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Popliteal pseudoaneurysm and arteriovenous fistula after arthroscopic meniscectomy
Case Report
Popliteal Pseudoaneurysm and Arteriovenous Fistula After Arthroscopic Meniscectomy Daniel J. Mullen, M.D., and George J. Jabaji, M.D.
Abstract: A 69-year-old woman developed 2 pseudoaneurysms and an arteriovenous fistula in the popliteal vasculature after arthroscopic knee surgery. Despite heightened suspicion, prompt diagnosis, and early surgical intervention, the patient had an incomplete resolution of her symptoms. Key Words: Meniscectomy—Pseudoaneurysm—Complication.
A
rthroscopic meniscectomy of the knee, the most commonly performed orthopaedic procedure, has become a very effective and safe procedure when performed by experienced arthroscopists. The overall complication rate in knee arthroscopy ranges from 0.56% to 8.2%, but vascular complications are reported to occur only rarely.1-4 We present a case of a popliteal pseudoaneurysm and arteriovenous fistula formation after a knee arthroscopy with medial meniscectomy. CASE REPORT An active 69-year-old woman with only occasional right knee pain began experiencing sharp, constant pain in her right knee. On presentation, she described new clicking and popping sensations that were exacerbated with activity but noted no recent twisting or traumatic event. On examination, she ambulated with
From the Department of Orthopaedic Surgery, The Union Memorial Hospital (D.J.M.); and the Department of Vascular Surgery, Franklin Square Hospital (G.J.J.), Baltimore, Maryland, U.S.A. Address correspondence and reprint requests to Daniel J. Mullen, M.D., c/o Elaine P. Bulson, Editor, Department of Orthopaedic Surgery, The Union Memorial Hospital, The Johnston Professional Building, Room 400, 3333 North Calvert St, Baltimore, MD 21218, U.S.A. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 1526-3231/01/1701-2690$35.00/0 doi:10.1053/jars.2001.16284
a limp but had no effusion. She had posteromedial joint line tenderness, positive Apley’s and McMurray’s tests, and no abnormal patellofemoral findings. Radiographs revealed minimal medial joint line narrowing with no subchondral sclerosis, osteophytes, or periarticular cystic changes. An intra-articular injection of 40 mg of Depo-Medrol (methylprednisolone acetate; Upjohn, Kalamazoo, MI) failed to alleviate her pain, and she subsequently elected to undergo knee arthroscopy. Under general anesthesia, the right leg was elevated, and a pneumatic thigh tourniquet was applied and inflated to 350 mm Hg. Anteromedial and anterolateral portals were used to investigate the knee. The medial compartment had mild chondromalacia on the femoral and tibial side of the joint as well as a tear in the posterior aspect of the medial meniscus. Straight and up-biting basket forceps and a meniscal shaver were used to partially resect the posterior medial meniscus and to perform femoral and tibial chondroplasties. The patellofemoral compartment had minimal undersurface erosions and the lateral compartment was normal. The knee was irrigated and evacuated of crystalloid, and the tourniquet was released. Then, 40 mg of Depo-Medrol were injected and the portals were closed with nylon sutures. The patient was discharged home from the recovery room. On postoperative day 7, the patient called complaining of calf pain and swelling. On examination, her surgical wounds were normal and the knee had a small
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: E1
1
2
D. J. MULLEN AND G. J. JABAJI
effusion. She had moderate edema in the calf, fullness in the popliteal fossa without a discrete mass but with a palpable thrill, and a positive Homan’s sign. An arteriovenous fistula was suspected, and the patient was referred to vascular surgery. Venous duplex ultrasound showed no deep venous thrombosis and confirmed an arteriovenous fistula in the popliteal vasculature. Femoral angiography revealed 2 adjacent pseudoaneurysms of the popliteal artery measuring 2.5 ⫻ 1.5 ⫻ 0.8 cm and 3.0 ⫻ 2.0 ⫻ 1.5 cm, each with a broad base and rapid arteriovenous shunting of contrast material from the popliteal artery into the popliteal vein at the level of the femorotibial joint line (Fig 1). Contrast material reached the foot but flow was weak distal to the knee.
FIGURE 1. (A) Internal oblique and (B) external oblique arteriograms of the popliteal artery showing 2 pseudoaneurysms with shunting of contrast into the venous system.
