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Arterial Injury in Total Knee Arthroplasty
The Journal of Arthroplasty Vol. 25 No. 8 2010
Review Article
Arterial Injury in Total Knee Arthroplasty Usman Butt, MB, ChB (Hons), MRCS, Rohit Samuel, BSc (Hons), MB, ChB, MSc (Orth Eng), FRCS (Orth), Ajay Sahu, MBBS, MS, MRCS, Imran S. Butt, BSc, MB, ChB, MRCS, David S. Johnson, MB, ChB, FRCS (Tr and Orth), and Philip G. Turner, FRCS
Abstract: Arterial complications associated with knee arthroplasty are relatively rare, although probably underreported, complications of knee arthroplasty that carry a risk of significant morbidity. Thorough preoperative assessment and close liaison with a vascular surgeon, combined with an appreciation of common anatomical variants or distorted anatomy, may help prevent both thromboembolic and direct injuries from occurring. Clinical features of arterial complications following knee arthroplasty may vary significantly from acute hemorrhage or ischemia in the immediate postoperative period to chronic pain and swelling presenting even months following the procedure. There is potential for diagnostic confusion and delay that may adversely affect outcome. Early diagnosis along with vascular surgical review and intervention is key to successful management. Keywords: arterial injury, vascular injury, total knee arthroplasty complications, arthroplasty complications, vascular complications in knee arthroplasty. © 2010 Elsevier Inc. All rights reserved.
Arterial injury associated with total knee arthroplasty (TKA) is a relatively rare but potentially devastating complication. There are a variety of ways in which arterial injuries and complications may present, with consequences ranging from transient bleeding to limb loss and even death. With the rising number of both primary and revision TKA being performed on an aging population, the potential for arterial injuries must not be underestimated. A considerable portion of the literature surrounding this topic consists of individual case reports, case series, and surveys, although a few large studies do exist with variable incidences reported. In one large multicenter study, Abularrage et al [1] reported an incidence of 0.09% lower extremity arterial injuries from a sample of 26 106 TKA, including 2077 revision procedures. The study did not accurately define the nature of the vascular injuries sustained. In the largest single-center series, Calligaro et al
From the Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, Manchester, UK. Submitted October 14, 2008; accepted May 3, 2010. No benefits or funds were received in support of the study. Reprint requests: Usman Butt, MB, ChB (Hons), MRCS, Stepping Hill Hospital, Stockport, SK2 7JE Manchester, UK. © 2010 Elsevier Inc. All rights reserved. 0883-5403/2508-0023$36.00/0 doi:10.1016/j.arth.2010.05.018
[2] demonstrated an overall incidence of 0.17% arterial complications during TKA. From their sample of 13 618 (including 1665 revisions), there were 24 arterial complications, of which 3 were popliteal artery transections, 5 were popliteal artery pseudoaneurysms, and 16 were solely ischemic complications. Rand reported 3 cases of arterial ischemia secondary to thrombosis from a sample of 9022 knee arthroplasties between 1971 and 1986 (incidence 0.03%) [3,4]. Parvizi et al [5] produced data from a single center on 15 383 hip and knee arthroplasties. They described 16 vascular injuries, of which 11 were related to knee arthroplasty (1 revision). The proportion of knee arthroplasties was not given, making a specific incidence impossible to calculate. Arterial thrombosis occurred in 9 patients, with direct injury being the mechanism in the other 2 patients. Wilson et al [6] reviewed a sample of 4350 elective orthopedic procedures including hip, knee, and ankle arthroplasties. Arterial injuries occurred during 21 procedures, of which two thirds were associated with TKA. The mechanisms of injury were not stratified according to which joint was replaced, and the exact number of TKAs performed was not stated. Da Silva and Sobel [7] conducted a survey in which 13 of 190 vascular surgeons provided information regarding their experiences of popliteal vascular injury associated with TKA. They reported a total of 19 complications, of which 12 were direct arterial
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1312 The Journal of Arthroplasty Vol. 25 No. 8 December 2010 lacerations. Rush et al [8] contacted 470 surgeons in Australia, from which 100 replied. Of these, there were 5 reports of direct arterial injury and 7 of arterial thrombosis. Kumar et al [9] surveyed 147 British orthopedic surgeons. From 107 responses plus their own case, there were 14 reports of vascular complications, which included arterial transection, thrombosis, arteriovenous fistula, or aneurysm formation.
Mechanism There are 4 principal mechanisms responsible for the arterial complications encountered in TKA. In patients with preexisting vascular disease, atheromatous plaques may fracture secondary to mechanical pressure, leading to emboli and arterial insufficiency. This is largely associated with the use of a pneumatic tourniquet and may occur at the level of the superficial femoral artery (SFA) [3,8-12]. Arterial thrombosis occurring at the level of the SFA or popliteal artery may be implicated as a second mechanism. Fixation of the SFA by a tourniquet and subsequent manipulation of the knee can lead to tears in the arterial intimal wall. These intimal tears, compounded by the low-flow state induced by tourniquet use, favor the formation of occlusive thrombus and subsequent ischemia [3,8-13]. Release of severe flexion contractures and subsequent traction on the popliteal artery may likewise cause
intimal tears, but can also lead to compression of the artery against bony or musculotendinous structures as a third mechanism [3,8-14]. Robson et al [14] reported such a case whereby compression of the popliteal artery, following correction of a flexion deformity, necessitated release of the musculofascial structures and surgical division of arterial branches. The fourth mechanism involves direct puncture or laceration injury to the perigeniculate vasculature. This can occur with any form of instrumentation such as a vibrating saw, scalpel blade, diathermy, or a misplaced retractor [12].
Preoperative Risk and Assessment Careful preoperative assessment can help identify those patients who are at higher risk of sustaining arterial complications during their knee arthroplasty (Fig. 1). A variety of strategies can then be used to minimize this risk. Important risk factors to consider include the following: Preexisting Arterial Disease History or examination findings suggestive of arterial insufficiency are among the most important factors to consider if one is to avoid vascular complications during TKA. Points in the history include tobacco use, hypertension, diabetes mellitus, claudication symptoms, rest pain, previous transient ischemic attacks or stroke, or
Fig. 1. System for preoperative assessment of arterial disease before TKA.
