Australian experience. J Bone Joint Surg 69B:400, 1987 16. Wychulis AR: Popliteal aneurysms. Surgery 68:942, I970
W i l l i a m J. H o z a c k , M D , * P e t e r A. C o l e , B A t R o n a l d G a r d n e r , MD,-]- a n d A r t u r o Corces:l:
Abstract: Vascular complications after total knee arthropIasty include arterial occlusion, arterial severance, arleriovenous fistula, and arterial aneurysm. Both a false aneurysm and a true aneurysm of the popliteal artery are described. The false poplitea] aneurysm resulted from direct surgical trauma and required excision and repair. The true pop]iteM aneurysm was unsuccessfully treated with excision, transfemoral thrombectomy, and bypass surgery. Many of the vascular complications after total knee arthroplasty may be preventable and the following prudent guidelines are suggested. Careful preoperative evaluation is critical, including past medical history, palpation of pedal pulses, and review of radiographs 1o identify abnormal calcification in the vessels. Vascular consultation may be necessary. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative. Key words: arthroplasty, vascular complications, aneurysm, complications.
venous fistula (4, 15), damaged or severed popliteal artery (15), and late ischemia of the distal extremity (13). Two popliteal aneurysms of different etiologies are described here.
Vascular complications after total knee arthroplasty are u n c o m m o n . An incidence of 0.03% was recorded by the Mayo Clinic from 1971 to 1986 (13). On the other hand, the variety of vascular complications is impressive, including: femoral or poplrteaI artery thrombosis (7, 12, 13, 15), popliteal artery occlusion by fascial structures (8, 14), femoral-popliteal bypass graft thrombosis, "foot ischemia" (2), traumatic popliteal aneurysm (15), false aneurysm of the inferior medial geniculate artery (4), arterio-
Case Reports Case 1 A 62-year-old man with a 10-year history of progressively severe knee pain and occasional episodes of locking and giving way was scheduled for an arthroscopic debridement on March 30, 1988. The surgical findings included degenerative fibrillation of both menisci with a lateral tear and grade IV arthritic changes throughout the knee joint. The tourniquet
* FronI the Departnlent of Orthopaedic Surgery, Thomas Jefferson University and The Rothman Institute, Philadelphia, Pennsyh'ania. f From the University of Miami School of Medicine, Miami, Florida. From the Department of Orthopaedic Surgery, University of Miami School of Medicine, Mianli, Florida.
Reprint requests: W. J. Hozack, MD, Reconstructive Orthopaedic Associates, Incorporated, 800 Spruce Street, Philadelphia, PA 19107.
301
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The Journal of Arthroplasty Vol. 5 No. 4 December 1990
time was 67 minutes. No complications ensued but the patient failed to note any improvement in symptoms and, with subsequent progression of his pain and disability, the patient was scheduled for total knee replacement o n November 9, 1988. Significant past medical history included a 30-pack-per-year history of smoking, but the patient had quit 10 years prior. Physical examination revealed a 17 ° varus deformity, 0 ° - 1 1 0 ° of motion, and no demonstrable knee instability. Dorsalis pedis pulses were 2 + bilaterally. Neither posterior tibial pulse was palpable. Both feet were pink and w a r m with normal nails and hair distribution. Preoperative radiographs revealed degenerative arthritic changes in the knee. Incidental note was made of calcification in the popliteal artery area (which had been present 1 year earlier prior to arthroscopic surgery) (Fig. 1). Uncemented total knee arthroplasty was performed using a minimally constrained posterior cruciate sparing system. Total tourniquet time was 107 minutes, which included a 15-minute reperfusion interval (with excellent bleeding noted) followed by
a 29-minute period of reischemia, during which time w o u n d closure was performed. Approximately 2 hours after operation, the patient was noted to have a cool left foot with bluish mottling below the ankle. Sensation was also decreased. The dorsalis pedis pulse was barely palpable. The dressing was released but progressive ischemia developed. Four hours after operation, Doppler studies failed to detect any pedal circulation; the left femoral pulse was 3 + . The vascular surgery team felt that popliteal artery thrombosis was the likely diagnosis and that immediate surgical intervention was indicated. No vascular angiographic studies were obtained. At surgery, thrombus was found extending from the superficial femoral artery to the anterior tibiaI artery. In the popliteal area, a large (3 × 2 cm) thrombosed popliteal artery aneurysm was found. Transfemoral thrombectomy was unsuccessful so a bypass from the left superficial femoral artery to the distal popliteal artery with a vein jump graft to the dorsalis pedis was performed. The popliteal aneurysm was excised. The postoperative course was difficult. The bypass grafts failed early and progressive ischemia developed. Ultimately an above-knee amputation was necessary.
Case 2
Fig. 1. Lateral radiograph of knee, showing calcification and enlargement in the area of the popliteal artery.