At vascular surgery, the pseudoaneurysms were identified and resected at their bases. The popliteal vein defect was closed primarily with 6-0 Prolene (Ethicon, Somerville, NJ). The zone of injury to the popliteal artery extended beyond the point where the fistula had formed. A piece of double-roll Hemashield Dacron (Boston Scientific Medi-tech, Wayne, NJ) was tailored to the size of the arterial defect, but the macerated wall of the artery would not adequately support small-patch angioplasty. The short saphenous vein was then harvested and used as an interpositional graft from the popliteal artery to the tibioperoneal trunk with end-to-end anastomoses. After awakening from vascular surgery, the patient complained of a new burning, shooting pain on the
PSEUDOANEURYSM AFTER MENISCECTOMY medial side of her calf as well as on the plantar and medial side of her foot. Her edema slowly resolved but the dysesthesias in the tibial nerve distribution did not. Two months later, the patient underwent neurolysis of the tibial nerve in the popliteal fossa, and her symptoms partially resolved. At 2-year follow-up, the patient still complains of moderate plantar and medial right foot pain, ambulates with a cane for assistance, and wears nonprescription shoes. DISCUSSION Complications of arthroscopic surgery involving the neurovascular elements in the popliteal fossa are extremely rare, but they do occur. In 1982, Mulhollan5 provided the first critical analysis of arthroscopic complications. He reviewed more than 9,000 cases from experienced arthroscopists and found none that involved the popliteal vasculature. In 1985, the Committee on Complications of the Arthroscopy Association of North America (CCAANA)1 reported the results of a national survey of 118,590 arthroscopic procedures. The vascular injury rate was 0.005%, and 4 of the 6 injuries to the popliteal artery resulted in amputation. In a follow-up survey,2 the CCAANA retrospectively reviewed data on 395,566 arthroscopies and found an overall complication rate of 0.56%, with 12 (0.003%) vascular injuries, all to the popliteal vessels. In 1988, the CCAANA2 developed a prospective registry to tabulate the complication rate of 21 experienced arthroscopists over a 19-month period. The overall complication rate for 10,282 procedures was 1.68%; the complication rate for medial meniscectomies was 1.78%. No vascular injuries were reported, a phenomenon attributed to good surgical technique, experienced surgeons, and familiarity with the anatomy.3 Despite the increasing number of arthroscopic surgeries performed annually and a greater exposure to them in orthopaedic training programs, occasional cases of vascular injury and pseudoaneurysms after arthroscopic procedures in the knee6-19 (as well as in the ankle and shoulder20,21) continue to be reported. Those in the knee may be due to the fact that the popliteal artery lies in very close apposition to the posterior knee capsule and that internal rotation moves the vascular funicle relatively laterally, but external rotation stretches it across the attachment of the posterior horn of the medial meniscus, putting the vessel more at risk for iatrogenic injury.12 The vessels reported to be injured during arthroscopic knee surgery include the popliteal,1,6-12 inferior lateral genicu-
3
late,12-16 inferior medial geniculate,17 descending geniculate,13,18 muscular branch of the vastus medialis,7 recurrent anterior tibial,19 and superior medial geniculate16 arteries. Pseudoaneurysm and arteriovenous fistula formation are serious complications, and involvement of the popliteal artery can be disastrous, as evidenced by amputations in 4 of 6 cases in the CCAANA review.1 Although those 4 reports did not define the duration of time between occurrence, diagnosis, and treatment, recent reports have emphasized the importance of prompt diagnosis and treatment6,8,15 and have indicated that heightened awareness of the symptoms of postoperative popliteal pain and/or mass, calf edema, and pulsatile hemarthrosis is associated with reduced morbidity after pseudoaneurysm development.6,13,15 Nevertheless, early recognition of such complications and the presumption that postoperative pulsatile swelling or a mass in the popliteal fossa is associated with a vascular injury that requires color Doppler sonography, computed tomography, magnetic resonance imaging, or angiography for definitive diagnosis, are not always sufficient. In addition, it must be noted that, although surgical methods for addressing repair of a pseudoaneurysm have included interpositional