Arterial Injury in TKA Butt et al
any previous cardiovascular surgery [1,2,4,6,10]. For every patient planned for TKA, the orthopedic surgeon should make an assessment of the limb vascularity. As a minimum, this should include inspection for trophic changes such as skin discoloration or absence of hair, skin ulceration (past or present), venous guttering, or signs of previous surgery. The lower limb should be palpated for temperature and pulses with comparison made to the contralateral limb. In particular, the popliteal fossa should be examined for aneurysms [4], which are often bilateral. If present, these should be assessed by a vascular surgeon before TKA given the high risk of thrombosis or embolism [15]. The presence of vascular calcification on plain radiographs should further alert the surgeon to the presence of arterial disease [10]. The ankle-brachial pressure index is a useful and simple test that can be performed in the clinic. A value of less than 0.9 suggests the presence of arterial disease, although results should be interpreted with caution in the presence of diabetes mellitus where results may be misleadingly high because of calcification and inelasticity of the vessels. Values less than 0.5 are indicative of severe ischemia [1,4]. Where concern exists regarding the vascularity of a limb, a vascular surgeon should be consulted in the preoperative phase. Any history or evidence of previous vascular intervention on the affected limb, including endovascular techniques, mandates a preoperative vascular opinion [4]. More detailed Doppler anklebrachial pressure index studies (including observation of pulse waveforms) at different levels in the limb can act as a useful screening tool. Preoperative duplex ultrasound scanning or angiography may subsequently be required to more formally assess flow in the native circulation, grafts, or across any stents. Where there is significant ischemia, revascularization may be recommended before TKA [2,4]. The use of a tourniquet should be considered in the preoperative phase. Tourniquets are often implicated or contributory to the development of arterial complications in TKA [2-4,7-11]. Although they do facilitate a dry bone surface for the placement of cemented components, their use is not essential in TKA and should be rationalized. Certainly, where there are signs or symptoms of peripheral arterial disease, they should be avoided. If any doubt exists, consultation with a vascular surgeon is recommended. Where there has been previous bypass surgery, a tourniquet should not be used because of the risk of graft occlusion [4,10]. Anatomical Considerations Anatomical variation or distortion increases the risk of direct arterial injury during major knee surgery [16-20]. In revision knee surgery, blood vessels may be firmly adherent within fibrous scar tissue, rendering them more vulnerable to the saw blade during tibial resection
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[1,5,19]. A tethered artery is also more likely to be damaged during manipulation of the knee joint [2,5,19]. This is also likely to be the case in some complex primary situations, for example, following previous knee trauma. Wilson et al [6] found that 71% of patients with arterial injury during an elective orthopedic procedure had previously had surgery and that 43% had a history of some bone or joint injury in proximity to the operative site (with or without subsequent surgery). Calligaro et al [2] found that arterial complications were more than twice as common following revision TKA compared with a primary procedure (0.36 vs 0.15%, P = .0112). As indicated earlier, the release of severe flexion contractures during TKA carries the risk of arterial stretching or compression [3,8-14]. It is therefore important that the operating surgeon notes the presence of any contracture preoperatively and is aware of this potential risk. Although anatomical distortions are extremely important to consider in the preoperative phase, one should also consider in detail the normal vascular anatomy and its variants before approaching TKA. Based on cadaveric studies, Rubash et al [16] used the analogy of a clock face to describe the position of the neurovascular structures around the tibial surface. For a left knee, taking the 6-o'clock position to be directly anterior, the popliteal vein would be at a 12-o'clock position, the popliteal artery at 1-o'clock, and the anterior tibial artery at 2-o'clock (after bifurcation of the popliteal artery)
Fig. 2. Illustration of the major neurovascular structures at risk during TKA (left knee). At the level of the joint line, the tibial nerve (TN), popliteal vein (PV), and popliteal artery (PA) are vulnerable to injury between 11 and 1 o'clock. Distal to the joint line, the anterior tibial artery (ATA) and common peroneal nerve (CPN) are vulnerable between 1 and 3 o'clock. P indicates posterior; A, anterior; M, medial; L, lateral.
1314 The Journal of Arthroplasty Vol. 25 No. 8 December 2010 (Fig. 2). A zone between 11 and 3 o'clock was highlighted as a risky area for neurovascular injury. The authors also concluded that extra caution be used during screw placement for the uncemented tibial knee arthroplasty components upon which the study was originally based [16]. Extrapolating the findings from this study, it is clear that these vessels would also be vulnerable during soft tissue retraction and procedures including meniscal or posterior cruciate ligament resection, or during posterior capsular releases, for example [17]. Ninomiya et al performed intraoperative arteriograms at the time of TKA on cadaveric specimens. They found that a posterior retractor placed the popliteal artery at risk when it was inserted lateral to the midline or if it was inserted more than 1 cm into the soft tissues [21]. Farrington et al studied the position of the popliteal artery in the arthritic knee. They reported a mean distance of 0.96 to 3.15 mm of the artery to the posterior tibial cortex in flexing the knee from 0° to 90° [22]. Tindall et al studied the prevalence of high-origin anterior tibial arteries (proximal to popliteus) in a sample of 100 knees [23]. They found 6 knees with a high-origin anterior tibial artery. The artery passed anterior to popliteus in direct contact with the posterior cortex of the tibia in all these cases, putting it at significant potential risk during knee arthroplasty. Klecker et al studied the prevalence of this variation of the anterior tibial artery (described as the “aberrant anterior tibial artery”) using magnetic resonance imaging studies [18]. They found a prevalence of 2.1% (23 of 1116 knees), again highlighting the significant risk of injury during orthopedic procedures (Fig. 3). Ethnicity Abularrage et al [1] found a higher incidence of arterial complications in African Americans. It has previously been shown that the black population tends to have lower ankle-brachial pressure indices [24] and more severe occlusive arterial disease in the tibial and peroneal arteries compared with the white population [25].
Presentation and Management There are 4 principal ways in which arterial complications secondary to TKA can present. These include (a) intraoperative hemorrhage, (b) acute ischemia, (c) false aneurysm formation, and (d) arteriovenous fistula formation. Intraoperative Hemorrhage If intraoperative vascular injury is suspected, the tourniquet should be deflated before implantation of components to allow for adequate assessment. Excessive bleeding, an enlarging popliteal swelling, or absent pedal pulses (where previously present) are highly indicative of arterial injury [12]. Releasing the tourniquet as routine practice prior to wound closure to ensure
Fig. 3. Illustrations of the anterior tibial artery (ATA) branching off the popliteal artery (left knee). (A) The ATA arises below the level of the popliteus muscle. (B) The ATA arises above popliteus passing anterior to it near the posterior margin of the tibia.
hemostasis has been suggested [26]. Although the overall benefits of this remain unclear in terms of postoperative recovery and complications, it would clearly facilitate early diagnosis of a major vascular injury [26]. Indeed, the routine use of a tourniquet in TKA has previously been questioned, with some studies showing no benefit or even delays in postoperative recovery [4,27,28].