A 70-year-old obese w o m a n with a history of hypertension and diverticulitis, and severe osteoarthritis of her left knee was admitted to the hospital on May 20, 1987, for a total knee arthroplasty. Physical examination of the left knee showed severe pain on range of motion from 5 ° to 100 °, a varus deformity of 5 °, and a moderate synovitis. The patient underwent an uncomplicated cemented Miller-Galante total knee arthroplasty with an unremarkable postoperative course. Five months after the surgery, the patient noted discomfort in the posterior aspect of her knee which had been increasing over the past several months, more so in the immediate past 2week period. Physical examination at this time was remarkable for a firm pulsating mass associated with a bruit iri the popliteal area. Peripheral pulses were intact. Aspiration of the mass yielded blood. An arteriogram demonstrated a popliteal aneurysm. (Fig. 2). The vascular surgeons subsequently explored the popliteal area and found a false aneurysm of the popliteal artery, requiring excision and repair. After operation the patient did well, with no evidence of infection, good w o u n d healing, and 0 ° - 9 0 ° of motion.
Popliteal Aneurysm After TKA
lb
Fig. 2. Subtraction arteriogram of the left knee, showing large popliteal mass consistent with a popliteal aneurysm.
Discussion The following general categories of vascular complications after total knee arthroplasty can be identified: arterial occlusion, arterial severance, arteriovenous fistula, and arterial aneurysm. Arterial occlusion usually is identified in the early postoperative period and can be caused by thrombosis, fascial obstruction, or embolization of plaquhs. Many different cases of thrombosis have been described. Rush (15) reported three cases of femoral artery thrombosis, all of which resulted in amputation (1 above-knee, 1 below-knee, 1 mid-tarsal). Seven cases of popliteal artery thrombosis have been reported (7, 13, 15). Bypass surgery salvaged only one case and thrombectomy another; three required amputations, one patient died, and one was lost to follow-up study. The potential causes of arterial thrombosis include tourniquet use (resulting in either direct trauma to the atherosclerotic vessels, fracture of plaques with e mbolization or direct thrombosis related to cessation of blood flow), or
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arterial damage created by knee manipulation during surgery (this could result directly in thrombosis or create intimal tears which then to on to thrombosis). Other authors (9, 10) have described literal fractures of calcified atherosclerotic arteries by application of a pneumatic tourniquet. Fascial obstruction of the popliteal artery was described by Robson (15). Before operation this patient had a 52 ° flexion contracture; after operation angiographic studies revealed no intra-anerial pathology, but rather occlusion of the artery occurred as the knee was extended. Surgical release of the tight fascial structures solved the problem. A similar etiology m a y have been at work in the two patients described by Arden (2) w h o had immediate postoperative ischemia of the foot, which was relieved by splitting the postoperative cast and flexing the knee. Embolization of an atherosclerotic plaque with subsequent thrombosis was proposed as the cause in one patient. After surgical repair, pathologic examination of the resected arterial segment showed a pre-existing 50% atherosclerotic occlusion with a fragment of plaque associated with the more distal thrombosis. Thrombosis of a pre-existing bypass graft was described by Rand (13). One case of late arterial occlusion was discussed by McAuley (12). He felt that local intimal injury sustained at surgery had lead to an acceleration of atherosclerosis at that location and subsequent ischemia. While direct arterial damage is usually unappreciated and usually presents as thrombosis, more dramatic presentations have been described. Rush (15) mentioned two cases of severed popliteal arteries. Fortunately both were salvaged with vascular repair. A false aneurysm is another iatrogenic complication related to direct trauma. In such a case, the trauma causes a hemorrhagic event with blood extravasating into the surrounding tissue. The resultant h e m a t o m a organizes with the intrusion of fibrin and connective tissue while a central cavity becomes endothelialized from the mother vessel. The false aneurysm and compromised vessel communicate through the defect. Such a situation was likely in case 2. A possible extension of this pathology is that an arteriovenous fistula can form. Dennis et al. (4) report two cases of aneriovenous fistulas with false aneurysm following total knee anhroplasty. Both cases resulted from laceration o f t h e inferior medial geniculate artery that occurred at the time of medial ligament release. In both cases a cystic mass medial to the tibial tubercle was palpable and an associated bruit could be heard. Surgical excision of the lesion with ligation of the inferior medial geniculate artery was necessaD'. Rush (15) briefly describes a similar case of an arteriovenous fistula of the inferior geniculate artery.