vein grafting, patch angioplasty for the popliteal artery, and ligation and coil embolization for smaller branch vessels, these modalities are not always sufficient nor successful. In the current case, for example, attempt at repair of the popliteal artery with a Dacron patch failed intraoperatively, most likely because the injury was more extensive than anticipated, with a fistula measuring 1 cm in diameter. Therefore, it is suggested that the surgeon use interpositional reverse venous bypass grafting for the treatment of traumatic popliteal pseudoaneurysm formation with broad-based arteriovenous fistula development. The case presented here is unique in that the diagnosis was suspected early and treatment was expedient, but further complications and a poor outcome still resulted. Therefore, emphasis must be placed on the necessity of prevention. Good surgical technique (including avoidance of Basket forceps and other arthroscopic instruments without adequate visualization of the surrounding tissues) and knowledge of the popliteal anatomy can minimize the morbidity this complication.3 CONCLUSION Although a very rare complication, vascular injuries after knee arthroscopy do occur and can end in a poor result, despite early recognition and intervention. Ar-
4
D. J. MULLEN AND G. J. JABAJI
throscopists should recognize the proximity of the popliteal artery to the posterior horn of the medial meniscus and suspect iatrogenic injury in the case of postoperative popliteal swelling, mass, bruit, thrill, pulsatile hemarthrosis, pain, and/or calf edema. REFERENCES 1. Committee on Complications of Arthroscopy Association of North America. Complications of arthroscopy and arthroscopic surgery: Results of a national survey. Arthroscopy 1985;1:214-220. 2. Committee on Complications of the Arthroscopy Association of North America. Complications in arthroscopy: The knee and other joints. Arthroscopy 1986;2:253-258. 3. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 4. Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopy—Noproblem surgery. An analysis of complications in two thousand six hundred and forty cases. J Bone Joint Surg Am 1986;68:256-265. 5. Mulhollan JS. Symposium: Arthroscopic knee surgery. Can Orthop 1982;5:79-112. 6. Beck DE, Robison JG, Hallett JW Jr. Popliteal artery pseudoaneurysm following arthroscopy. J Trauma 1986;26:87-89. 7. Hilborn M, Munk PL, Miniaci A, MacDonald SJ, Rankin RN, Fowler PJ. Pseudoaneurysm after therapeutic knee arthroscopy: Imaging findings. AJR Am J Roentgenol 1994;163:637639. 8. Jeffries JT, Gainor BJ, Allen WC, Cikrit D. Injury to the popliteal artery as a complication of arthroscopic surgery. A report of two cases. J Bone Joint Surg Am 1987;69:783-785. 9. Vassallo P, Reiser MF, Strobel M, Peters PE. Popliteal pseu-
10. 11. 12. 13. 14. 15. 16. 17. 18.
19. 20. 21.
doaneurysm and arteriovenous shunt following arthroscopic meniscectomy: Case report. Cardiovasc Intervent Radiol 1989;12:142-144. Jimenez F, Utrilla A, Cuesta C, et al. Popliteal artery and venous aneurysm as a complication of arthroscopic meniscectomy. J Trauma 1988;28:1404-1405. Potter D, Morris-Jones W. Popliteal artery injury complicating arthroscopic meniscectomy. Arthroscopy 1995;11:723-726. Bernard M, Grothues-Spork M, Georgoulis A, Hertel P. Neural and vascular complications of arthroscopic meniscal surgery. Knee Surg Sports Traumatol Arthrosc 1994;2:14-18. Vincent GM, Stanish WD. False aneurysm after arthroscopic meniscectomy. A report of two cases. J Bone Joint Surg Am 1990;72:770-772. Manning MP, Marshall JH. Aneurysm after arthroscopy. J Bone Joint Surg Br 1987;69:151. Guy RJ, Spalding TJ, Jarvis LJ. Pseudoaneurysm after arthroscopy of the knee. A case report. Clin Orthop 1993;295:214217. Armato DP, Czamecki D. Geniculate artery pseudoaneurysm: A rare complication of arthroscopic surgery [letter]. AJR Am J Roentgenol 1990;155:659. Sarrosa EA, Ogilvie-Harris DJ. Pseudoaneurysm as a complication of knee arthroscopy. Arthroscopy 1997;13:644-645. Tozzi A, Ferri E, Serrao E, Colonna M, De Marco P, Mangialardi N. Pseudoaneurysm of the descending genicular artery after arthroscopic meniscectomy: Report of a case. J Trauma 1996;41:340-341. Aldrich D, Anschuetz R, LoPresti C, Fumich M, Pitluk H, O’Brien W. Pseudoaneurysm complicating knee arthroscopy. Arthroscopy 1995;11:229-230. Cameron SE. Venous pseudoaneurysm as a complication of shoulder arthroscopy. J Shoulder Elbow Surg 1996;5:404-406. O’Farrell D, Dudeney S, McNally S, Moran R. Pseudoaneurysm formation after ankle arthroscopy. Foot Ankle Int 1997; 18:578-579.