Arterial Injury in TKA Butt et al
If any concern exists regarding the possibility of a significant vascular injury, an immediate vascular surgical opinion should be sought. Primary repair or patch angioplasty may be all that is required for the majority of arterial lacerations. Where complete arterial transection has occurred, an end-to-end anastomosis is occasionally possible, although an interposition graft may be necessary where excess tension would be placed on the repair. Arterial ligation with a bypass procedure is more commonly required [2,6]. These interventions are often carried out through a separate medial incision permitting an extensile exposure of the SFA and popliteal vessels with which most vascular surgeons are familiar [7]. Acute Ischemia In the immediate postoperative period, signs of acute limb ischemia such as a cold and pale foot, absent or weak pedal pulses, excessive pain, paresthesia, or motor weakness may be difficult to appreciate because of the effects of a spinal anesthesia, dressings, or venous thromboembolic deterrent devices [2]. However, any suspicion in conjunction with an excessively swollen knee or, if used, a high drain output with fresh blood is suggestive of arterial laceration. The signs of acute limb ischemia in isolation suggest thromboembolism or mechanical occlusion. Whether diagnosed immediately or early in the postoperative period, an urgent vascular opinion is required. It is imperative that, immediately following every TKA, the operating surgeon examines the vascularity of the limb. This should be repeated in further postoperative checks on the ward. A delay in diagnosis may lead to irreversible ischemia or compartment syndrome and potential limb loss [2,8]. Once a clinical diagnosis has been made, further investigation and management will be dictated by the clinical picture and severity of injury. Where indicated and where the risk of further delay is deemed acceptable, the vascular surgeon may request angiography before revascularization surgery or as a therapeutic option in select cases [1,2]. Hemorrhagic arterial complications are treated in a similar fashion as if diagnosed intraoperatively. In the case of arterial thrombosis, options include angioplasty or thrombectomy, with or without concomitant intraarterial thrombolysis. Bypass grafting is often carried out as the primary revascularization procedure [1,2,6,8,29]. Percutaneous aspiration of thrombus material has also been performed [30,31]. Where a revascularization procedure is undertaken after TKA (regardless of etiology), there should be a relatively low threshold for prophylactic limb fasciotomies [1]. In one study, fasciotomies were performed for any patient suspected of having limb ischemia for greater than 6 hours or where muscle swelling was seen at exploration [2].
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False Aneurysm Formation False or pseudoaneurysms following popliteal arterial injury during TKA have been described in the literature [2,15,32-42]. Time to presentation is variable, with reports ranging from 2 days postoperatively [33] to 5 months [15] following TKA for popliteal artery pseudoaneurysms and up to 30 months for those of the geniculate artery [43]. Often, pain is felt in the popliteal fossa or calf, which may be associated with swelling and a pulsatile mass. Hemarthroses occur where there is communication between a perigeniculate or popliteal pseudoaneurysm and the joint capsule [36]. Thrombosis and/or distal emboli can lead to limb ischemia [36]. There may be an associated neurologic deficit particularly in the peroneal nerve territory [33,34]. The condition may be confused with the more common complication of deep venous thrombosis and investigated as such. Indeed, a deep venous thrombosis may coexist and can occur secondary to venous compression by mass effect of the pseudoaneurysm [37]. Early assessment with duplex ultrasound scanning will help distinguish the diagnoses. Management options include arterial embolization using coils or intraluminal thrombin [36], endovascular stenting [35,38,39], oversewing of the aneurysm neck [34], or excision and repair/ bypass, depending on the nature of the pseudoaneurysm and surgeon preference [15,33,39]. Arteriovenous Fistula Formation Arteriovenous fistulae are a less reported complication of TKA [4,32]. They may occur following injury to the popliteal vessels [39,44,45] or to the medial or lateral geniculate arteries [8,15,32,46]. Presentation of this complication is variable. Pain is often felt around the knee, and there may be diffuse swelling in the lower limb [32,44]. There may be a pulsatile mass with a palpable thrill in the popliteal fossa [32]. As with pseudoaneurysms, recurrent hemarthroses are a potential mode of presentation [8]. One reported case presented with an acutely ischemic limb 6 months postoperatively [45]. Definitive diagnosis is made with ultrasonography or angiography. The majority of cases will require operative excision of the fistula and vascular repair, although arteriovenous fistulae of the geniculate vessels have been reported to settle spontaneously [32]. Outcome Mortality and limb loss are fortunately quite infrequent occurrences. Calligaro et al [2] reported no deaths with limb salvage achieved in all 24 patients who suffered arterial complications (13 618 TKA). There were 2 limbs lost from 20 patients (10%) in the study by Abularrage et al [1] (26 106 TKA). In neither study were the individual mechanisms described in relation to outcome. Parvizi et al [5] had no deaths, but one above-knee amputation in a patient who developed popliteal artery thrombosis after TKA.