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The Journal of Arthroplasty Vol. 5 No. 4 December 1990
The first case we have reported is a rather unique finding in the literature on total knee arthroplasty. In contrast to the second case, in which a false aneurysm developed secondary to the t r a u m a of surgery, the first represents a true arterial a n e u r y s m that was already present and in which subsequent thrombosis led to severe consequences. Popliteal a n e u r y s m s account for the majority of all peripheral atherosclerotic aneurysms and are the second most c o m m o n type after aneurysms of abdominal aorta. Twenty-nine percent of popliteal aneurysms are bilateral, and, according to Englund (6), almost half of all patients presenting with popliteal a n e u r y s m are likely to h a v e an a n e u r y s m at some other site. The most c o m m o n sequela of such aneurysms are not rupture (approximately 6%) (3), but rather thrombosis and embolization (42%) (8). Once t h r o m b o e m o b l i c complications develop, a m p u t a t i o n rates vary from 20% to 50% (8, 16). Therefore, presymptomatic prophylactic intervention is considered the treatment of choice for patients with diagnosed popliteal aneurysm, with long-term success rates as high as 96% (1, 3, 11). Diagnosis of this problem is therefore critical. Downing et al. (5) feel that palpation alone (of a pulsating popliteal mass) will pick up 94% of existing popliteal aneurysms. Additional information can be helpful, as in decreased pedal pulses, calcification of the artery seen on radiographs, and suggestive family history of atherosclerotic vascular disease. Our patient did not have a palpable mass and the absence of posterior tibial pulses was a symmetric finding. On surgical exploration of the left leg during the early postoperative course it was found that no such artery existed in this patient (a congenital a n o m a l y of very low incidence). However, calcification of the popliteal artery was present bilaterally and, finally, it was discovered later that the patient h a d two sisters severely affected by arteriovascular d i s e a s e - - o n e w h o had lost a foot and o n e with a cerebrovascular stroke. Surprisingly, this patient had already endured an arthroscopic procedure on the left knee with a" tourniquet time similar to the subsequent total knee arthroplasty. Most of these vascular complications m a y be preventable and the following prudent guidelines are suggested. As the arthritic population is elderly and also the most likely to h a v e atherosclerotic vascular disease, careful preoperative evaluation is important. A past medical history of vascular disease might be significant. Careful d o c u m e n t a t i o n of pedal and popliteal pulses is advisable. Review of radiographs m a y reveal abnormal calcification within arteries. Vascular consultation should.be considered if any questions arise regarding the peripheral circulation. Tour-
niquets may be contraindicated in certain patients with documented significant peripheral vascular disease. Similarly, pre-existing patent bypass grafts may not survive the application of a tourniquet for total knee arthroplasty. Accordingly, if both total knee arthroplasty and vascular bypass are being considered, it might be advisable to perform the bypass surgery after the total knee arthroplasty. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative.
Acknowledgment The authors thank Paul A. Lotke, MD, for contributing the case material on the second patient in this report.
References 1. Anton GE, ttertzer NR, Beven EG et al: Surgical management of popliteal aneurysms: trends in presentation, treatment, and results from 1952 to 1984. J Vase Surg 3:125, 1986 2. Arden GP: Total knee replacement. Clin Orthop 94:92, 1973 3. Barroy JP, Banhel J, Locufier JL et ah Atherosclerotic popliteal aneurysms; report of one ruptured popliteal aneurysm. J Cardiovasc Surg 27:42, 1986 4. Dennis DA, Neumann RD, Toma P e t al: Arteriovenous fistula with false aneurysm of the inferior medial geniculate artery. Clin Orthop 222:255, 1987 5. Downing R, Ashton F, Grimley RP, Slaney G: Problems in diagnosis of popliteal aneurysms. J R Soc Med 78:440, 1985 6. Englund R, Schache D, Magee HR: Atherosclerotic popliteal aneurysms with particular regard to the contralateral side. Aust NZ J Surg 57:387, 1987 7. Fortune WP: Complications of total and partial arthroplasty in the knee. p. 949. In Epps CH (ed): Complications in orthopaedic surgery. J. B. Lippincott, Philadelphia, 1986 8. Imparato AM, Riles TS: Peripheral artery disease, p. 988. In Schwartz St, Shires TG, Spencer FC (eds): Principles of surgery. McGraw-Hill, New York, 1989 9. Jayasellan S, Stevenson TM, Pfitzner J: Tourniquet failure'and arterial calcification: case report and theoretical dangers. Anaesthesia 36:48, 1981 10. Klenerman L, Lewis JD: Incompressible vessels. Lancet 1:811, 1976 11. Lilly MP, Flinn WR, McCarthy WJ et al: J Vase Surg 7:653, 1988 12. McAuley CE, Steed DL, Webster MW: Arterial complications of total knee replacement. Arch Surg 119:960, 1984
Popliteal Aneurysm After TKA 13. Rand JA: Vascular complications of total knee arthroplasty. J Arthroplasty 2:89, 1987 14. Robson LI, Walls CE, Swanson AB: Popliteal artery obstruction following Shiers total knee replacement: a case report. Clin Orthop 109:I30, 1975
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15. Rush JH, Vidovich JD, Johnson MA: Arterial complications of total knee replacement: the Australian experience. J Bone Joint Surg 69B:400, 1987 16. Wychulis AR: Popliteal aneurysms. Surgery 68:942, I970