Popliteal Pseudoaneurysm and Arteriovenous Fistula After Arthroscopic Meniscectomy Daniel J. Mullen, M.D., and George J. Jabaji, M.D.
Abstract: A 69-year-old woman developed 2 pseudoaneurysms and an arteriovenous fistula in the popliteal vasculature after arthroscopic knee surgery. Despite heightened suspicion, prompt diagnosis, and early surgical intervention, the patient had an incomplete resolution of her symptoms. Key Words: Meniscectomy—Pseudoaneurysm—Complication.
A
rthroscopic meniscectomy of the knee, the most commonly performed orthopaedic procedure, has become a very effective and safe procedure when performed by experienced arthroscopists. The overall complication rate in knee arthroscopy ranges from 0.56% to 8.2%, but vascular complications are reported to occur only rarely.1-4 We present a case of a popliteal pseudoaneurysm and arteriovenous fistula formation after a knee arthroscopy with medial meniscectomy. CASE REPORT An active 69-year-old woman with only occasional right knee pain began experiencing sharp, constant pain in her right knee. On presentation, she described new clicking and popping sensations that were exacerbated with activity but noted no recent twisting or traumatic event. On examination, she ambulated with
From the Department of Orthopaedic Surgery, The Union Memorial Hospital (D.J.M.); and the Department of Vascular Surgery, Franklin Square Hospital (G.J.J.), Baltimore, Maryland, U.S.A. Address correspondence and reprint requests to Daniel J. Mullen, M.D., c/o Elaine P. Bulson, Editor, Department of Orthopaedic Surgery, The Union Memorial Hospital, The Johnston Professional Building, Room 400, 3333 North Calvert St, Baltimore, MD 21218, U.S.A. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 1526-3231/01/1701-2690$35.00/0 doi:10.1053/jars.2001.16284
a limp but had no effusion. She had posteromedial joint line tenderness, positive Apley’s and McMurray’s tests, and no abnormal patellofemoral findings. Radiographs revealed minimal medial joint line narrowing with no subchondral sclerosis, osteophytes, or periarticular cystic changes. An intra-articular injection of 40 mg of Depo-Medrol (methylprednisolone acetate; Upjohn, Kalamazoo, MI) failed to alleviate her pain, and she subsequently elected to undergo knee arthroscopy. Under general anesthesia, the right leg was elevated, and a pneumatic thigh tourniquet was applied and inflated to 350 mm Hg. Anteromedial and anterolateral portals were used to investigate the knee. The medial compartment had mild chondromalacia on the femoral and tibial side of the joint as well as a tear in the posterior aspect of the medial meniscus. Straight and up-biting basket forceps and a meniscal shaver were used to partially resect the posterior medial meniscus and to perform femoral and tibial chondroplasties. The patellofemoral compartment had minimal undersurface erosions and the lateral compartment was normal. The knee was irrigated and evacuated of crystalloid, and the tourniquet was released. Then, 40 mg of Depo-Medrol were injected and the portals were closed with nylon sutures. The patient was discharged home from the recovery room. On postoperative day 7, the patient called complaining of calf pain and swelling. On examination, her surgical wounds were normal and the knee had a small
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: E1
1
2
D. J. MULLEN AND G. J. JABAJI
effusion. She had moderate edema in the calf, fullness in the popliteal fossa without a discrete mass but with a palpable thrill, and a positive Homan’s sign. An arteriovenous fistula was suspected, and the patient was referred to vascular surgery. Venous duplex ultrasound showed no deep venous thrombosis and confirmed an arteriovenous fistula in the popliteal vasculature. Femoral angiography revealed 2 adjacent pseudoaneurysms of the popliteal artery measuring 2.5 ⫻ 1.5 ⫻ 0.8 cm and 3.0 ⫻ 2.0 ⫻ 1.5 cm, each with a broad base and rapid arteriovenous shunting of contrast material from the popliteal artery into the popliteal vein at the level of the femorotibial joint line (Fig 1). Contrast material reached the foot but flow was weak distal to the knee.
FIGURE 1. (A) Internal oblique and (B) external oblique arteriograms of the popliteal artery showing 2 pseudoaneurysms with shunting of contrast into the venous system.