1316 The Journal of Arthroplasty Vol. 25 No. 8 December 2010 Da Silva and Sobel [7] reported the experience of 13 vascular surgeons (6.8% survey response rate). There were 2 amputations, but no deaths, from a total of 19 described arterial complications. Again, the exact mechanism of initial arterial injury in the 2 patients who subsequently lost their limbs is not clear. Rush et al [8] demonstrated 1 death and 5 amputations at varying levels in their survey reflecting the combined experience of 100 Australian orthopedic surgeons. Kumar et al [9] described the experience of 107 members of the British Association of Surgeons of the Knee in addition to their own case; there were 3 deaths and 6 amputations. All deaths and amputations described in these surveys were secondary to thrombosis of the popliteal or femoral artery. All those with direct arterial injuries achieved limb survival following vascular intervention. It is not possible to glean from the literature the relative incidences of peripheral arterial disease in patients who subsequently go on to develop thrombosis or suffer a direct arterial injury. It would be interesting to know, as this could possibly provide further explanation for the worse observed outcomes after arterial thrombosis. What does seem clear is that ischemia secondary to thrombotic occlusion tends to be diagnosed later than hemorrhagic complications resulting from direct arterial injury. This may be due to delayed manifestation but also due to difficulties in diagnosis [2]. It is thought that delays of greater than 4 to 6 hours can lead to irreversible muscle and nerve ischemia and subsequent poor outcomes [8,39]. Wilson et al [6] found that 3 of 5 patients with a delayed diagnosis of arterial ischemia after lower limb arthroplasty (including hip and ankle) ultimately required amputation. Although not achieving statistical significance, Calligaro et al [2] reported that where diagnosis is delayed for more than 24 hours postoperatively, patients more frequently required fasciotomies and developed neuromotor complications including foot drop. Abularrage et al [1] also reported a slightly higher proportion of patients requiring fasciotomy where vascular repair occurred greater than 24 hours postoperatively (7/16 vs 5/18). These findings were not however deemed clinically significant by the authors. Notably, of the 2 amputees in this series, 1 had a thrombendarterectomy on day 12 and subsequently an amputation on day 19. The other patient had an amputation as a primary procedure on day 15 postoperatively. Several case reports are also available in the literature regarding arterial thromboses after TKA with varied results. Berger et al [30] described a good outcome for a patient who was promptly diagnosed and treated for arterial thrombosis by percutaneous aspiration. Bellemans et al [31] performed a similar procedure in 2 cases diagnosed 1 and 2 days postoperatively. Reperfusion was achieved in both patients, although compartment syn-
drome requiring fasciotomies and a subsequent foot drop occurred in both. Matziolis et al [29] reported on 2 cases of arterial thrombosis diagnosed within 2 hours, both of which were successfully treated with thrombectomies. Mureebe et al [47] also reported 2 cases where diagnosis was made immediately postoperatively in one patient and 1 day postoperatively in the other. Both were successfully treated with thrombectomy and bypass grafting. Holmberg et al [39] reported on a selection of arterial complications, 2 of which were due to thrombotic occlusion. They both went on to a successful recovery after thrombectomy, undertaken at 12 hours postoperatively in one patient and at a week in the other patient. Hagan and Kaufman [48] reported one case where thrombectomy performed 1 day postoperatively achieved a good result with no residual effects from the arterial occlusion. Hozack et al [15] described a case where a thrombectomy performed in the early postoperative period was unsuccessful, with the patient subsequently undergoing an above-knee amputation. Although results are mixed, there is a clear consensus that early diagnosis and treatment are important. The best form of treatment remains contentious, however, particularly where thrombectomy or thrombendarterectomy is carried out as the sole primary revascularization procedure. Abularrage et al [1] found that more than one half of patients who underwent thrombectomy/thrombendarterectomy alone required further procedures. Calligaro et al [2] found that arterial thrombectomy was successful as a sole procedure in only one quarter of patients. Restricting thrombectomy/ thrombendarterectomy to a few select cases and an aggressive approach to revascularization may improve outcome in arterial thrombosis after TKA [1,2,6]. Outcomes for pseudoaneurysm and arteriovenous fistulae are generally only accounted in case reports, albeit with favorable results. Collating the results for popliteal pseudoaneurysms shows the following: 3 had excision of their aneurysms with repair or bypass and with no further complications reported [15,33,39]; 1 had patch angioplasty with no complications at 1 year [37]; 1 had direct repair with oversewing of the pseudoaneurysm neck with no surgical complications, although there was no improvement in the reduced plantar sensation at 6 months [34]; 5 had endovascular stenting with no evidence of stent failure at follow-up ranging from 12 to 24 months [35,38,40,41,49]; 1 had embolization using an angioplasty balloon and intraluminal thrombin injection and was asymptomatic at 2 years [36]; and 1 had a similar procedure using an angioplasty balloon alone to induce thrombosis within the pseudoaneurysm, with good results at 2-month follow-up [42]. Calligaro et al [2] had 5 popliteal pseudoaneurysms in their study and Wilson et al [6] had 3, although neither described the outcome for this group of patients in isolation.
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It is important to be aware that, although endovascular stenting for pseudoaneurysms after TKA has been carried out with apparent success for both popliteal [26,35,38] and geniculate arteries [36,40,50,51], ongoing surveillance is required to detect any endoleaks, stent migration, fracture, or occlusion, given the highly mobile nature of the knee joint [35]. Regarding arteriovenous fistulae of the popliteal and perigeniculate vessels, good results are obtained after surgical excision and vascular repair. Thomas et al [44] reported complete resolution of symptoms after resection of a fistula between the popliteal vessels 3 years following TKA. Dennis et al [46] reported 2 cases of traumatic arteriovenous fistula associated with false aneurysms of the inferior medial geniculate artery. Surgical excision with ligation of the artery resolved the problem in both patients. From the survey by Rush et al [8], the single case of an arteriovenous fistula had a good result after surgical repair. Interestingly, Langkamer [32] reported 1 case that settled spontaneously after 3 months. Burger et al [45] described the percutaneous endovascular treatment of a thrombosed arteriovenous fistula 6 months after TKA with a polytetrafluoroethylene stent, with no complications at 3 months.
Summary Careful preoperative risk assessment will help identify those patients at increased risk of arterial complications associated with TKA. Where there is significant anatomical distortion following previous surgery or trauma or where there is evidence of arterial disease, preoperative vascular consultation and angiography may be warranted. The use of a tourniquet should be considered carefully in light of the preoperative examination findings. A thorough understanding of normal and anatomical variants combined with careful intraoperative instrumentation and manipulation of the knee is essential. If all these factors are considered carefully, then the risks of arterial injury will hopefully be reduced. In the event that an arterial complication does occur, prompt recognition is of paramount importance to limb survival and limiting patient morbidity. Postoperative diagnosis may be delayed by atypical presentations, although arterial compromise in any form must always be considered in the event of pain or swelling following TKA, even in an outpatient setting. Once the diagnosis is suspected, a timely vascular surgical opinion should be obtained to achieve the best possible outcome for the patient.
