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Updated: Aug 19 2022

TKA Vascular Injury and Bleeding

  • summary
    • TKA Vascular Injury and Bleeding, is a rare, potentially devastating, complication that may occur during TKA most commonly as a result of direct injury to the popliteal artery.
    • Diagnosis is made with visual inspection for significant arterial bleeding and a change in patient hemodynamic status.
    • Treatment is recognization of the injured vessel, hemostasis and vascular consultation.
  • Epidemiology
    • Incidence
      • 0.017%-0.2%
    • Risk factors
      • revision surgery
      • peripheral vascular disease
  • Etiology
    • Causes
      • direct laceration
        • sharp dissection in posterior compartment of knee
      • blunt trauma
        • posterior retractor placement
          • stay medial with single-prong retractor (do not go lateral to PCL)
          • popliteal artery is a lateral structure at the level of the joint line
          • do not insert retractor more >1cm into posterior soft tissues
          • hyperflexion displaces artery and can avoid injury
        • excessive hyperextension brings the artery closer to the knee
          • increases likelihood of injury during bone cuts
      • thrombosis
  • Anatomy
    • Popliteal artery
      • origin before knee
        • a continuation of the superficial femoral artery
        • transition is at hiatus of adductor magnus muscle
        • anchored by insertion of adductor magnus as enters region of posterior knee
      • course in posterior knee
        • relation to anatomy structures of knee
          • lies posterior to the posterior horn of the lateral horn of the lateral meniscus
            • lies directly behind posterior capsule
      • branches within knee
        • at supracondylar ridge gives branches the provide blood supply to the knee
          • above knee joint branches include
            • medial and lateral sural arteries
            • cutaneous branch
            • middle genicular artery
          • at level of knee joint branches include
            • medial genicular artery
            • lateral genicular artery
      • exit of knee
        • anchor
          • as artery exits knee it is anchored by soleus tendon (originates form medial aspect of tibial plateau)
        • distal branches
          • branches into anterior and posterior tibial arteries at distal popliteus muscles
  • Presentation
    • Intraoperative
      • brisk bleeding
      • loss of pulses
    • Postoperative
      • ischemia
      • sensory changes
      • loss of distal pulses
      • skin mottling
  • Imaging
    • Intraoperative
      • angiogram
        • indications
          • if brisk intraoperative bleeding and/or loss of pulses than obtain immediate vascular surgery consultation.
          • vascular consultation will dictate intraoperative imaging, including angiogram.
    • Postoperative
      • CT angiogram
        • indications
          • signs of ischemia
            • loss of pulses
            • skin mottling
            • sensory changes
  • Treatment
    • Immediate vascular surgery consultation
      • indications
        • whenever a concern for injury to the popliteal artery
      • modalities may include
        • nonoperative and observation
          • closed suction drainage is associated with increased incidence of transfusion
        • stent placement
        • bypass
        • endarterectomy
        • prophylactic fasciotomy
          • may be indicated to avoid reperfusion compartment syndrome
  • Complications
    • Compartment syndrome
    • Amputation
    • Mortality
    • Socioeconomic consequences
      • increased length of stay
      • increased cost
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