At vascular surgery, the pseudoaneurysms were identified and resected at their bases. The popliteal vein defect was closed primarily with 6-0 Prolene (Ethicon, Somerville, NJ). The zone of injury to the popliteal artery extended beyond the point where the fistula had formed. A piece of double-roll Hemashield Dacron (Boston Scientific Medi-tech, Wayne, NJ) was tailored to the size of the arterial defect, but the macerated wall of the artery would not adequately support small-patch angioplasty. The short saphenous vein was then harvested and used as an interpositional graft from the popliteal artery to the tibioperoneal trunk with end-to-end anastomoses. After awakening from vascular surgery, the patient complained of a new burning, shooting pain on the
PSEUDOANEURYSM AFTER MENISCECTOMY medial side of her calf as well as on the plantar and medial side of her foot. Her edema slowly resolved but the dysesthesias in the tibial nerve distribution did not. Two months later, the patient underwent neurolysis of the tibial nerve in the popliteal fossa, and her symptoms partially resolved. At 2-year follow-up, the patient still complains of moderate plantar and medial right foot pain, ambulates with a cane for assistance, and wears nonprescription shoes. DISCUSSION Complications of arthroscopic surgery involving the neurovascular elements in the popliteal fossa are extremely rare, but they do occur. In 1982, Mulhollan5 provided the first critical analysis of arthroscopic complications. He reviewed more than 9,000 cases from experienced arthroscopists and found none that involved the popliteal vasculature. In 1985, the Committee on Complications of the Arthroscopy Association of North America (CCAANA)1 reported the results of a national survey of 118,590 arthroscopic procedures. The vascular injury rate was 0.005%, and 4 of the 6 injuries to the popliteal artery resulted in amputation. In a follow-up survey,2 the CCAANA retrospectively reviewed data on 395,566 arthroscopies and found an overall complication rate of 0.56%, with 12 (0.003%) vascular injuries, all to the popliteal vessels. In 1988, the CCAANA2 developed a prospective registry to tabulate the complication rate of 21 experienced arthroscopists over a 19-month period. The overall complication rate for 10,282 procedures was 1.68%; the complication rate for medial meniscectomies was 1.78%. No vascular injuries were reported, a phenomenon attributed to good surgical technique, experienced surgeons, and familiarity with the anatomy.3 Despite the increasing number of arthroscopic surgeries performed annually and a greater exposure to them in orthopaedic training programs, occasional cases of vascular injury and pseudoaneurysms after arthroscopic procedures in the knee6-19 (as well as in the ankle and shoulder20,21) continue to be reported. Those in the knee may be due to the fact that the popliteal artery lies in very close apposition to the posterior knee capsule and that internal rotation moves the vascular funicle relatively laterally, but external rotation stretches it across the attachment of the posterior horn of the medial meniscus, putting the vessel more at risk for iatrogenic injury.12 The vessels reported to be injured during arthroscopic knee surgery include the popliteal,1,6-12 inferior lateral genicu-
3
late,12-16 inferior medial geniculate,17 descending geniculate,13,18 muscular branch of the vastus medialis,7 recurrent anterior tibial,19 and superior medial geniculate16 arteries. Pseudoaneurysm and arteriovenous fistula formation are serious complications, and involvement of the popliteal artery can be disastrous, as evidenced by amputations in 4 of 6 cases in the CCAANA review.1 Although those 4 reports did not define the duration of time between occurrence, diagnosis, and treatment, recent reports have emphasized the importance of prompt diagnosis and treatment6,8,15 and have indicated that heightened awareness of the symptoms of postoperative popliteal pain and/or mass, calf edema, and pulsatile hemarthrosis is associated with reduced morbidity after pseudoaneurysm development.6,13,15 Nevertheless, early recognition of such complications and the presumption that postoperative pulsatile swelling or a mass in the popliteal fossa is associated with a vascular injury that requires color Doppler sonography, computed tomography, magnetic resonance imaging, or angiography for definitive diagnosis, are not always sufficient. In addition, it must be noted that, although surgical methods for addressing repair of a pseudoaneurysm have included interpositional