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total knee replacement. Knee Surg Sports Traumatol Arthrosc 2000;8:53. Plagnol PH, Diard N, Bruneteau P, et al. Pseudoaneurysm of popliteal artery complicating a total knee replacement: a successful percutaneous endovascular treatment. Eur J Vasc Endovasc Surg 2001;21:81. Holmberg A, Milbrink J, Bergqvist D. Arterial complications after knee arthroplasty: 4 cases and review of the literature. Acta Orthop scand 1996;67:75. Sloan K, Mofidi R, Nagy J, et al. Endovascular treatment for traumatic popliteal artery pseudoaneurysms after knee arthroplasty. Vasc Endovascular Surg 2009;43:286. D'Angelo F, Carrafiello GP, Lagana D, et al. Popliteal artery pseudoaneurysm after revision of total knee arthroplasty: endovascular treatment with a stent graft. Emerg Radiol 2007;13:323. Cowell GW, Boom SJ, Ablett MJ. Thrombosis of popliteal artery pseudoaneurysm by deployment of angioplasty balloon after total knee arthroplasty. J Arthroplasty 2009; 24:825. Katsimihas M, Robinson D, Thornton M, et al. Therapeutic embolization of the genicular arteries for recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty 2001;16:935. Thomas R, Agarwal M, Lovell M, et al. An unusual presentation of a popliteal arteriovenous fistula after primary total knee arthroplasty. J Arthroplasty 2008;23:945. Burger T, Meyer F, Tautenhahn J, et al. Percutaneous treatment of rare iatrogenic arteriovenous fistulas of the lower limbs. Int surg 1998;83:198. Dennis DA, Neumann RD, Toma P, et al. Arteriovenous fistula with false aneurysm of the inferior medial geniculate artery. A complication of total knee arthroplasty. Clin Orthop Relat Res 1987;255. Mureebe L, Gahtan V, Kahn M. Popliteal artery injury after total knee arthroplasty. Am Surg 1996;62:366. Hagan P, Kaufman E. Vascular complication of knee arthroplasty under tourniquet. Clin Orthop Rel Res 1990; 257:159. Hartford JM, Kwolek C, Circle B. Popliteal pseudoaneurysm after total knee arthroplasty: MRI of the vascular anatomy. Orthopedics 2002;25:187. Moran M, Hodgkinson J, Tait W. False aneurysm of the superior lateral geniculate artery following total knee replacement. Knee 2002;9:349. Pritsch T, Parnes N, Menachem A. A bleeding pseudoaneurysm of the lateral genicular artery after total knee arthroplasty—a case report. Acta Orthop 2005;76:138.
Review Article
Arterial Injury in Total Knee Arthroplasty Usman Butt, MB, ChB (Hons), MRCS, Rohit Samuel, BSc (Hons), MB, ChB, MSc (Orth Eng), FRCS (Orth), Ajay Sahu, MBBS, MS, MRCS, Imran S. Butt, BSc, MB, ChB, MRCS, David S. Johnson, MB, ChB, FRCS (Tr and Orth), and Philip G. Turner, FRCS
Abstract: Arterial complications associated with knee arthroplasty are relatively rare, although probably underreported, complications of knee arthroplasty that carry a risk of significant morbidity. Thorough preoperative assessment and close liaison with a vascular surgeon, combined with an appreciation of common anatomical variants or distorted anatomy, may help prevent both thromboembolic and direct injuries from occurring. Clinical features of arterial complications following knee arthroplasty may vary significantly from acute hemorrhage or ischemia in the immediate postoperative period to chronic pain and swelling presenting even months following the procedure. There is potential for diagnostic confusion and delay that may adversely affect outcome. Early diagnosis along with vascular surgical review and intervention is key to successful management. Keywords: arterial injury, vascular injury, total knee arthroplasty complications, arthroplasty complications, vascular complications in knee arthroplasty. © 2010 Elsevier Inc. All rights reserved.
Arterial injury associated with total knee arthroplasty (TKA) is a relatively rare but potentially devastating complication. There are a variety of ways in which arterial injuries and complications may present, with consequences ranging from transient bleeding to limb loss and even death. With the rising number of both primary and revision TKA being performed on an aging population, the potential for arterial injuries must not be underestimated. A considerable portion of the literature surrounding this topic consists of individual case reports, case series, and surveys, although a few large studies do exist with variable incidences reported. In one large multicenter study, Abularrage et al [1] reported an incidence of 0.09% lower extremity arterial injuries from a sample of 26 106 TKA, including 2077 revision procedures. The study did not accurately define the nature of the vascular injuries sustained. In the largest single-center series, Calligaro et al
From the Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, Manchester, UK. Submitted October 14, 2008; accepted May 3, 2010. No benefits or funds were received in support of the study. Reprint requests: Usman Butt, MB, ChB (Hons), MRCS, Stepping Hill Hospital, Stockport, SK2 7JE Manchester, UK. © 2010 Elsevier Inc. All rights reserved. 0883-5403/2508-0023$36.00/0 doi:10.1016/j.arth.2010.05.018
[2] demonstrated an overall incidence of 0.17% arterial complications during TKA. From their sample of 13 618 (including 1665 revisions), there were 24 arterial complications, of which 3 were popliteal artery transections, 5 were popliteal artery pseudoaneurysms, and 16 were solely ischemic complications. Rand reported 3 cases of arterial ischemia secondary to thrombosis from a sample of 9022 knee arthroplasties between 1971 and 1986 (incidence 0.03%) [3,4]. Parvizi et al [5] produced data from a single center on 15 383 hip and knee arthroplasties. They described 16 vascular injuries, of which 11 were related to knee arthroplasty (1 revision). The proportion of knee arthroplasties was not given, making a specific incidence impossible to calculate. Arterial thrombosis occurred in 9 patients, with direct injury being the mechanism in the other 2 patients. Wilson et al [6] reviewed a sample of 4350 elective orthopedic procedures including hip, knee, and ankle arthroplasties. Arterial injuries occurred during 21 procedures, of which two thirds were associated with TKA. The mechanisms of injury were not stratified according to which joint was replaced, and the exact number of TKAs performed was not stated. Da Silva and Sobel [7] conducted a survey in which 13 of 190 vascular surgeons provided information regarding their experiences of popliteal vascular injury associated with TKA. They reported a total of 19 complications, of which 12 were direct arterial
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1312 The Journal of Arthroplasty Vol. 25 No. 8 December 2010 lacerations. Rush et al [8] contacted 470 surgeons in Australia, from which 100 replied. Of these, there were 5 reports of direct arterial injury and 7 of arterial thrombosis. Kumar et al [9] surveyed 147 British orthopedic surgeons. From 107 responses plus their own case, there were 14 reports of vascular complications, which included arterial transection, thrombosis, arteriovenous fistula, or aneurysm formation.
Mechanism There are 4 principal mechanisms responsible for the arterial complications encountered in TKA. In patients with preexisting vascular disease, atheromatous plaques may fracture secondary to mechanical pressure, leading to emboli and arterial insufficiency. This is largely associated with the use of a pneumatic tourniquet and may occur at the level of the superficial femoral artery (SFA) [3,8-12]. Arterial thrombosis occurring at the level of the SFA or popliteal artery may be implicated as a second mechanism. Fixation of the SFA by a tourniquet and subsequent manipulation of the knee can lead to tears in the arterial intimal wall. These intimal tears, compounded by the low-flow state induced by tourniquet use, favor the formation of occlusive thrombus and subsequent ischemia [3,8-13]. Release of severe flexion contractures and subsequent traction on the popliteal artery may likewise cause
intimal tears, but can also lead to compression of the artery against bony or musculotendinous structures as a third mechanism [3,8-14]. Robson et al [14] reported such a case whereby compression of the popliteal artery, following correction of a flexion deformity, necessitated release of the musculofascial structures and surgical division of arterial branches. The fourth mechanism involves direct puncture or laceration injury to the perigeniculate vasculature. This can occur with any form of instrumentation such as a vibrating saw, scalpel blade, diathermy, or a misplaced retractor [12].
Preoperative Risk and Assessment Careful preoperative assessment can help identify those patients who are at higher risk of sustaining arterial complications during their knee arthroplasty (Fig. 1). A variety of strategies can then be used to minimize this risk. Important risk factors to consider include the following: Preexisting Arterial Disease History or examination findings suggestive of arterial insufficiency are among the most important factors to consider if one is to avoid vascular complications during TKA. Points in the history include tobacco use, hypertension, diabetes mellitus, claudication symptoms, rest pain, previous transient ischemic attacks or stroke, or
Fig. 1. System for preoperative assessment of arterial disease before TKA.
Arterial Injury in TKA Butt et al
any previous cardiovascular surgery [1,2,4,6,10]. For every patient planned for TKA, the orthopedic surgeon should make an assessment of the limb vascularity. As a minimum, this should include inspection for trophic changes such as skin discoloration or absence of hair, skin ulceration (past or present), venous guttering, or signs of previous surgery. The lower limb should be palpated for temperature and pulses with comparison made to the contralateral limb. In particular, the popliteal fossa should be examined for aneurysms [4], which are often bilateral. If present, these should be assessed by a vascular surgeon before TKA given the high risk of thrombosis or embolism [15]. The presence of vascular calcification on plain radiographs should further alert the surgeon to the presence of arterial disease [10]. The ankle-brachial pressure index is a useful and simple test that can be performed in the clinic. A value of less than 0.9 suggests the presence of arterial disease, although results should be interpreted with caution in the presence of diabetes mellitus where results may be misleadingly high because of calcification and inelasticity of the vessels. Values less than 0.5 are indicative of severe ischemia [1,4]. Where concern exists regarding the vascularity of a limb, a vascular surgeon should be consulted in the preoperative phase. Any history or evidence of previous vascular intervention on the affected limb, including endovascular techniques, mandates a preoperative vascular opinion [4]. More detailed Doppler anklebrachial pressure index studies (including observation of pulse waveforms) at different levels in the limb can act as a useful screening tool. Preoperative duplex ultrasound scanning or angiography may subsequently be required to more formally assess flow in the native circulation, grafts, or across any stents. Where there is significant ischemia, revascularization may be recommended before TKA [2,4]. The use of a tourniquet should be considered in the preoperative phase. Tourniquets are often implicated or contributory to the development of arterial complications in TKA [2-4,7-11]. Although they do facilitate a dry bone surface for the placement of cemented components, their use is not essential in TKA and should be rationalized. Certainly, where there are signs or symptoms of peripheral arterial disease, they should be avoided. If any doubt exists, consultation with a vascular surgeon is recommended. Where there has been previous bypass surgery, a tourniquet should not be used because of the risk of graft occlusion [4,10]. Anatomical Considerations Anatomical variation or distortion increases the risk of direct arterial injury during major knee surgery [16-20]. In revision knee surgery, blood vessels may be firmly adherent within fibrous scar tissue, rendering them more vulnerable to the saw blade during tibial resection
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[1,5,19]. A tethered artery is also more likely to be damaged during manipulation of the knee joint [2,5,19]. This is also likely to be the case in some complex primary situations, for example, following previous knee trauma. Wilson et al [6] found that 71% of patients with arterial injury during an elective orthopedic procedure had previously had surgery and that 43% had a history of some bone or joint injury in proximity to the operative site (with or without subsequent surgery). Calligaro et al [2] found that arterial complications were more than twice as common following revision TKA compared with a primary procedure (0.36 vs 0.15%, P = .0112). As indicated earlier, the release of severe flexion contractures during TKA carries the risk of arterial stretching or compression [3,8-14]. It is therefore important that the operating surgeon notes the presence of any contracture preoperatively and is aware of this potential risk. Although anatomical distortions are extremely important to consider in the preoperative phase, one should also consider in detail the normal vascular anatomy and its variants before approaching TKA. Based on cadaveric studies, Rubash et al [16] used the analogy of a clock face to describe the position of the neurovascular structures around the tibial surface. For a left knee, taking the 6-o'clock position to be directly anterior, the popliteal vein would be at a 12-o'clock position, the popliteal artery at 1-o'clock, and the anterior tibial artery at 2-o'clock (after bifurcation of the popliteal artery)
Fig. 2. Illustration of the major neurovascular structures at risk during TKA (left knee). At the level of the joint line, the tibial nerve (TN), popliteal vein (PV), and popliteal artery (PA) are vulnerable to injury between 11 and 1 o'clock. Distal to the joint line, the anterior tibial artery (ATA) and common peroneal nerve (CPN) are vulnerable between 1 and 3 o'clock. P indicates posterior; A, anterior; M, medial; L, lateral.
1314 The Journal of Arthroplasty Vol. 25 No. 8 December 2010 (Fig. 2). A zone between 11 and 3 o'clock was highlighted as a risky area for neurovascular injury. The authors also concluded that extra caution be used during screw placement for the uncemented tibial knee arthroplasty components upon which the study was originally based [16]. Extrapolating the findings from this study, it is clear that these vessels would also be vulnerable during soft tissue retraction and procedures including meniscal or posterior cruciate ligament resection, or during posterior capsular releases, for example [17]. Ninomiya et al performed intraoperative arteriograms at the time of TKA on cadaveric specimens. They found that a posterior retractor placed the popliteal artery at risk when it was inserted lateral to the midline or if it was inserted more than 1 cm into the soft tissues [21]. Farrington et al studied the position of the popliteal artery in the arthritic knee. They reported a mean distance of 0.96 to 3.15 mm of the artery to the posterior tibial cortex in flexing the knee from 0° to 90° [22]. Tindall et al studied the prevalence of high-origin anterior tibial arteries (proximal to popliteus) in a sample of 100 knees [23]. They found 6 knees with a high-origin anterior tibial artery. The artery passed anterior to popliteus in direct contact with the posterior cortex of the tibia in all these cases, putting it at significant potential risk during knee arthroplasty. Klecker et al studied the prevalence of this variation of the anterior tibial artery (described as the “aberrant anterior tibial artery”) using magnetic resonance imaging studies [18]. They found a prevalence of 2.1% (23 of 1116 knees), again highlighting the significant risk of injury during orthopedic procedures (Fig. 3). Ethnicity Abularrage et al [1] found a higher incidence of arterial complications in African Americans. It has previously been shown that the black population tends to have lower ankle-brachial pressure indices [24] and more severe occlusive arterial disease in the tibial and peroneal arteries compared with the white population [25].