vein grafting, patch angioplasty for the popliteal artery, and ligation and coil embolization for smaller branch vessels, these modalities are not always sufficient nor successful. In the current case, for example, attempt at repair of the popliteal artery with a Dacron patch failed intraoperatively, most likely because the injury was more extensive than anticipated, with a fistula measuring 1 cm in diameter. Therefore, it is suggested that the surgeon use interpositional reverse venous bypass grafting for the treatment of traumatic popliteal pseudoaneurysm formation with broad-based arteriovenous fistula development. The case presented here is unique in that the diagnosis was suspected early and treatment was expedient, but further complications and a poor outcome still resulted. Therefore, emphasis must be placed on the necessity of prevention. Good surgical technique (including avoidance of Basket forceps and other arthroscopic instruments without adequate visualization of the surrounding tissues) and knowledge of the popliteal anatomy can minimize the morbidity this complication.3 CONCLUSION Although a very rare complication, vascular injuries after knee arthroscopy do occur and can end in a poor result, despite early recognition and intervention. Ar-
4
D. J. MULLEN AND G. J. JABAJI
throscopists should recognize the proximity of the popliteal artery to the posterior horn of the medial meniscus and suspect iatrogenic injury in the case of postoperative popliteal swelling, mass, bruit, thrill, pulsatile hemarthrosis, pain, and/or calf edema. REFERENCES 1. Committee on Complications of Arthroscopy Association of North America. Complications of arthroscopy and arthroscopic surgery: Results of a national survey. Arthroscopy 1985;1:214-220. 2. Committee on Complications of the Arthroscopy Association of North America. Complications in arthroscopy: The knee and other joints. Arthroscopy 1986;2:253-258. 3. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 4. Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopy—Noproblem surgery. An analysis of complications in two thousand six hundred and forty cases. J Bone Joint Surg Am 1986;68:256-265. 5. Mulhollan JS. Symposium: Arthroscopic knee surgery. Can Orthop 1982;5:79-112. 6. Beck DE, Robison JG, Hallett JW Jr. Popliteal artery pseudoaneurysm following arthroscopy. J Trauma 1986;26:87-89. 7. Hilborn M, Munk PL, Miniaci A, MacDonald SJ, Rankin RN, Fowler PJ. Pseudoaneurysm after therapeutic knee arthroscopy: Imaging findings. AJR Am J Roentgenol 1994;163:637639. 8. Jeffries JT, Gainor BJ, Allen WC, Cikrit D. Injury to the popliteal artery as a complication of arthroscopic surgery. A report of two cases. J Bone Joint Surg Am 1987;69:783-785. 9. Vassallo P, Reiser MF, Strobel M, Peters PE. Popliteal pseu-
10. 11. 12. 13. 14. 15. 16. 17. 18.
19. 20. 21.
doaneurysm and arteriovenous shunt following arthroscopic meniscectomy: Case report. Cardiovasc Intervent Radiol 1989;12:142-144. Jimenez F, Utrilla A, Cuesta C, et al. Popliteal artery and venous aneurysm as a complication of arthroscopic meniscectomy. J Trauma 1988;28:1404-1405. Potter D, Morris-Jones W. Popliteal artery injury complicating arthroscopic meniscectomy. Arthroscopy 1995;11:723-726. Bernard M, Grothues-Spork M, Georgoulis A, Hertel P. Neural and vascular complications of arthroscopic meniscal surgery. Knee Surg Sports Traumatol Arthrosc 1994;2:14-18. Vincent GM, Stanish WD. False aneurysm after arthroscopic meniscectomy. A report of two cases. J Bone Joint Surg Am 1990;72:770-772. Manning MP, Marshall JH. Aneurysm after arthroscopy. J Bone Joint Surg Br 1987;69:151. Guy RJ, Spalding TJ, Jarvis LJ. Pseudoaneurysm after arthroscopy of the knee. A case report. Clin Orthop 1993;295:214217. Armato DP, Czamecki D. Geniculate artery pseudoaneurysm: A rare complication of arthroscopic surgery [letter]. AJR Am J Roentgenol 1990;155:659. Sarrosa EA, Ogilvie-Harris DJ. Pseudoaneurysm as a complication of knee arthroscopy. Arthroscopy 1997;13:644-645. Tozzi A, Ferri E, Serrao E, Colonna M, De Marco P, Mangialardi N. Pseudoaneurysm of the descending genicular artery after arthroscopic meniscectomy: Report of a case. J Trauma 1996;41:340-341. Aldrich D, Anschuetz R, LoPresti C, Fumich M, Pitluk H, O’Brien W. Pseudoaneurysm complicating knee arthroscopy. Arthroscopy 1995;11:229-230. Cameron SE. Venous pseudoaneurysm as a complication of shoulder arthroscopy. J Shoulder Elbow Surg 1996;5:404-406. O’Farrell D, Dudeney S, McNally S, Moran R. Pseudoaneurysm formation after ankle arthroscopy. Foot Ankle Int 1997; 18:578-579.