Presentation and Management There are 4 principal ways in which arterial complications secondary to TKA can present. These include (a) intraoperative hemorrhage, (b) acute ischemia, (c) false aneurysm formation, and (d) arteriovenous fistula formation. Intraoperative Hemorrhage If intraoperative vascular injury is suspected, the tourniquet should be deflated before implantation of components to allow for adequate assessment. Excessive bleeding, an enlarging popliteal swelling, or absent pedal pulses (where previously present) are highly indicative of arterial injury [12]. Releasing the tourniquet as routine practice prior to wound closure to ensure
Fig. 3. Illustrations of the anterior tibial artery (ATA) branching off the popliteal artery (left knee). (A) The ATA arises below the level of the popliteus muscle. (B) The ATA arises above popliteus passing anterior to it near the posterior margin of the tibia.
hemostasis has been suggested [26]. Although the overall benefits of this remain unclear in terms of postoperative recovery and complications, it would clearly facilitate early diagnosis of a major vascular injury [26]. Indeed, the routine use of a tourniquet in TKA has previously been questioned, with some studies showing no benefit or even delays in postoperative recovery [4,27,28].
Arterial Injury in TKA Butt et al
If any concern exists regarding the possibility of a significant vascular injury, an immediate vascular surgical opinion should be sought. Primary repair or patch angioplasty may be all that is required for the majority of arterial lacerations. Where complete arterial transection has occurred, an end-to-end anastomosis is occasionally possible, although an interposition graft may be necessary where excess tension would be placed on the repair. Arterial ligation with a bypass procedure is more commonly required [2,6]. These interventions are often carried out through a separate medial incision permitting an extensile exposure of the SFA and popliteal vessels with which most vascular surgeons are familiar [7]. Acute Ischemia In the immediate postoperative period, signs of acute limb ischemia such as a cold and pale foot, absent or weak pedal pulses, excessive pain, paresthesia, or motor weakness may be difficult to appreciate because of the effects of a spinal anesthesia, dressings, or venous thromboembolic deterrent devices [2]. However, any suspicion in conjunction with an excessively swollen knee or, if used, a high drain output with fresh blood is suggestive of arterial laceration. The signs of acute limb ischemia in isolation suggest thromboembolism or mechanical occlusion. Whether diagnosed immediately or early in the postoperative period, an urgent vascular opinion is required. It is imperative that, immediately following every TKA, the operating surgeon examines the vascularity of the limb. This should be repeated in further postoperative checks on the ward. A delay in diagnosis may lead to irreversible ischemia or compartment syndrome and potential limb loss [2,8]. Once a clinical diagnosis has been made, further investigation and management will be dictated by the clinical picture and severity of injury. Where indicated and where the risk of further delay is deemed acceptable, the vascular surgeon may request angiography before revascularization surgery or as a therapeutic option in select cases [1,2]. Hemorrhagic arterial complications are treated in a similar fashion as if diagnosed intraoperatively. In the case of arterial thrombosis, options include angioplasty or thrombectomy, with or without concomitant intraarterial thrombolysis. Bypass grafting is often carried out as the primary revascularization procedure [1,2,6,8,29]. Percutaneous aspiration of thrombus material has also been performed [30,31]. Where a revascularization procedure is undertaken after TKA (regardless of etiology), there should be a relatively low threshold for prophylactic limb fasciotomies [1]. In one study, fasciotomies were performed for any patient suspected of having limb ischemia for greater than 6 hours or where muscle swelling was seen at exploration [2].
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False Aneurysm Formation False or pseudoaneurysms following popliteal arterial injury during TKA have been described in the literature [2,15,32-42]. Time to presentation is variable, with reports ranging from 2 days postoperatively [33] to 5 months [15] following TKA for popliteal artery pseudoaneurysms and up to 30 months for those of the geniculate artery [43]. Often, pain is felt in the popliteal fossa or calf, which may be associated with swelling and a pulsatile mass. Hemarthroses occur where there is communication between a perigeniculate or popliteal pseudoaneurysm and the joint capsule [36]. Thrombosis and/or distal emboli can lead to limb ischemia [36]. There may be an associated neurologic deficit particularly in the peroneal nerve territory [33,34]. The condition may be confused with the more common complication of deep venous thrombosis and investigated as such. Indeed, a deep venous thrombosis may coexist and can occur secondary to venous compression by mass effect of the pseudoaneurysm [37]. Early assessment with duplex ultrasound scanning will help distinguish the diagnoses. Management options include arterial embolization using coils or intraluminal thrombin [36], endovascular stenting [35,38,39], oversewing of the aneurysm neck [34], or excision and repair/ bypass, depending on the nature of the pseudoaneurysm and surgeon preference [15,33,39]. Arteriovenous Fistula Formation Arteriovenous fistulae are a less reported complication of TKA [4,32]. They may occur following injury to the popliteal vessels [39,44,45] or to the medial or lateral geniculate arteries [8,15,32,46]. Presentation of this complication is variable. Pain is often felt around the knee, and there may be diffuse swelling in the lower limb [32,44]. There may be a pulsatile mass with a palpable thrill in the popliteal fossa [32]. As with pseudoaneurysms, recurrent hemarthroses are a potential mode of presentation [8]. One reported case presented with an acutely ischemic limb 6 months postoperatively [45]. Definitive diagnosis is made with ultrasonography or angiography. The majority of cases will require operative excision of the fistula and vascular repair, although arteriovenous fistulae of the geniculate vessels have been reported to settle spontaneously [32]. Outcome Mortality and limb loss are fortunately quite infrequent occurrences. Calligaro et al [2] reported no deaths with limb salvage achieved in all 24 patients who suffered arterial complications (13 618 TKA). There were 2 limbs lost from 20 patients (10%) in the study by Abularrage et al [1] (26 106 TKA). In neither study were the individual mechanisms described in relation to outcome. Parvizi et al [5] had no deaths, but one above-knee amputation in a patient who developed popliteal artery thrombosis after TKA.
1316 The Journal of Arthroplasty Vol. 25 No. 8 December 2010 Da Silva and Sobel [7] reported the experience of 13 vascular surgeons (6.8% survey response rate). There were 2 amputations, but no deaths, from a total of 19 described arterial complications. Again, the exact mechanism of initial arterial injury in the 2 patients who subsequently lost their limbs is not clear. Rush et al [8] demonstrated 1 death and 5 amputations at varying levels in their survey reflecting the combined experience of 100 Australian orthopedic surgeons. Kumar et al [9] described the experience of 107 members of the British Association of Surgeons of the Knee in addition to their own case; there were 3 deaths and 6 amputations. All deaths and amputations described in these surveys were secondary to thrombosis of the popliteal or femoral artery. All those with direct arterial injuries achieved limb survival following vascular intervention. It is not possible to glean from the literature the relative incidences of peripheral arterial disease in patients who subsequently go on to develop thrombosis or suffer a direct arterial injury. It would be interesting to know, as this could possibly provide further explanation for the worse observed outcomes after arterial thrombosis. What does seem clear is that ischemia secondary to thrombotic occlusion tends to be diagnosed later than hemorrhagic complications resulting from direct arterial injury. This may be due to delayed manifestation but also due to difficulties in diagnosis [2]. It is thought that delays of greater than 4 to 6 hours can lead to irreversible muscle and nerve ischemia and subsequent poor outcomes [8,39]. Wilson et al [6] found that 3 of 5 patients with a delayed diagnosis of arterial ischemia after lower limb arthroplasty (including hip and ankle) ultimately required amputation. Although not achieving statistical significance, Calligaro et al [2] reported that where diagnosis is delayed for more than 24 hours postoperatively, patients more frequently required fasciotomies and developed neuromotor complications including foot drop. Abularrage et al [1] also reported a slightly higher proportion of patients requiring fasciotomy where vascular repair occurred greater than 24 hours postoperatively (7/16 vs 5/18). These findings were not however deemed clinically significant by the authors. Notably, of the 2 amputees in this series, 1 had a thrombendarterectomy on day 12 and subsequently an amputation on day 19. The other patient had an amputation as a primary procedure on day 15 postoperatively. Several case reports are also available in the literature regarding arterial thromboses after TKA with varied results. Berger et al [30] described a good outcome for a patient who was promptly diagnosed and treated for arterial thrombosis by percutaneous aspiration. Bellemans et al [31] performed a similar procedure in 2 cases diagnosed 1 and 2 days postoperatively. Reperfusion was achieved in both patients, although compartment syn-
drome requiring fasciotomies and a subsequent foot drop occurred in both. Matziolis et al [29] reported on 2 cases of arterial thrombosis diagnosed within 2 hours, both of which were successfully treated with thrombectomies. Mureebe et al [47] also reported 2 cases where diagnosis was made immediately postoperatively in one patient and 1 day postoperatively in the other. Both were successfully treated with thrombectomy and bypass grafting. Holmberg et al [39] reported on a selection of arterial complications, 2 of which were due to thrombotic occlusion. They both went on to a successful recovery after thrombectomy, undertaken at 12 hours postoperatively in one patient and at a week in the other patient. Hagan and Kaufman [48] reported one case where thrombectomy performed 1 day postoperatively achieved a good result with no residual effects from the arterial occlusion. Hozack et al [15] described a case where a thrombectomy performed in the early postoperative period was unsuccessful, with the patient subsequently undergoing an above-knee amputation. Although results are mixed, there is a clear consensus that early diagnosis and treatment are important. The best form of treatment remains contentious, however, particularly where thrombectomy or thrombendarterectomy is carried out as the sole primary revascularization procedure. Abularrage et al [1] found that more than one half of patients who underwent thrombectomy/thrombendarterectomy alone required further procedures. Calligaro et al [2] found that arterial thrombectomy was successful as a sole procedure in only one quarter of patients. Restricting thrombectomy/ thrombendarterectomy to a few select cases and an aggressive approach to revascularization may improve outcome in arterial thrombosis after TKA [1,2,6]. Outcomes for pseudoaneurysm and arteriovenous fistulae are generally only accounted in case reports, albeit with favorable results. Collating the results for popliteal pseudoaneurysms shows the following: 3 had excision of their aneurysms with repair or bypass and with no further complications reported [15,33,39]; 1 had patch angioplasty with no complications at 1 year [37]; 1 had direct repair with oversewing of the pseudoaneurysm neck with no surgical complications, although there was no improvement in the reduced plantar sensation at 6 months [34]; 5 had endovascular stenting with no evidence of stent failure at follow-up ranging from 12 to 24 months [35,38,40,41,49]; 1 had embolization using an angioplasty balloon and intraluminal thrombin injection and was asymptomatic at 2 years [36]; and 1 had a similar procedure using an angioplasty balloon alone to induce thrombosis within the pseudoaneurysm, with good results at 2-month follow-up [42]. Calligaro et al [2] had 5 popliteal pseudoaneurysms in their study and Wilson et al [6] had 3, although neither described the outcome for this group of patients in isolation.
Arterial Injury in TKA Butt et al
It is important to be aware that, although endovascular stenting for pseudoaneurysms after TKA has been carried out with apparent success for both popliteal [26,35,38] and geniculate arteries [36,40,50,51], ongoing surveillance is required to detect any endoleaks, stent migration, fracture, or occlusion, given the highly mobile nature of the knee joint [35]. Regarding arteriovenous fistulae of the popliteal and perigeniculate vessels, good results are obtained after surgical excision and vascular repair. Thomas et al [44] reported complete resolution of symptoms after resection of a fistula between the popliteal vessels 3 years following TKA. Dennis et al [46] reported 2 cases of traumatic arteriovenous fistula associated with false aneurysms of the inferior medial geniculate artery. Surgical excision with ligation of the artery resolved the problem in both patients. From the survey by Rush et al [8], the single case of an arteriovenous fistula had a good result after surgical repair. Interestingly, Langkamer [32] reported 1 case that settled spontaneously after 3 months. Burger et al [45] described the percutaneous endovascular treatment of a thrombosed arteriovenous fistula 6 months after TKA with a polytetrafluoroethylene stent, with no complications at 3 months.
Summary Careful preoperative risk assessment will help identify those patients at increased risk of arterial complications associated with TKA. Where there is significant anatomical distortion following previous surgery or trauma or where there is evidence of arterial disease, preoperative vascular consultation and angiography may be warranted. The use of a tourniquet should be considered carefully in light of the preoperative examination findings. A thorough understanding of normal and anatomical variants combined with careful intraoperative instrumentation and manipulation of the knee is essential. If all these factors are considered carefully, then the risks of arterial injury will hopefully be reduced. In the event that an arterial complication does occur, prompt recognition is of paramount importance to limb survival and limiting patient morbidity. Postoperative diagnosis may be delayed by atypical presentations, although arterial compromise in any form must always be considered in the event of pain or swelling following TKA, even in an outpatient setting. Once the diagnosis is suspected, a timely vascular surgical opinion should be obtained to achieve the best possible outcome for the patient.
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